The document outlines the implementation of zinc as a treatment for childhood diarrhea, demonstrating its effectiveness in reducing duration and severity when used with ORS/ORT. It details program objectives aimed at increasing access to pediatric zinc, enhancing caregiver and provider knowledge, and performing research to track utilization and behavior change. Key findings highlight challenges in compliance and provider behavior, emphasizing the importance of mass media in promoting zinc use.

1. In Sync with Zinc April 30, 2010 Core Group Meeting

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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%

14. 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%

15. Knowledge about Zinc (Nepal: all respondents)

16. 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.”

17. 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)

18. 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.

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

20. Nepal: Impact of Behavior Change Communications on Zinc Use Behaviors

21. Benin – Impact of Communications

22. 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

23. 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

24. 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%

25. 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%)

26. Thank you!