Reaching the goal of Universal Salt Iodization (USI): experience of Uttar Pradesh, India.
BACKGROUND
In 2002, the percentage of households consuming iodized salt in the state of Uttar Pradesh (UP) in India dropped to as low as 6%. This implied that 3.5 million newborns in this non-salt producing state, with 180 million population, were at risk of brain damage unless universal accessibility and consumption of iodized salt was ensured and sustained.


OBJECTIVE
Urgent measures were introduced in 3 phases in the statefor accelerating procurement, distribution and consumption of iodized salt.


METHODS
In the first phase, a study on mapping of salt wholesalers and understanding the salt trading system--including understanding the knowledge, attitudes, and practices of salt traders was undertaken to accelerate efforts to influence availability, marketing, and accessibility of iodized salt. The study revealed that a total of only 344 primary wholesalers supplied salt to the entire state. Of these, 126 wholesalers marketed 80% of salt and were located in only 15 of the total 70 districts of the state. This finding became a very strong basis for the program in phase II, which focused on the critical group of wholesalers and set up a system to frequently interact with them. The salt wholesalers were equipped with Salt Testing Kits (STKs) to ensure adequate iodine content in the salt procured by them and adherence to the legal ban on the sale of non-iodized salt for human consumption. Simultaneously, a "child-to-community" approach was launched through involvement of middle and high school children to create demand and monitor consumption of iodized salt at the household level. Over 217,000 salt samples (about 26,000 samples per quarter) were brought in by school children and tested for iodine content.


RESULTS
The school activities resulted not only in influencing consumption of iodized salt, but also galvanized the entire chain linking consumers, retailers, and wholesalers. In less than 2 years, salt procured with nil iodine decreased from 38% to 15.3%, and salt marketed with adequate iodine level increased from 28.6% to 64.9%. School data revealed an increase in consumption of iodized salt from 6% to 46.7%. In phase 3, additional standardized activities at the school level were included and the program was taken to scale in the state.


CONCLUSIONS
The findings revealed that identification and inclusion of salt wholesalers-not only the salt manufacturers-was important for achieving a rapid positive shift in iodized salt marketing and consumption practices.
Vir
Sheila C
SC
UNICEF India country office, Field Office Lucknow, Uttar Pradesh, India. sheila.vir@gmail.com
Dwivedi
Shraddha
S
Singh
Richa
R
Mukherjee
Ashish
A
D003132:Commerce; D005260:Female; D006043:Goiter, Endemic / Q000517:prevention & control*; D006266:Health Education; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D007194:India / Q000453:epidemiology; D007455:Iodine / Q000008:administration & dosage / Q000172:deficiency*; D008297:Male; D011159:Population Surveillance; D015995:Prevalence; D017673:Sodium Chloride, Dietary / Q000008:administration & dosage*
D017673:Sodium Chloride, Dietary; C034024:iodized salt; D007455:Iodine