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In Sync with Zinc
 

In Sync with Zinc

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In Sync with Zinc

In Sync with Zinc

Vicki MacDonald, Abt Associates
Cecilia Kwak, Population Services International

CORE Group Spring Meeting, April 30, 2010

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  • Our program objectives: First, We wanted to make sure that a quality affordable zinc product was widely available through the commercial sector (specifically in private pharmacies and chemist shops) Then we focused on improving caregiver knowledge about zinc along with ORS/ORT as the newly recommended first line treatment for childhood diarrheas and encouraging zinc use for every bout of uncomplicated diarrhea. Finally, we wanted to improve private provider knowledge and change their treatment recommendations away from antibiotics and antidiarrheals—replacing these treatments with zinc, while still encouraging ORS/ORT use.
  • Our three main activities in Nepal focused on: Encouraging three local pharmaceutical firms to produce quality, affordable dispersible zinc tablets and distribute them through their normal commercial channels. Creating a generic communications campaign to educate the public about zinc, raise their awareness, and encourage use. We created a program logo, pictured here, that was used on all communication materials. The campaign encompassed radio and TV spots, billboards, posters, and point-of-sale materials. And, we trained over 8000 public and private providers (including doctors, nurses, chemists and Female Health Care Volunteers).
  • Use RESULTS: 15% of children with diarrhea in the last 2 weeks had been treated with zinc. Our baseline from the DHS in 2006 was less than 1 percent. We were concerned that mothers might substitute zinc for ORS as it was not co-packaged, but our research data shows that 79% of caregivers treating with zinc also treated with ORS or ORT — and 66% treated for the full 10 days. Again, very encouraging results
  • Use RESULTS: 15% of children with diarrhea in the last 2 weeks had been treated with zinc. Our baseline from the DHS in 2006 was less than 1 percent. We were concerned that mothers might substitute zinc for ORS as it was not co-packaged, but our research data shows that 79% of caregivers treating with zinc also treated with ORS or ORT — and 66% treated for the full 10 days. Again, very encouraging results
  • Household survey results. In terms of knowledge of zinc among all caregivers of children under 5: 52% had heard of zinc and knew that it was an appropriate diarrhea treatment. 28 percent knew that zinc needed to be given for 10 days, and 41% knew where to obtain zinc. These are excellent results, given that knowledge is the first step in changing behavior.
  • Zinc can be successfully marketed as an accompaniment to ORS without being co-packaged where ORS is well established and use is relatively high. We need to continue to monitor the behaviors of providers—particularly chemists—and seek to find ways to reduce the use of anti-diarrheals and other pills and syrups There were a number of significant policy lessons learned: Zinc treatment programs are most effective when public and private sector programs are coordinated and working in tandem. While this type of coordination takes time and effort, in the end, the strong public-private partnership that was developed in Nepal, with MOH leadership championing both programs, was a key element in program success
  • This slide shows the impact of exposure to mass media communications (those who heard zinc messages on TV or radio). 98% of those exposed to a zinc message knew that zinc was an appropriate treatment for diarrhea compared to 39% of those who had received the information through another channel. 86% exposed vs 21% of those not exposed to the messages knew that zinc needed to be taken for 10 days.
  • This graph demonstrates the impact of the mass media communications on correct use behaviors which supplement provider education. 38% of those who heard (and recalled) the message about using zinc and ORS together correctly administered zinc with ORS or ORT vs 9% who had not heard a radio or TV message but received advice from a provider 25% of caregivers who had heard the message about treating for 10 days used the zinc for the full 10 days, vs 8 percent of those who had not. And in terms of overall correct use (both ORT/ORS and 10 days) 33% of those who had heard the messages vs 7% who did not treated correctly.
  • Th e household survey results parallel the findings of our Mystery Client Survey: 82% recommended an anti-diarrheal. About 2/3 recommended ORS, Fewer than hoped for (about 30%) recommended zinc as the first line treatment In discussions with chemists, their response was: mothers want the diarrhea to stop TODAY. When told to take the zinc the full 10 days,caregivers’ initially think it will take 10 days for the diarrhea to stop. Work still needs to be done to convince both providers and caregivers of the value of zinc in protecting against further bouts of diarrhea and that antidiarrheals may be harmful for children under 5. The good news is: recommendation for Antibiotic use is low (confirmed in our discussions with chemists)
  • This table shows treatment practices for diarrhea in the past two weeks: This data indicates that both public and private sector providers are providing zinc and that ORS and ORT use is high—even among traditional healers and those who treat at home. The promotion of zinc and early promotion of ORT by the Ministry continues to result in high ORS/ORT use However, the continuing high use of antibiotics, use of antidiarrheals and prescription of other unknown pills and syrups by private sector chemists and doctors are concerning. And, there is still a portion of caregivers who do nothing to treat the diarrhea. 1 Public sector: government hospitals/clinics, PHC centers, health posts, FCHV 2. Private Sector: private hospitals/clinics

In Sync with Zinc In Sync with Zinc Presentation Transcript

    • 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!