A global review of the evidence on the social and behavioral drivers of demand for the child health commodities was conducted and synthesized into summary tables for the child health commodities. This research was analyzed and described in a full report and spotlight brief. Background information and technical documents, such as technical briefs and links to key resources, are available for amoxicillin and ORS/zinc.

The situation analysis focuses on gaining a deeper understanding of the challenges and barriers to address within a specific context that influence the current demand and utilization of a priority RMNCH commodity, including individual knowledge, attitudes and behaviors of providers, end-users and other influencing audiences; social and cultural norms; potential constraints on and facilitators for individual and collective change; and media access and use by the intended audiences. It also examines the status of each commodity, including relevant policies, regulations, manufacturing, prices, supply-chains, and availability. In short, the situation analysis answers the question, “Where are we now?” 

Conducting a situation analysis typically involves collating available data and resources and then convening a group of stakeholders to review and identify key information.

“Conducting a National Assessment on Demand Generation for Underutilized, Life-Saving Commodities: Guidance and Tools” provides guidance to country-based partners to carry out collection of relevant data. Sources of country-specific secondary data may include Demographic and Health Surveys (DHS) or Multiple Indicator Cluster Surveys (MICS), quantitative and qualitative research conducted by NGOs, or private sector market research, where available, such as Nielsen. RMNCH policies and guidelines may also assist in analyzing the situation.

The tool also provides semi-structured interview guides to collect information from key stakeholders, including RMNCH program staff within the Ministry of Health, procurement agencies, donors and other experts such as private sector wholesalers, manufacturers and academic institutions.

Lastly, the tool provides guidance in holding a stakeholder workshop to review the findings and reach consensus on implications and next steps for country activities.

If existing data, particularly on social and behavioral drivers, is not sufficient, is outdated, or does not provide enough insight into priority audiences, it may be necessary to conduct additional primary formative research through quantitative surveys or qualitative research methods such as focus group discussions, key informant interviews, and observation checklists. It may be especially important to conduct formative research around provider attitudes and other drivers to provider behavior, as this information is typically less available. If primary formative research is required, the findings should be analyzed prior to the start of strategy development. Guidance and tools to conduct formative research are provided in the additional resources listed.

The situation analysis has two main sections:

Health and Commodity Context:
An important part of the situation analysis is information on the health situation and the commodity context. This section examines the disease incidence and prevalence of diarrhea and pneumonia, recommended treatment protocols, and issues around amoxicillin and ORS/zinc commodity registration, prices, manufacturing, supply-chains, and point-of-access for end-users.

Audience and Communication Analysis:
The audience and communication analysis examines the social and behavioral drivers that facilitate or act as barriers to uptake of the commodity. Completing this section enables program managers to

1. Determine potential audiences and their characteristics, those who influence them, and the drivers and barriers to behavior change.
2. Identify potential communication resources, including communication channels, ongoing activities, and organizational and professional resources.
3. Assess the environment to determine availability of products and services being promoted, accessibility, affordability and acceptability.
4. Assess the social, economic and political conditions influencing behavior.

Illustrative questions to guide a situation analysis for ORS, zinc and amoxicillin can be found here.

Gender norms, cultural expectations, and roles of males and females within a community may be key barriers to increasing demand for contraceptive implants, emergency contraception, and female condoms. Therefore, it is important to identify gender-related determinants of health behavior during the situation analysis in order to achieve successful program design and implementation.

Addressing the Role of Gender in the Demand for RMNCH Commodities: A Programming Guide provides information and practical tools to help program managers determine how gender norms and roles for both men and women affect the demand for the commodities, and how to address these norms and roles to ultimately increase the demand for and utilization of these commodities. The Guide includes guidance and a checklist on integrating gender into the situation analysis.

After developing a strong situation analysis, program managers should be able to identify the key implications or challenges from the data. What are the reasons that ORS, zinc and amoxicillin are not being utilized? Are the commodities available? Are they affordable? Are they part of the national essential medicines list or standard delivery protocols?  What do potential users – end-user, health care providers, and health educators – believe about the commodity? What is the potential market for commodities? Finally, select only a few key factors that the demand generation strategy will address. While it is tempting to address all factors, successful communication programs focus on the factors that will have the biggest impact given available resources.

Population Services International Global Social Marketing Department offers the following series of questions to guide the the selection of strategic priorities:

Initial segmentation is often based on demographics, such as: age, sex, marital status, education level, socio-economic status, employment, and residence (urban/rural). Audiences can be further segmented by psychographics, which refer to people’s personalities, values, attitudes, interests, and lifestyles.

Audience profiles are the cornerstone of a communication strategy. Audience profiles first help bring to life and personify each audience segment, which subsequently guide communication messaging and activity planning. The profile should embody the characteristics of the specific audience, with a focus on telling the story of an imagined individual within the group who can neutrally represent the intended audience. Basing decisions on a representative, personalized example from a specific audience segment rather than a collection of statistics or a mass of anonymous people allows for more intimate knowledge of that audience segment and better defined and focused communication strategies. Therefore, the profile is important to ensure the messages are tailored to members of this selected group, resonate with them, and motivate them to take action.

Audience profiles for each audience segment are developed using the information collected in the situation analysis. The profile consists of a paragraph that should include details on current behaviors, motivation, emotions, values, and attitudes as well as socio-demographic information such as age, income level, religion, sex, and place of residence. The profile should exemplify the primary barriers to the desired behavior relative to the audience segment. The profile may include the name of this individual or a photo that represents this person to help visualize who this person is and tell his or her story. If the information gathered in the situation analysis lacks detail on a particular audience segment, additional research may need to be conducted to address the identified gaps. For example, for all provider audiences, it may be especially important to conduct formative research around provider attitudes and other drivers to provider behavior that could be used to better inform the audience profile and strategic design.

Characteristics of a good audience profile

• No two profiles will follow the same outline because the same data will not always be available for every 
group in every country.
• The best profiles include qualitative research as a source. Qualitative research will generate a wealth of in-depth audience insight.
• The profile should be a “living document”, meaning it is regularly updated when new information becomes available.

Source: PSI.org

As one of the cornerstones of the communication process, the audience profile helps guide our demand generation planning. For example, when making decisions about communication pieces or commodity distribution strategies, we should continually refer to the audience profile. The profile can aide in answering questions like:

• Where will our target audience learn about ORS, zinc and amoxicillin?
• Would our target audience read this brochure/poster? Where would they encounter it? Where would they read it?
• Where would our target audience want to access child health commodities?
• How would our target audience react to the message in this radio spot or TV advertisement?
• Which of the determinants of behavior can we most effectively address?

Basing decisions on a representative example, the audience profile, from our target audience allows us to better define and focus demand generation strategies.

Source: PSI.org

Communication objectives are measurable statements that clearly and concisely state what the target audience should know (think), what they should believe (feel), and what they should do (behave) as well as the timeframe required for the change. “SMART” objectives are Specific; Measurable; Attainable; Relevant; and Time-bound. Communication objectives should be derived from available evidence on the factors that drive or inhibit adoption by target users, as well as influencing audiences.

Positioning is the heart of the demand generation strategy and identifies the most compelling and unique benefit that the product offers the target audience. Positioning is often the emotional "hook" upon which the demand generation strategy hinges. Effective positioning moves beyond the functional benefits of the commodity and appeals to the target audience with emotional benefits.

Positioning presents the desired behavior in a way that is both persuasive and appealing to the target audience. It provides direction for developing a memorable identity, shapes the development of messages, and helps determine the communication channels to be used. Positioning ensures that messages have a consistent voice and that all planned activities reinforce each other for a cumulative effect.

As part of the positioning, a key promise is identified that highlights the main benefit associated with the proposed change. Changes in behavior, policies, and social norms are made only because there is a perceived benefit to those changes. The benefit must outweigh the personal cost of the change.

An accompanying support statement, also called a “reason to believe” in marketing, describes why the audience should believe the promise. This could be based on data, peer testimonials, a statement from a reliable source, or a demonstration. The key promise and support statement should include a balance of emotion and reason.

Key Messages outline the core information that will be conveyed to audiences in all materials and activities. Messages cut across all channels, and must reinforce each other across these channels. When all approaches communicate iterative and harmonized key messages, effectiveness increases. Well-designed messages are specific to the audience of interest, and clearly reflect both a specific behavioral determinant and positioning. They also clearly describe the desired behavior, which must be “doable” for the audience. Key messages are not the text that appears in print materials (taglines), or the words that are used to define a campaign (slogans). Creative professionals are often hired to translate key messages into a creative brief, which is a document for creative agencies or internal teams that guides the development of communication materials or media products, including taglines and slogans.

It is important that key messages are always:

• Developed on the basis of country-specific formative research;
• Derived from context-specific, strategic choices regarding segmentation, targeting, and positioning;
• Addressed to known drivers of and barriers to behavior change in the country context; and

Pre-tested with the target audience and refined based on audience engagement.

Mass media includes radio, television, print (newspapers and magazines), and outdoor signage (billboards, advertising on buses and taxis, etc.). Mass media is an excellent option to reach a wide audience, although it can be expensive and cost of production and purchase of airtime must be factored into budgeting. Television allows for storytelling, demonstrations of the desired behavior and, when well done, a TV spot can be highly memorable.  In some countries television reaches all socio-economic sectors, while in other countries TV is a luxury. Radio can also reach a wide audience, allow for storytelling and be memorable, especially when messages are linked with songs or jingles. In some countries, radio stations are targeted to specific audiences, which may be helpful when selecting the best ways to reach audience segments. Radio is typically less expensive than TV.

The effectiveness of print media varies widely by country and literacy rates must be considered. Print can be effective for advocacy efforts, especially when selecting newspapers read by decision-makers. Outdoor advertising reaches audiences based on geography and not based on demographics. The audience reached will likely see the message repeatedly if they pass by the outdoor media regularly.

Given the wide reach of mass media, with the potential to reach thousands of people, a small to moderate effect size will have a greater impact on public health than would an approach that has a large effect size but only reaches a small number of people. Thus mass media can have a major public health impact given its wide reach, when done well. However, not all messages are appropriate for all media, and may for example, be better suited to interpersonal communication or other channels.

Illustrative activities in the mass media domain are provided in the illustrative examples. Materials from mass media campaigns and other tools are also available in the additional resources.

Information and Communication Technologies (ICTs) are electronic, digital technologies that enable the creation and exchange of information. ICTs provide the platform for new media, such as web-based applications and social media sites, which, in comparison to traditional media like radio or television, are interactive and empowering. Given the global proliferation of mobile and wireless technologies, ICTs and new media have the potential to transform health communication and service delivery. ICTs and new media offer methods for connecting and mobilizing consumers and providers – even those living in hard-to-reach areas – and reaching them with up-to-date health information.

Examples of demand generation programs utilizing ICT and new media are presented in “Utilizing ICT in Demand Generation for Reproductive, Maternal, Newborn and Child Health: Three Case Studies and Recommendations for Future Programming” which presents key program design elements, evaluation data and lessons learned. Other tools and examples on the use of ICT and new media are also available in the additional resources.

Demand generation activities focused on clinics, pharmacies and drug shops can be targeted both to providers and to clients. Effective activities targeting providers include medical detailing, provider training, and supportive supervision. For clients, the most common demand generation activity is high quality counseling. Additional activities targeted to clients include clinic-based small group education sessions and availability of print materials such as brochures and posters.

Counseling is a critical demand generation activity in clinics because the environment is ideal for communicating key messages.  Counseling sessions are often one-to-one communication opportunities, which allow clients to ask questions and providers to tailor the information and key messages. Second, health care providers are typically trusted and influential sources of information, which lends credibility to the key messages. Counseling tools or job aids can be part of a demand generation plan, and are used to help clients and counselors improve their interactions. Service providers should be trained to use the tools and aids.

Illustrative activities in clinics, pharmacies and drug shops are provided in the illustrative examples. Materials from such activities and other tools are also available in the additional resources.

Community-based services and outreach are an excellent option for increasing demand for ORS, zinc and amoxicillin among hard to reach audiences.  At the outset, it is important to note the differences between community-based services and community-based communication efforts, even though both approaches share many similarities.

Community-based outreach is generally face-to-face interaction with a target audience that aims to generate demand for commodities or services, or to change behavior. Community-based outreach can be conducted through interpersonal communication (IPC) in one-to-one or one-to-group counseling. Job aids such as flip charts and brochures are helpful communication tools for IPC workers, when they are culturally appropriate and designed to accommodate literacy levels, and their development or adaptation should be included in demand generation plans that contain IPC activities. Another community-based outreach approach is community mobilization, which is the process of bringing people together to share a vision, promote dialogue, build their capacity and take collective actions to address problems affecting the entire community. It makes people feel that they are a member of a community even if they are not directly affected by the issue.

Community-based services are the provision of health care services in communities, outside of clinics. Most community-based service programs include an IPC strategy to generate demand for the services. In countries such as El Salvador, the ministry of health transports primary health center staff to communities to offer prevention and basic treatment, with referrals to facilities for more complex services. In Madagascar, community health workers distribute ORS and zinc, Artemisinin-based Combination Therapy (ACT) for malaria and other medicines in order to increase access to treatment for people unable to easily reach health centers.

Recent studies are showing that community-based services are effective for improving outcomes in health areas as diverse as post-partum hemorrhage and childhood pneumonia. Incorporating community-based strategies into a demand generation plan can be an effective if community-based services are permitted in the context where you work. If community-based services are not permitted, you may consider adding advocacy for this strategy to the demand generation plan.

Illustrative activities in community-based services and outreach are provided in the illustrative examples. Materials from such activities and other tools are also available in the additional resources.

Structural approaches for demand generation include development and/or dissemination of policy and guidelines, advocacy with decision-makers, and pre-service training for providers. Scaling Up Lifesaving Commodities for Women, Children, and Newborns: An Advocacy Toolkit  provides advocacy resources for utilizing the Commission platform to raise awareness and engage stakeholders in addressing commodity-related gaps in policy.

Illustrative activities for structural interventions are provided in the illustrative examples below. Materials from such activities and other tools are also available in the additional resources.

Communication campaigns will be most successful when they link with programs that have an impact on demand. For child health communication campaigns two important program linkages are efforts to train health care providers to offer ORS, zinc and amoxicillin, and supply and distribution initiatives to ensure the availability of the commodities. The following are examples of additional programs to which demand generation programs should develop linkages:

• Other child health programs that do not currently include ORS and zinc
• Quality of care improvement initiatives for service providers/clinics
• Pre-service education and existing continuing education or in-service refresher training initiatives for clinical and non-clinical providers
• Supply chain management and market shaping
• Cross-sectoral programs (e.g. water and sanitation, education, economic empowerment, transport)

Public Private Partnerships (PPPs) are sometimes an appropriate and effective way to increase resources, expand revenue streams, increase visibility and expand credibility for demand generation programs. Successful partnerships are engaging and mutually beneficial for both parties and consider the other partner’s relative comparative strengths. Each partner brings expertise to the table, but also each has constraints and competing demands, as well as opportunities to be explored.

“"The P for Partnership": Addressing the Role of Public Private Partnerships to Increase the Demand for RMNCH Commodities provides information and practical tools to help program managers determine how to develop PPPs to ultimately increase the demand for and utilization of these commodities. This tool provides a typology of PPP models along with step-by-step guidelines on how to select private sector companies and how to create effective partnerships for demand generation programs. By utilizing this tool, managers will be better equipped to engage the private sector and understand various types of partnerships for demand generation.

Other tools and examples on PPPs are also available in the additional resources.

Low cost option

The low cost option will make use of existing data sources and opportunities to gain insight into the program and its associations with changes in demand or uptake of zinc and ORS.  However, it will only allow for the identification of trends and will not allow for the attribution of change to a given program or to program activities. Illustrative data sources for a low cost option include:

• Formative research for key messages, positioning, development of materials and media choice (focus groups with intended audiences and in-depth interviews with members of primary and influencing audiences)
• Evaluation of communication campaigns (focus groups with intended audiences; in-depth interviews with primary and influencing audience members; adding questions to omnibus surveys on campaigns, messages and activities)
• Service statistics (Information from clinics and providers such as referral cards and attendance sheets)
• Communication channel statistics (Information from television or radio stations on listenership of mass media activities)
• Omnibus surveys (Addition of questions related to program exposure and impact to omnibus surveys)
• Provider self reported data (Small scale surveys among providers about services rendered and prescription practices; small-scale retail audits among pharmacies and rural drug shops on medicines requested and offered)
• Demographic and Health surveys (Trends in child health and care-seeking approximately every five years)

High cost option

The high cost option will make use of representative program-specific surveys and other data collection methods to gain considerable insight into the effects of the program and the way in which it worked. Illustrative data sources for a high cost option include:

• Formative research for key messages, positioning, development of materials and media choice (focus groups; in-depth interviews; photo narrative or observation with families or inside clinics, pharmacies, or with CHWs to observe and record)
• Service statistics (Information from clinics and providers such as referral cards and attendance sheets)
• Communication channel statistics (Information from television or radio stations on listenership of mass media activities)
• Provider self-reported data (about services rendered, product and sales audits among wholesalers and government procurement agencies; retail audits at pharmacies and drug shops to check medicines requested and rendered)
• Large, nationally representative program-specific surveys (focus on issues related to knowledge, perceptions, acceptability and use) – may include baseline survey, follow-up and endline to measure changes and outcomes
• Client exit interviews (to assess whether caregivers were prescribed ORS and zinc, whether counseling and health education took place, whether other medicines were prescribed, and user satisfaction with services delivered including their perceptions, experience and intentions)

M&E indicators should include process, output, outcome and impact indicators:

Process indicators: Measure the extent to which demand creation activities were implemented as planned.

Program Output Indicators: Measure (a) changes in audiences’ opportunity, ability and motivation to use the commodity, and (b) the extent to which these changes correlate with program exposure

Behavioral Outcome Indicators: Measure (a) changes in audiences’ behavior, and (b) the extent to which these changes correlate with program exposure

Health Impact Indicators: Measure changes in health outcomes

To increase the utility of M&E data, indicators should be disaggregated to facilitate more in-depth analysis of program performance.  It is recommended that indicators are disaggregated by, for example, gender, geographic location, type of provider etc.

Common biases that programmers should be aware of when designing, implementing and interpreting M&E include:

• Self-selection bias – for example, an individual who has seen their young child survive a diarrheal illness because of ORS and zinc may be more interested and willing to answer a survey about ORS and zinc use compared to someone who does not believe in the effectiveness of ORS and zinc, or who has lost a child to diarrheal illness.
• Social desirability bias – following exposure to health promotion initiatives, intended audiences may feel pressured to give ‘right answers’ to survey questions, e.g. to report positive attitudes towards a commodity even though they do not really feel that way.  As demand generation interventions are successful at shaping positive social norms, social desirability bias may become more of a challenge in M&E.