Pre-trial focus group work and findings

Ngombe focus groups - brand

In early 2012, as we were planning the launch of the ColaLife Trial – scheduled for Sep 2012 –  ColaLife was very fortunate to find a local volunteer in Zambia – Dr Beth-Anne Pratt. A social anthropologist with a Postgraduate Diploma in Health Systems Management, Beth has lived and worked in Africa since 1996 and first began working on understanding access to health technologies, in terms of barriers and facilitating factors, in 2006. She also had a keen interest in innovation, and what the private sector could do. So, her experience mapped really well against our need to check our trial plans through Consumer Consultation Groups. Together with our partners Keepers Zambia Foundation (KZF), Beth helped ColaLife develop a market research focus group methodology (this is available to download here: colalife.org/resources) and advised on best practice in child health communication.

With the kit packaging already into several design iterations, and the baseline data collection, to kick off the year-long field trial, due to start in Sep-2012, time was short. So, we decided to research and build on existing materials (known as IEC/BCC in the jargon – Information, Education and Communication/Behaviour Change Communciation) and on market research methods that had already been used successfully in Zambia and elsewhere. Working through our multi-lingual field implementation partner, Keepers Zambia Foundation, we chose to run the customer consultations in the two remote rural trial areas where our distribution and marketing interventions were going to be tested: Kalomo in Southern Province and Katete in Eastern Province.  We also needed to test the methodology in practice. KZF had an existing project running with the community in Ng’ombe Compound, Lusaka, which allowed us to call together a ‘pilot’ group at short notice.

Although prototype designs for the diarrhoea kit were well underway, working with manufacturing partners Pharmanova and packaging experts PIGlobal, there was still time for last minute changes. After an online call-out to health experts in the rehydration field, and some early informal discussions with both potential customers, health stakeholders and local manufacturers, we’d already just decided to switch from the traditional 1 litre ORS sachet and move to a more practical and appropriate amount of rehydration fluid that could be easily measured and mixed at home for one sick child. We already suspected that this design feature might be a more relevant innovation than the concept of piggy-backing on Coca-Cola’s distribution. But what would customers make of the smaller ORS sachet size? Also, we didn’t have a definitive name for the kit yet and, crucially, we hadn’t finalised the Recommended Retail Price. We also wanted to test caregivers’ prior knowledge of ORS and Zinc, their reactions to the kit and their opinions:

  • What aspects of the kits did they find appealing, attractive and desirable?
  • What did they think of the kits’ branding and packaging and what name resonated with them?
  • In what ways did they asses the value – both monetary and non-monetary – of the kit?
  • What would be their willingness to pay for the kits?
  • How well did they understand the kit contents?
  • What suggestions did they have for making the kits more marketable to rural Zambians?

Study Objectives

In spite of the tight timescales, we were confident that with Beth’s expertise, our experience of being ‘fleet of foot’ and our partners’ brilliant flexibility we could respond to focus group timings within our schedule. Our aims were:

  • To assess caregivers’ perceptions and preferences as to the naming, branding and packaging of the kits.
  • To ascertain both social and monetary value and willingness-to-pay in both cash and in kind for such kits.
  • To understand caregiver’s recognition of the components in the kits: ORS – and the smaller sachet format – zinc tablets and soap for hand washing, and to identify where they normally acquire these products.

Sample Population

We wanted to consult with caregivers of under-5 children in Katete and Kalomo Districts. We aimed to work with groups of 6-10 participants, recruited at public venues: markets, health-settings or social gatherings at points like wells, schools and churches.  District Health Office staff, District Community Development staff and other charities/NGOs working in the target areas helped to find and invite suitable people. We aimed to run 10 groups in each district, over 3 weeks in May-2012, each with a trained facilitator and a note-taker who both spoke local language.

Data Collection

Each session consisted of a 60-75 minute discussion.  Data was collected on flip charts and through photographs (with permissions) of group activities.  We took basic information from participants (eg gender, age, age of children, education, work, and village) to identify any potential bias, but we didn’t record names to protect anonymity.

Kits, sample kit contents and other materials were available for participants to explore and group discussions focussed around:

  1. opinion of the kit, its contents, packaging and branding – including the enclosed info-leaflet;
  2. willingness to pay and value;
  3. knowledge of ORS, zinc and soap.

The resources and methods we used are here in full: COTZ Consumer Consultation Group Methodology.pdf

Findings

In the event, we only managed to conduct 4 sessions in each district, with 9 to 12 people in each. There were 82 participants overall (40 in Kalomo, 42 in Katete).

The kit and its contents

84% of all participants identified the container plus its contents as something to treat diarrhoea. Although people understood the concept of a ‘kit’ (ka-kit), without this prompt they more usually (76% of participants) referred to it as a ‘ka-box’ (there being no word for either concept in local languages). Nevertheless, when presented, at the end of the session, with possible brand names, 79% voted for “Kit Yamoyo”, meaning Kit of Life. Participants were offered mock-ups of kits with the following names/brandings:

Tip Top Tummy 5%
Top Tum 18%
Happy & Strong 2%
Kit Yamoyo 79%

“Kit Yamoyo” was preferred by 71% of participants in Eastern Province and 88% of Southern Province. Despite the areas having different local languages, the concept of umoyo/yamoyo (life, health, spirit, life-force) was common to both. The branding featuring a full colour, photo-realistic mother and child was more popular than abstract logos or cartoon depictions.

Focus group materials
Mix and Match names and images used in focus groups

Oral Reyhdration Salts

Overall, there was high recognition of ORS. 94% of group participants had heard previously of ORS, although there was less recognition in Kalomo (87.5%) than in Katete (100%).  (Participants were only asked if they had heard of it, not if they used it, so these figures are not related to potential utilisation of ORS; the latest government’s figures (DHS, 2007) at that time recorded ORS coverage as 60%). In all groups, ORS was clearly identified as something that either treats or prevents diarrhoea. Participants appreciated the colour of the sachet covering and the mixture (orange). Of 82 participants, only 3 commented on the unfamiliar 200ml size of the ORS sachet as being ‘too small’; universally, people are used to a 1 litre sachet (although anecdotally they are not sure how much 1 Litre is*). The demonstration, using the kit pack (ka-box) to measure the water for the sachet, was well-received.

* Addendum (Nov-2016): This was actually later confirmed in the formal household surveys conducted for our Midline and Endline, and our P.I. Dr Rohit Ramchandani wrote about it here

Zinc

Zinc was barely known in our focus groups. Only 3 out of 82 participants had heard of Zinc, all in Katete. When presented with the PedZinc packet, which we used in both the prototype and the trial kit, participants could generally identify it as a medicine, but it was frequently variously misidentified, for example as aspirin or panadol and in several groups it was  misidentified as Coartem or Fansidar (for malaria), as a deworming medicine and – worryingly – as candy.

Soap

The trial kit contained a small bar of soap. All but 4 people (all in Kalomo) could identify it as soap. Due to its small size, most people identified its use as for hand washing (not laundry).

Towards a recommended retail price

By the time the focus groups were run, selecting a ‘trial’ recommended retail price for the kit was an area of prime interest. In the focus group discussions, we separated ‘Willingness’ to pay and ‘Ability’ to pay, to try to separate perceived value and the practical issue of purchase for people who were generally living on a a dollar a day (or less).

Willingness to pay

The average amount that participants were willing to pay across both districts was 12,912 Kwacha, with the most frequent amount mentioned being 10,000 Kwacha (at the time, about USD 2.00). The range was 1,500 Kwacha to 100,000 Kwacha. (The 100,000 should be seen as an outlier as it drags the overall average far up).  Participants who described themselves only as willing to pay 5,000 Kwacha or under for the product represented 17% of the overall total participants (23% in Kalomo). Generally, participants said they would be willing to pay more than 5,000 Kwacha.

Ability to pay

The average amount that participants describe themselves as able to pay across both districts was 11,914 Kwacha, with the most frequent amount being 10,000 Kwacha.  The range was 1,500 Kwacha to 100,000 Kwacha. (Again, 100,000 should be seen as an outlier that drags the overall average far up).  Participants who described themselves only able to pay 5,000 Kwacha or under for the product represented 55% of the overall total participants (68% in Kalomo).

Although in Kalomo (a cattle-owning area) willingness and ability were both higher than in Katete, there were also signs of lower ability to pay amongst poorer families in that district, with 15% of respondents saying they would only be able to pay 1,500 Kwacha.

Conclusions

Given these findings, we selected the preferred name and branding: Kit Yamoyo and the mother and child image. Our manufacturing partner, Pharmanova, agreed to manufacture the smaller size ORS sachets. We felt confident in proceding with the kit containing the smaller ORS sachets, Zinc tablets and soap, but ensured that our training materials – for both community retailers and health workers – focused on correct measuring, mixing and expected consumption of the ORS (using safe water) and a strong emphasis on the recognition and correct use of Zinc over ten days to strengthen the child’s immune system. The inclusion of soap in the kit was emphasised to carry the message of hand washing. Equally, we ensured that the kit leaflet and demonstrations at health centres were clear on these points.

We fixed the recommended retail price for the trial at 5,000 kwacha (about $1 at the time), but included promotional vouchers, to ensure that poorer families could try the kit (alongside the prime voucher aim: to ensure a quick establishment of ‘pull’ in the value chain).**  Our manufacturing partner Pharmanova agreed to meet this target retail price with an ex-factory costing that made the value chain viable, with the intention of reducing costs in the medium term, for example through economies of scale.

** Addendum (Nov-2016):ED: Interestingly, more formal Willingness to Pay work in Oct-Nov 2013 (PDF) and Feb-April 2014 (PDF) independently verified the K5,000/1USD Retail Price Point.

 

2022 Update

Kit Yamoyo has continued to be produced by Pharmanova profitably and sold in Zambia (mainly through Supermarkets and Pharmacies). It is now priced at under 14,000 Kwacha – which is about USD 0.85. So, in spite of inflation, in dollar terms the retail price of Kit Yamoyo in the market has actually gone down, with the economies of scale of local production. However, poverty in Zambia has scarcely improved. In 2010, when we began work in Zambia, an estimated 66% of the population lived on under $1.90 a day  Over a decade later, in 2022, still 64% of Zambians live under $2 a day  putting the purchase of Kit Yamoyo further out of reach. However, due to the work of the trial partnership, a free, government-branded version of Kit Yamoyo, made in Zambia by Pharmanova, is now classed as ‘an essential medicine’, free in government health clinics.