HKI’s Experiences on Social Marketing

of Vitamin A in Indonesia
by: Roy Tjiong, Helen Keller International1

SOMATA (1986-89)
The first social marketing project of HKI Indonesia was the Somata (SOcial MArketing viTamin
A) project in West Sumatra (1986-89), in district of Pariaman with inhabitant over 400,000. The
project achieved to decrease the number of pregnant mothers who believed that eating green leafy
vegetables will cause difficult delivery or that young children do not like green leafy vegetables.
Daily consumption of vitamin A rich-vegetables increased in all target groups: from 19% to 32%
of pregnant mothers, 14% to 33% of nursing mothers, 10 to 21% of infants 5-12 months old, and
from 17% to 27% of children 13-60 months old. The VAC coverage increased from 35 to 58 per
cent, according to the mothers. Project materials included counselling cards, motivational posters,
radio spots, and specially market bags for vegetable sellers (Pollard: 1990). This project was
carried out with full technical support of The Manoff Group, since we did not have in-country
social marketing expert, yet. The project was funded by USAID. Many of the positive
experiences learned were incorporated into the Center for Health Education’s national posyandu
promotion program. The key components of success of this project are: (1) the development of
intervention and message strategies based entirely on consumer attitudes, practices, and
behaviour; (2) the transmission of successfully tested intervention message strategies into mass
and interpersonal media using the commercial advertising experience of brand image definition
and repositioning (expanding the value of Dark Green Leafy Vegetables from eye health to general
health); (3) adding creative solutions specifically to overcome defined and targeted resistance
points; and (4) using a standard commercial mix of radio and “point-of-sale” (the weekly markets).

ROVITA (1988-89)
The ROVITA project is a collaborative project among Department of Health Republic of
Indonesia (the implementor),2 Helen Keller International (management facilitator). The project is
also receiving technical assistance from Academy of Educational Development (AED) through
Healthcom project (1988-89). Through the use of social marketing techniques the project
attempted to promote the appropriate use of oral rehydration therapy (ORT) and vitamin A
supplements to prevent dehydration secondary to diarrhea and blindness due to insufficient
amounts of vitamin A. The project was carried out in the regencies of Jepara and Demak of the
province of Central Java. The total population of these two regencies was approximately 1.5
million with an estimated 230,000 children under five years of age. Like other community
development projects in Indonesia, health promotion efforts rely on village health volunteers
known as kader. The result of the study showed that village health volunteers are more likely to
carry out routine activities.

Lessons learned from ROVITA: the volunteers and health auxiliaries (existing PHC system) offer
a tremendous human resource for efforts that could provide health care and education services for

1
Presented at SEAMEO/TROPMED’s Community Nutrition Training, February 4, 2002.
2
The project relied additionally upon the expertise of Diponegoro University, Central Java as internal evaluator
everyone. Without appropriate and ongoing training and supervision, however, the work
performed by these individuals may prove to be of questionable quality. Without sufficient
reinforcement for their work, volunteers may serve only a minimal amount of time, further
decreasing their effectiveness and increasing the costs of recruitment and training (Reis, et.al.:
1990-91).

Putting into the perspective of the limitation of the health volunteers, it was recommended to focus
the double focus project, ROVITA, to focus only on increasing the coverage of vitamin A capsule
supplementation. It was later renamed as SOMAVITA (Social Marketing Vitamin A) (1989-90).

SOMAVITA I (1989-90)
The SOMAVITA (Social Marketing Vitamin A) Project in Central Java helped increase vitamin A
capsule receipt from 24% to 41% with a posyandu.. The primary target audience was caretakers
(mostly mothers) of children between one and five years of age. Approximately 65 to 80 per cent
of the audience were from low-income groups and lived in rural and semi-urban areas. Only about
one-third of the mothers had completed six years of schooling. The first tier secondary audience -
those who deal most directly with mothers – included kader, a community health volunteers
(usually local mothers), and district health center staff, or puskesmas workers. The project found
that by having special month for the capsule distribution. Logistically for distribution and
campaign it could double the coverage.3 It help to focus the campaign strategy. The message core
of: (1) the product is vitamin A capsule (VAC); (2) it is distributed every February and August; (3)
it is available at the posyandu; (4) it is free; (5) it is for children between the age of one and five;
and (6) vitamin A is for healthy eyes. The awareness of capsules increased from 57 to 60 percent
among all mothers within intervention area, with the largest increases among those living near a
posyandu. Awareness among latter increased beyond 80 per cent, capsule consumption in villages
with posyandu remained near 40 per cent although the number of posyandu may have greatly
increased during that time. No significant changes in awareness of capsule coverage were
recorded in the control area. Interpersonal channels were the most effective means of reaching
mothers. The project was later expanded to the whole province of Central Java (Seidel: 1996).

Lessons learned from Somavita I: the first and foremost was a communication campaign must be
based upon careful audience research and materials pre-testing. Every product has unique aspects
that must be fully investigated from the target audiences’ perspectives. Second, if the basic
communication program messages are concise, memorable, and action oriented, they can be
conveyed through a number of different media. If the media are culturally appropriate, they can be
effectively reinforce each other even if a single channel has a limited reach, however, no
communication program can succeed if the aggregate reach of these media is inadequate. Third,
different media can communicate core messages in unique ways. Radio can convey more
complicated message than a banner, and face-to-face communication can convey yet more detailed
information. Consistency of message and timing of delivery are the heart of an integrated social
marketing activity. Fourth, a communication effort can only be as successful as the capacity of the
service delivery system to satisfy the created demand.

3
The Department of Health pick-up the idea on 1990, and decided to go for semi-annual capsule distribution, that
month of February and August as the month for VAC distribution. A semi annual intervention would fix in the public
mind the association of vitamin A with these months and local health post, or posyandu, where capsules are
distributed.
SOMAVITA II (1991-94)
Building on the project results and lessons learned, the Ministry of Health was designing a
nationwide program, initially targeting the 13 provinces with the highest incidence of vitamin A
deficiency. Television spots were added and a greater emphasis were placed on social
mobilization through local leadership structures and volunteer groups such as PKK (national
women’s organization). Continued on the expansion of the posyandu system also was one of the
focuses of the project. The new project was called SOMAVITA II (Expanding Vitamin A
Supplementation & Nutrition Education for the Prevention and Control of Vitamin A Deficiency)
(1991-1994). With an underlying goal of reducing vitamin A deficiency and resultant mortality
the Somavita Project had 3 main objectives: (1) to increase the capsule consumption rates among
children 1-5, (2) to increase the consumption of vitamin A rich foods among children under fives
in specific areas, and (3) to increase the capacity of local NGOs to implement vitamin A and social
marketing programs. The program focused mainly on capsule distribution, at the same time, the
government therefore launched an effort to develop a long-term strategy of increasing the
production and consumption of vitamin A-rich foods. Previous studies had shown that vitamin
A-rich foods are readily available in Indonesia but are not eaten by the children in sufficient
quantities due to lack of information among caretakers, time constraints, or cultural beliefs.

The Somavita capsule campaigns clearly had a dramatic impact,4 according to DOH national
statistics. Children consumption of vitamin A capsule tripled in less than 3 years. In 1991 at the
start of Somavita , only 20.7 per cent of all Indonesian children aged one through five had received
a capsule in the previous six month period. With the first national campaign in February 1992, this
proportion jumped to 43.4 per cent. By August 1993, overall coverage in the last distribution
period reached 56.2 per cent according to DOH statistics (service-based). An end-line survey of
two of three provinces surveyed as a baseline measure in 1991 (Central Java and West Sumatra)
was conducted in October 1993.5 About 70 per cent of the children receiving capsules were aged
one to three.
Somavita’s pilot projects for promoting dietary change were conducted to develop a model that
could be used on a national scale. Dietary change interventions often focus on investigating on
what is feasible in relatively small geographic areas, two regencies each in Central Java and West
Sumatra, totaling 2.2 million people. The team conducted a qualitative study in a sub-sample of
six villages. Using observation, focus group discussions, and in-depth interviews, the study
assessed ten vitamin A-rich foods in term of their nutritional value, availability, price,
acceptability, and current level of consumption. In Central Java, planners selected eggs. In West
4
Somavita’s capsule promotion messages were broadcast over more than 600 television and radio stations through out
the country, the umbrella mass media campaign was reinforced at 13 high-risk provinces with province specific
messages. All materials used in the national campaign were pre-tested at the provincial level with intended audiences
and revised as indicated. The provincial team (health education staff, and or member of the NGOs who were trained in
the social-marketing workshop) conducted the pretest at the village level. The project provided funds to conduct the
pre-testing. They also developed their own provincial campaign strategy for each six-month capsule distribution with
full technical support from the national team, and they were also provided small grants, USD 2,000 for every six
months. The national team also provided print materials. Leaflet for health workers (47,000 copies), leaflets for
community leaders (124,000 copies), Guidelines for capsule distribution for district health officers (20,000 copies),
Resource Packets for provincial and central health staffs (440 packets), Safe Use of Vitamin A Capsules for district
health officers (20,000 copies), and other print materials.
5
The end-line showed changes in mother’s reports of capsule coverage between 1991 and August 1993 of 20.3 per
cent to 30.6 per cent in West Sumatra and 45.7 per cent to 58 per cent in Central Java (p<0.001)
Sumatra, planners selected amaranth – green leafy vegetable. Message emphasized the benefits of
the recommended foods and the importance of eating them every day. Central Java chief slogan,
NEVER A DAY WITHOUT EGGS, in West Sumatra the message stressed “Amaranth is a good
source of Vitamin A that’s cheap and easy to get”. The provincial nutrition offices in Central Java
and West Sumatra prepared one-year implementation plans for their interventions, the project
provided sub-grants about US$ 10,000 to assist it in carrying out the plans. In Central Java the
provincial health office developed: six individual radio spots, which were broadcast about 60
times in each district, plus a radio spot for family series, broadcast 12 times; a poster for
sub-district health centers; leaflet about eggs and other vitamin A-rich foods for agricultural
extension workers. The public health offices in West Sumatra were also prolific. They produced
several campaign materials: a radio spot - encouraging varied ways to use amaranth in local
dishes, banners for sub-district health centers, a poster for health centers featuring amaranth and
various vitamin A food sources, leaflets for religious leaders; a cassette recording of such a
sermon. A cassette containing traditional music and songs about vitamin A in local language, for
health centers and village health posts (Seidel : 1996)

In June of 1994, rapid end-line surveys in the pilot district provided information on changes in the
target group behaviors. Both provinces saw substantial increases in desired practices since the
baseline a year earlier. In West Sumatra, the percent of surveyed women who reported that their
children had eaten amaranth three of more days in previous week rose from 27 to 48 percent. In
Central Java, the percent of women who reported giving their children eggs three or more days in
previous week jumped from 40 to 77 percent.

Lessons learned from Somavita II, the program demonstrated that governments could bring
vitamin A capsule promotion programs to national scale quickly. A decentralized approach has
better likelihood for sustainability because local agencies gain the skills and confidence to
continue on their own. Training of core groups is essential to the success of this process. The
necessary investment in training and monitoring of these groups saves costs in the long run,
contributes to capacity building, and provides a tangible benefit to participating organization
through skills development and motivation.

SUVITAL - THE CENTRAL JAVA PROJECT (1996-97)

To improve the vitamin A status of the population in Central-Java province, especially of women
and children, three strategies were chosen. Strengthening the delivery of the mother and child
health services; more emphasis on distribution of high-dose vitamin A capsules to women within
one month after delivery; and a social marketing campaign of vitamin A-rich foods. The project
was coordinated by UNICEF Indonesia, in collaboration with the Ministry of Health Indonesia and
Helen Keller International Indonesia. The Micronutrient Initiative Canada funded the project. The
major focus of the project is produce a model social marketing approach for the planning and
implementation of a Vitamin A intervention that can be readily replicated and expanded
nationwide.
The model is based on the successful Somavita II project, the promoting dietary change
component in Central Java (1993-94). The Somavita II project focussed specifically on eggs only,
this project added green leafy vegetables, and the promotional activities were being furthered
refined and expanded to include the entire province (six different ecological zones and 35
regencies), reaching around 35 million population. The project developed a series of media
campaign strategy using the media-mix (radio-spot, banners, flyers, face-to-face communication,
etc. The message was a bowl of vegetables plus an egg everyday will make you healthy and
productive. Several radio spots (Indonesian, Solo, and Banyumas) were developed, which were
broadcast about more than 30,000 times. Plus a TV spot for family series, broadcast 4 times. A
billboard for each regency (35 regencies). Flyers and banners for each health center (30,000
copies of flyers were distributed, and around 2,000 banners). Booklet for caders (including the
Women NGO activists from Al-Hidayah, Muslimat-NU, Muhammadiyah, etc.), stressing on give
more eggs and vegetables to pregnant mothers as early as possible (27,000 copies).
A nutrition surveillance system was set up to monitor both the process and the impact of the social
marketing campaign. Because the aim of the campaign was to increase the consumption of vitamin
A-rich foods, in order to improve vitamin A status and hence reduce morbidity and mortality, the
impact of the campaign is measured at different levels, including food consumption, vitamin A
status and morbidity. Until now, only one evaluation of a social marketing campaign has studied
both its process and its impact (Dr Suttilak Smitassiri, Thailand). That study found an impact on
behavior, a small decline of night-blindness among preschool children, but no impact on serum
retinol concentration.
The nutrition surveillance system in Central-Java was set up to collect data every 3 months from a
total of 7200 households, each round newly selected. Data are collected on general household
characteristics, food production, and food consumption practices, radio and television use and, for
the mother and her youngest child ≤ 36 mo old, vitamin A intake, anthropometrical indices and
morbidity. From a sub-sample of them (n=1440), blood is collected for analysis of concentrations
of hemoglobin and serum retinol. The social marketing campaign started in March 1996, while the
first round of the nutrition surveillance system had been conducted in December 1995 - January
1996. The third round of the surveillance system was conducted in the months June-August 1996.
Before the campaign, baseline results showed relatively low percentage of mothers and children
consuming eggs on a frequent basis, after five months of the campaign. There were far fewer
mothers and children who never eaten egg, and more of them had consumed eggs within the period
of a week (increased from 10% to 22.1%).6 Furthermore, the analysis revealed that there was a
relationship between egg consumption and vitamin A status among the mothers and children in
target population, the data was controlled against vitamin A capsule receipt for children for the last
6 months and socioeconomic status for mothers. A stronger trend toward higher serum retinol
levels when vitamin A intake from animal foods was higher, than vitamin A intake from plant
foods.7 The conclusion of the analysis was serum retinol of children related to both egg
consumption and VAC receipt, egg consumption increased considerably after the campaign

6
The following results were found after analysis of data from round 3. Median vitamin A intake of the women was
339 RE/d (retinol equivalents), with 89% from plant and 11% from animal foods. Median vitamin A intake of the
children, not including vitamin A from breastmilk, was 130 RE/d, with 81% from plant foods and 19% from animal
foods. Mean serum retinol concentration of women and children was 1.33 and 0.92 µmol/L, respectively. Further
analysis of the relationship between vitamin A intake and vitamin A status of the women showed that vitamin A intake
from plant foods was as important for vitamin A status as vitamin A intake from animal foods, although plant foods
contributed 8 times more to vitamin A intake. This emphasizes the importance of having included eggs in the social
marketing campaign.
7
Although vitamin A intake from plant foods was eight times higher, the relationship between vitamin A intake from
plant foods and vitamin A intake from animal foods and vitamin A status was as strong as that between vitamin A
intake from animal foods and vitamin A status.
started.8 9 The message of one bowl of vegetables and an egg a day through the different
media-mix was powerful in shifting the behavior of the target population and banners appeared to
have been an important source of reinforcement of the right information on vitamin A-rich foods.
Of the 75% of the women that had had an egg no longer than a week ago, 20-25% said they had
seen banners, 7-15% had heard radio messages, and <10% had seen posters

Lessons learned from the Central Java Project. Since the ultimate goal of the program was to
reduce morbidity and mortality associated with poor vitamin A status, the intervention should be
based on a sound conceptual framework. It should be carefully monitored against the conceptual
framework (increase the intake of vitamin A-Rich foods, and increase the vitamin A status of the
children and mothers). Animal sources are more effective to improve the vitamin A status, but the
food availability and affordability (economic status) are the determinant factor. Although plant
sources (vegetables) are only 16-23 percent as effective as animal sources, it is more available and
more affordable; furthermore women with home-garden will have more access to consume more
vegetables.

THE LOCALVITA PROJECT (1995-98).

The project is collaboration among the Department of Health of Indonesia, OMNI, USAID and
Helen Keller International. The goal of the project is to improve the survival and health of
Indonesian women in their reproductive years and preschool children by reducing vitamin A
deficiency. The purpose of the project is to strengthen the provincial managements and local
NGOs’ capacity to carry out social marketing campaign to increase the consumption of
micronutrient-rich foods. The project sites comprise three regencies in the provinces South
Sulawesi (Gowa, Pinrang and Bulukumba – control area) and South Kalimantan (Banjarmasin,
Tanah Laut and Martapura – control area). The total population of these six regencies was
approximately 2.4 million with an estimated 400,000 children under five years of age, and more
than 100,000 lactating mothers.
Formative research was conducted by the local team (with technical assistance from the central
team) in order to design the social marketing campaign. Because the effectiveness of vegetables in
improving vitamin A status appears lower than assumed, the feasibility of promoting animal foods

8
Comparison of data from round 1 to data from round 3, showed that the women that reported to never have consumed
eggs had decreased from 4.8 to 0.3%. The proportions that reported to have had eggs in the past week or the past 3 days
had increased from 14.0 to 28.6% and from 25.8 to 34.2%, respectively. For children, the pattern was comparable,
with a more dramatic decline of the group that had never had an egg, from 24.1 to 11.1%.
9
Women's serum retinol concentration (µmol/L) by the last time they consumed an egg, <24 hours ago, 1-3 days ago,
4-7 days ago, >7 days ago was (mean [n]) 1.37 [171], 1.32 [216], 1.31 [175] and 1.24 [57], respectively. When
controlled for socio-economic status, expressed as house size <72 m2 or > 72 m2, the relationship still existed. For
smallest house size serum retinol concentration for the above mentioned groups of egg consumption was 1.33 [74],
1.30 [93], 1.29 [84], and 1.25 [32] µmol/L respectively. For largest house size they were 1.41 [97], 1.34 [123], 1.34
[91], and 1.24 [25] µmol/L respectively. The same positive relationship was found for children by those categories of
egg consumption: 1.01 [83], 0.94 [108], 0.86 [54], and 0.88 [24] µmol/L respectively. When controlled for receiving a
vitamin A capsule, the relationship still existed. For those that received no capsule, serum retinol concentrations were
0.98 [79], 0.91 [73], 0.82 [38] and 0.81 [17] µmol/L respectively. For those that received a high-dose vitamin A
capsule they were 1.07 [30], 0.99 [35], 0.96 [16], and 1.06 [7] µmol/L respectively (note that the last group is very
small), S de Pee et. al: 1999:53, 291.
rich in vitamin A was also investigated, as were appropriate ways of reaching the target
population. Based on the results, the decision was to promote eggs and dark-green leafy
vegetables. The availability of eggs was found to be adequate and most people could afford them.
Dark-green leafy vegetables were found to be available the whole year through and the target
population perceived them as cheap. The local team also developed the campaign strategy with
technical assistance from central team. The media chosen for promoting the consumption of eggs
and vegetables were banners, posters, billboards, shop-blinds, leaflets, stickers, radio spots,
jingles, and "face-to-face" communication with a special motto and slogan. The project provided
seed-fund to support the local campaign around USD 40,000 each province.
In order to monitor changes in food consumption, intake data were collected from mothers and
their under-five children before the start of the campaign in December ’96 -January ’97 and will be
collected again a year after its start. Three kinds of intake data were collected.10 Vitamin A intake
during the previous day, consumption of fruits, vegetables, eggs, fish and industrially produced
foods (salt, sugar, MSG, cooking oil, sweetened condensed milk, snacks, sweets and cookies)
during the past week, and monthly consumption of different brands of noodles (Martini, et.al.:
1997).
Vitamin A intake will be expressed by source: vegetables, fruits, animal foods and fortified
products. This will show the contribution to vitamin A intake by the different food groups and
vitamin A intake can be recalculated based on new information about bioavailability of provitamin
A carotenoids. The data on frequency of intake of different foods will be used to assess the
feasibility of increasing their consumption as a way to increase vitamin A intake, as well as to
identify potential vehicles for vitamin A fortification. The data on noodle consumption will show
what segment of the population currently benefits from the fortification practiced by some
producers of noodles and which brands should be fortified in order to reach other parts of the
population.
The baseline survey revealed that in South Kalimantan the mean age of the mothers was 28.3
years, approximately 9.7 percent of the women and 4.6 percent of their husbands had had less than
three years of education (considered illiterate). Among children aged 1-5 years old, 37.7 percent
were stunted11 and 19.7 percent were wasted12. Also children in this age group. 1.7 percent had a
mid-upper-arm-circumference (MUAC) of less than 12.5 cm. Mean hemoglobin concentration
among the children measured 11.3 g/dl and 35.7 per cent of them were anemic. On the day of the
interview, 2.9 per cent of the children and 0.2 per cent of the mothers were suffering from diarrhea
(point prevalence), whereas 6.5 per cent of the children and 1 per cent of the mothers had suffered
from diarrhea in the previous seven days (period prevalence). Forty-four per cent of the children
had a runny nose and/or were coughing on the day of the interview. In total, 11.9 per cent of the
mothers reported that their child had suffered from measles in the previous 12 months.13 Among
the mothers, dark-green leafy vegetables (DGLV) were the most frequently consumed vitamin
A-rich food item, while among around 40 per cent of the children (aged 1 to 5), eggs as well as
dark-green leafy vegetables were consumed frequently. Among the mothers, it does not seem to be
the frequency of consuming vegetables that should be increased, but rather the quantity. It was
estimated that the amount used per person per day (under-fives accounted for 50%) was around

10
The method is called 24-VASQ
11
with height for age (HAZ-scores) of less than -2SD (Standard Deviation)
12
with weight for age (WAZ-scores) by age less than –2Z
13
When children suffer from measles, their body vitamin A stores decrease rapidly
74g. The fruits that are consumed do not seem to be rich sources of vitamin A as the data on
sources of vitamin A intake show that the percentage of vitamin A intake from fruits was only 1 to
4 per cent. Among both the mothers and children, animal foods were found to be the greatest
source of vitamin A. In LOCALVITA’s other project site in South Sulawesi, vegetables were found
to the greatest source of vitamin A among both mothers and children (HKI: 1997)
Among the households interviewed in South Sulawesi, the majority of main earners, in the
families, were farmers (37%), with ‘businessman’ being the second most common occupation
(20%). The term ‘businessman’ includes traders, entrepreneurs, carpenters and people who make
handicrafts. Twelve per cent of the main earners worked for the government, while the rest were
mostly employed as daily laborers, drivers, sharecroppers and factory workers. Daily laborers
include people who are given work on a daily basis, becak (or trishaw) drivers and boatmen. There
was very little difference among the households in the control district, Bulukumba, as forty-five
per cent of the main earners were farmers, fourteen per cent were businessmen, and nine per cent
worked for the government. Among children aged 1 to 5 years old, almost half (46.9%) were
stunted, while 11 per cent were wasted, 3.9 per cent had a mid-upper-arm circumference (MUAC)
of less than 12.5cm. The mean BMI of the mothers was 21.7kg/m2 and 5.5 per cent of the women
had a BMI greater than 27kg/m2 (the figure that is often used as a cut-off value for obesity in
Indonesia). Mean hemoglobin concentration among the (non-pregnant) women measured
13.1g/dL (grams/deciliter) and 14.3 per cent of them were anemic (with hemoglobin
concentrations of less than 12g/dL). Mean hemoglobin concentration among the children
measured 11.2g/dL and 39.4 per cent of them were anemic (with hemoglobin concentrations of
less than 11g/dL). On the day of the interview, 4.3 per cent of the children and 0.5 per cent of the
mothers were suffering from diarrhea (point prevalence), whereas 9 per cent of the children and
1.3 per cent of the mothers had suffered from diarrhea in the previous seven days (period
prevalence). Twenty-four per cent of the children had a runny nose and/or were coughing on the
day of the interview. In total, 16 per cent of the mothers reported that their child had suffered from
measles in the previous 12 months (HKI: 1997).
Among both the mothers and children (aged 1 to 5 years old), dark-green leafy vegetables were the
most frequently consumed vitamin A-rich food item, followed by fruits, and then eggs. From this,
it can be concluded that the frequency of egg consumption can be increased. For vegetables, it does
not seem to the frequency but the quantity that should be increased. On the question of how many
vegetables the women had prepared during the previous three days, it was estimated that the
amount used per person per day (children under five accounted for 50%) was 85g. The fruits that
are consumed do not seem to be rich sources of vitamin A, as the percentage of vitamin A intake
from fruits was found to be only 2 to 3 per cent (HKI: 1997)
In South Sulawesi, 47.7 per cent of the women reportedly listen to the radio on a regular basis. The
most popular time to tune in was in the morning. Forty-one per cent of the households interviewed
in Gowa, and 20 per cent of those in Bulukumba, owned a television set. However, 71 per cent of
the women were reported to regularly watch television. The most popular times for watching TV
were in the afternoon and early evening. In South Kalimantan, 67.8 per cent of the women
reportedly listen to the radio on a regular basis. The most popular time to tune in was in the
morning. In Banjarmasin, 86.3 per cent of the households owned a TV set, compared to 76.8 per
cent in Martapura. In both districts, 96 per cent of the women regularly watch television. The most
popular times for watching television were in the afternoon and in the evening. In urban South
Kalimantan, where the Tella Novella (South American soap operas dubbed in Indonesian) seemed
to be quite popular, it was found that the preferred TV channels were largely RCTI and SCTV. The
households interviewed in rural Sulawesi, however, appeared to favor the state education channel,
TPI, and Indosiar (HKI: 1997)

Actually, the end-line survey was planned to be conducted on last December 1997 and January
1998, due to the haze (forest fire)14 and prolonged drought, we anticipated that there would be
non-availability of some food-items. Therefore, the end-line survey is cancelled to March and
April 98. Unfortunately, at the end of December 1997 the Indonesian economic was starting to
meltdown, the local currencies plunged to 20% against USD, this is a regional economic
catastrophe. It seems food non-availability (supply side) will be combined with low buying
capacity (demand side), may be the campaign could not achieve the same level of success like in
Central Java. However, the end-line survey will provide us evidence whether the food-based
approach is determined by the political economy.
Lessons learned of Localvita: the program demonstrated that the local team with sufficient
technical assistance could promote the vitamin A-Rich Food at local context with strong support
from the local government and other concerned parties. A decentralized approach has better
likelihood for sustainability because local agencies gain the skills and confidence to continue on
their own. Training of core groups is essential to the success of this process. The necessary
investment in training and monitoring are proven to be more cost effective, contributes to capacity
building, and provides a tangible benefit to participating organization through skills development
and motivation. Furthermore, after SOMATA and SOMAVITA, the central team is confident
enough to provide technical support with in-country technical experts on social marketing.

Acceleration of Vitamin A Coverage (1999-2002)

As Indonesia approaches the new millenium, the fabric of the country has been subjected to
unprecendented pressures for economic, social and political changes. From July 1997 the
economy suffered a steep and severe fall in the currency exchange rate in conjunction to the capital
flight. Following steady 7 to 8 percent growth in the first six years of this decade, Indonesia has
since been mired in its worst recession since the 1960s. Political disturbances in the aftermath of
the financial crisis resulted in the downfall of the New Order government. Popular demands for
political transparency and greater government accountability continue unabated and have provided
the main focus for the mass media over the last two years. The country is going through a period of
deep and wide ranging political transition and great uncertainty. According to World Bank
poverty now claims an estimated 50 million people or 24 per cent of population, undoing a decade
and a half of poverty reduction.

Furthermore the achievements of the last two decades are now threatened by an economic crisis,
the social impact of which remains to be fully assessed. The trend of government expenditures on
health and education (1990-1997), however, is not encouraging. Health expenditure was as low as
3 percent of the central government expenditure (compared with an average of 8 percent in
neighbouring ASEAN countries). Children and women are the most vulnerable members of a

14
Fires in Kalimantan and on Sumatra Island sent haze over the region last year, causing deaths and numerous health
and transportation problems. They were blamed largely on big firms setting fires to clear land. Severe drought
exacerbated the problem. The smog, which blanketed a large swathe of Southeast Asia in 1997, was causing
widespread health and environmental problems.
society undergoing rapid transition.15 The nutritional status of children and women remains a most
pressing concern, and one further aggravated by the economic crisis. Moreover a recent crisis
impact study indicates that malnutrition for both males and females increases sharply for children
aged 6-11 months. The crisis also has dramatically reduced the household intake of micronutrient
rich foods. 16 The re-emergence of vitamin A deficiency is potential threat that bears close
monitoring. The main malnutrition problems and their direct causes are: (1) widespread
deficiencies of micronutrients, notably vitamin A, iodines, iron and possibly zinc; (2) recurrent
infections, widespread parasite infestation, and disease related to poor sanitation and hygiene; (3)
chronic energy deficiency of women and deficiencies of multiple micronutrients resulting in low
pregnancy weight gain, low birth weight and inadequate stores of micronutrients at birth in both
mother and infant; (4) poor initiation and premature termination of exclusive breastfeeding,
exposing the infant unnecessarily to food contamination and infection.
Coping with the crisis starts at family and community levels and ways to support and empower
them will need to be enhanced utilizing the mechanisms put in place through the existing
programme activities at the village level. The focus of the crisis response programme is helping
families and communities to cope with the effects of the crisis on the health, nutrition and
education of those most vulnerable. Revitalization of the posyandu network as an outreach vehicle
of the health and nutrition programme is a valuable and critical asset which needs to be revitalized
and vitamin A capsule distribution will be augmented and expanded to cover also children age
6-11 months with the blue capsule (100,000 IU) and newly delivered mothers with the red capsule
(200.000 IU), special effort to increase the coverage of vitamin A capsule among the urban poor is
also being addressed.

References:
HKI: Localvita: Improvement of maternal and child-survival through promotion of vitamin A-Rich foods, HKI,
OMNI, Depkes RI, USAID, Jakarta, 1996
HKI: GIRLS: Gizi Intervensi kepada Remaja Lokal di Sekolah, HKI, OMNI, Depkes RI, USAID, Jakarta, 1997
HKI: Localvita: Baseline Survey Results: South Kalimantan, HKI, OMNI, Depkes RI, USAID, Jakarta 1997
HKI: Localvita: Baseline Survey Results: South Sulawesi, HKI, OMNI, Depkes RI, USAID, Jakarta 1997
HKI: The Central Java Project: Maternal Postpartum Supplementation, Increased Intake of Vitamin A-Rich Foods
and Early Childhood Survival in Central Java, Special Report, HKI, Depkes RI, Jakarta 1997
HKI: GIRLS: Baseline Survey Results, Project Update, HKI, OMNI, Depkes RI, USAID, Jakarta 1997

15
Before the start of the crisis (June-August 1996), mean BMI among the women in Central Java was 21.5 kg/m2, it
drops significantly to 21.0 kg/m2 (p<0.000)one year after the onset of the crisis (June-August 1998). The prevalence
of low BMI (<18.5 kg/m2) increased significantly from 15.1 percent to 17.5 percent (p<0.000). HKI. Crisis Bulletin
Year I Issue 4, October 1998. Have 30 years of nutritional improvement in Southeast Asia disappeared in one year of
the crisis? HKI & Ministry of Health Republic of Indonesia. Jakarta. October 1998.
16
The success of social marketing campaign on promoting eggs in Central Java (1996-1997) had resulted in increased
dietary intake of vitamin A, improving vitamin A status among their population. Yet, the situation appears to be
deteriorating as the economic crisis bites deeper into the pockets of the larger majority of the population, as high
inflation sends foods prices skyrocketing and mass of lay-offs due to economic collapse pushes greater numbers of
families below the poverty line. HKI. Crisis Bulletin Year 1 Issue 2. October 1998. Re-emergence of the threat of
vitamin A deficiency. HKI and Ministry of Health Republic of Indonesia. Jakarta. October 1998.
IVACG: Nutrition Communications in Vitamin A Program: A Resource Book, IVACG, Washington, 1992
Martini E; Halati S; Mayangsari; de Pee S; Bloem M.W.; Muhilal: Monitoring consumption of vitamin A-Rich Foods,
to evaluate promotion of an increased vitamin A intake in remote provinces of Indonesia, IVACG XCVIII,
Cairo.
McGuire, Judith: Best Practices in Addressing Micronutrient Malnutrition, 1992
Pollard, R: Proyek Social Marketing Vitamin A (Somata) di Sumatra Barat: Laporan Akhir, HKI & Ditzi Depkes RI,
1990
Porter; Novelli : Results & Realities: A Decade of Experience in Communication for Child Survival. A Summary
Report, AED, Washington DC, 1992
Reis, Thomas; Elder, John; Satoto; Kodyat, Benny; Palmer, Anne: An Examination of the Performance and
Motivation of Indonesian Village Health Volunteers, in International Quarterly of Community Health
Education, Vol. 11 (1) 19-27, 1990-91
S de Pee, MW Bloem, R Tjiong, E Martini, Satoto, J. Gorstein, R. Shrimpton, and Muhilal: Who has a high vitamin A
intake from plant foods, but a low serum retinal concentration? Data from women in Indonesia, European
Journal of Clinical Nutrition 1999: 53, 288-297
Seidel, Renata (ed.): Strategies for Promoting Vitamin A: Production, Consumption & Supplementation: Four Case
Studies, AED, Washington DC, 1996
Soekaton A; Bloem M.W.; Satoto; Tjiong, Roy; Muis F; Muhilal; Kodyat, B: Impact of a social marketing program
of the promotion of eggs on vitamin A status of children and women in Central Java, IVACG XCVIII, Cairo
Soekarjo, D; Bloem, MW; de Pee, S; Yip, R; Kodyat, B, Muhilal: Should vitamin A supplementation be included as
part of anemia control program for adolescent girls?: School supplementation program in East Java,
Indonesia, IVACG XCVIII, Cairo