In Sync with Zinc

In Sync with Zinc
April 30, 2010 Core Group Meeting

Zinc for Treatment of Diarrheas
Field research demonstrates 25% reduction in duration, reduction in severity and protective effect of zinc if taken for 10-14 days
May 2004 WHO/UNICEF issues revised recommendation for the treatment of childhood diarrhea to include zinc in addition to ORT/ORS

Program Objectives
Sustained provision and use of pediatric Zinc in addition to ORS/ORT as the first line treatment for uncomplicated diarrhea for children under 5
Increased access to pediatric Zinc through either commercial supply of pediatric zinc products with local manufacturers producing and marketing their own brands or social marketing imported zinc and ORS products. Improved caregiver knowledge and use so that caregivers provide ORS/ORT together with zinc for uncomplicated diarrhea Improved private provider knowledge and treatment practices

Program Activities
Sustainable Supply : Encourage and support local zinc manufacturing or manage importation of products and develop diarrhea treatment kits (ORS plus zinc).
Improve caregiver knowledge : Radio/TV/billboards/posters/IEC materials and generic communication campaign to reach caregivers of children under five
Improve provider knowledge : Training or sensitization of private sector providers and pharmacists
Generic Campaign Logos

Research Designs
Household surveys conducted after at least one year of implementation
Comparison with DHS in countries with no previous zinc program and no use
Pre- and Post-program surveys in countries with zinc available in market
Operations research comparing different delivery systems with control districts

Indicators
Zinc Use:
% children under five who had diarrhea in the preceding 2 weeks who were treated with zinc
Correct zinc use:
% children under five who had diarrhea in the preceding 2 weeks who were given the correct amount of zinc for age for a full 10 days
ORS/ORT use:
% of children under five who had diarrhea in the preceding 2 weeks who were given ORS/ORT in conjunction with zinc

Indicators
Caregiver Knowledge:
% of caregivers of children under five who know that zinc needs to be administered along with ORS/ORT
% of caregivers of children under five who are aware that zinc is an appropriate treatment for diarrhea
Knowledge/access :
% of caregivers of children under five who know where to obtain zinc
%/# of consumers residing within a specified distance of a zinc treatment product
Source of Supply (Private vs Public)
% children under five who had diarrhea in the preceding 2 weeks who were treated with zinc by source of supply

Indicators
Correct Provider Behavior:
% of drug sellers who recommend zinc treatment along with ORS/ORT as the first line treatment for diarrhea before antibiotics or anti-diarrheals
Not Available from HH survey – need Mystery Client Survey

Purpose of Qualitative Tools Pharmacists/Providers
Formative Phase
How they get information about new products
Background on distribution system
Inputs into materials development (point of sale, counseling tools, detailing materials)
Reactions to new products
Implementation Phase
Feedback on sales and client reactions
Reactions on zinc marketing (cost/margins)
Actual behaviors (mystery client surveys)

Qualitative Tools Caregivers
Formative Phase
Attitudes about diarrhea/terminology
Motivators/demotivators
Experience with ORS/other medications
Sources of medical advice
Experience with zinc use
Ease of Use/Attitudes on effectiveness
Problems (including access and affordability)
Source of Zinc
Feedback on Media messages

Qualitative Tools
Community Sales Agents
Background (role in community health)
Experience in diarrhea case management
Reaction of caregivers to Zinc and ORS
Sales experience
Health Facility
Background information on area and prevalence
Program status in public and private sectors
Social safety net
Training of clinic staff and community agents
Supplies and stock-outs

Research Results
Initial levels of zinc use are encouraging and use of ORS remains high, even in countries where the products are not co-packaged
Compliance with the full 10 day regimen is not as good

Zinc Utilization Results (NEPAL August 2008) ORS use: 68% RHF use: 56%** % all children with diarrhea % zinc users Treated with zinc 15.4% Treated with zinc and ORS/ORT 12.1% 79% Treated with zinc for 10 days or more 10.1% 66%

Zinc Utilization Results (Benin November 2009) ORS use: 40%, RHF: 18% % all children with diarrhea % zinc users Treated with zinc 30.9% Treated with zinc and ORS/ORT 27% 87.5% Treated with zinc for 10 days or more 14.1% 45.7%

Knowledge about Zinc (Nepal: all respondents)

Lessons Learned from Research
Zinc can be successfully marketed as an accompaniment to ORS/ORT, without being co-packaged, in countries with relatively high ORS/ORT use. POUZN messages reinforced this correct behavior by instructing caregivers to “use ORS and Zinc tablets—the most effective diarrhea treatment for children under 5.”

Cross Country Table ----- 14.1 ----- 10.10% ----- Zinc for 10 full days ------ 14.5 ----- na ----- Diarrhea treatment kit ----- 27 ----- 12.10% ----- ORS + Zinc ----- 30.9 ----- 15.40% 0.40% Zinc 72 33 57.7 30 68 61% ORS/RHF/SSS Endline Baseline Endline Baseline Endline Baseline Cambodia (2006 - 2007) Benin (2008 – 2010) Nepal (2006 - 2008)

Lessons Learned
Zinc promotion through mass media has been essential in not only creating demand but in providing consumers with information about zinc, its correct use, and access points. Those who had heard POUZN’s radio or television messages were four times more likely to use zinc during the diarrhea episode, provide the child with ORS along with the zinc and provide the zinc for the full 10 days. Several chemists reported having also seen and heard the media spots, motivating them to obtain stocks of the products.

Impact of Communications: Nepal: Knowledge of Zinc by Exposure to Relevant Messages through Radio and Television

Nepal: Impact of Behavior Change Communications on Zinc Use Behaviors

Benin – Impact of Communications

Challenges
Assuring compliance with 10-14 day regimen is extremely challenging.
Nepal: 15% zinc use but only 66% of those treated for the full 10 days
Benin: 30% use rate but only 46% of those treated for the full 10 days

Challenges
Changing chemists’ and providers’ behaviors, motivating their sale and promotion of zinc to accompany ORS is harder than getting caregivers to change their behaviors. On-going interaction with providers is needed to reinforce messages re: anti-diarrheals or other pills and syrups

Results of Mystery Client Survey (Kathmandu Valley – September 2008) Treatment Recommendations by Chemists Percent Provided counseling before recommending treatment 97% Recommended anti-diarrheal 82% Recommended ORS 63% Recommended Zinc 31% Recommended another pill/syrup 10% Recommended an antibiotic 3%

Treatment by Source of Care (among caregivers with children having diarrhea in last 2 weeks) 23.4% 0.0% 0.0% 2.8% 21.7% Nothing 76.7% 14.8% 7.0% 23.4% 13.4% Home remedy/traditional 45.2% 87.9% 82.2% 49.8% 44.3% Other unknown pills/syrups 68.5% 54.9% 68.1% 67.3% 32.8% Recommended home fluid 0.0% 24.3% 25.3% 21.9% 2.1% Antidiarrheal 0.0% 7.1% 27.1% 12.0% 7.3% Antibiotics 45.2% 61.7% 54.8% 85.2% 49.8% ORS 0.0% 10.4% 10.2% 25.7% 5.3% Zinc Traditional healer (1%) Pharmacy (19%) Private sector (13%) Public sector (42.0%) Home (25.0%)

Thank you!

In Sync with Zinc

by jehill3

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