In Sync with ZincIn Sync with Zinc

April 30, 2010Core Group Meeting

Zinc for Treatment of DiarrheasZinc for Treatment of Diarrheas

Field research demonstrates 25% Field research demonstrates 25% reduction in duration, reduction in severity reduction in duration, reduction in severity and protective effect of zinc if taken for 10-and protective effect of zinc if taken for 10-14 days 14 days

May 2004 WHO/UNICEF issues revised May 2004 WHO/UNICEF issues revised recommendation for the treatment of recommendation for the treatment of childhood diarrhea to include zinc in childhood diarrhea to include zinc in addition to ORT/ORSaddition to ORT/ORS

Program ObjectivesProgram ObjectivesSustained provision and use of pediatric Zinc in Sustained provision and use of pediatric Zinc in

addition to ORS/ORT as the first line treatment for addition to ORS/ORT as the first line treatment for uncomplicated diarrhea for children under 5uncomplicated diarrhea for children under 5

Increased Increased accessaccess to pediatric Zinc to pediatric Zinc throughthrough either commercial either commercial supplysupply of pediatric zinc products with local manufacturers of pediatric zinc products with local manufacturers producing and marketing their own brands or social producing and marketing their own brands or social

marketing imported zinc and ORS products.marketing imported zinc and ORS products.

Improved Improved caregiver knowledgecaregiver knowledge and and useuse so that so that caregivers provide ORS/ORT together with zinc for caregivers provide ORS/ORT together with zinc for uncomplicated uncomplicated diarrheadiarrhea

Improved private Improved private providerprovider knowledgeknowledge and and treatmenttreatment practices practices

Program ActivitiesProgram Activities

Sustainable SupplySustainable Supply: Encourage and : Encourage and support local zinc manufacturing or support local zinc manufacturing or manage importation of products and manage importation of products and develop diarrhea treatment kits (ORS plus develop diarrhea treatment kits (ORS plus zinc). zinc).

Improve caregiver knowledgeImprove caregiver knowledge: : Radio/TV/billboards/posters/IEC materials Radio/TV/billboards/posters/IEC materials and generic communication campaign to and generic communication campaign to reach caregivers of children under five reach caregivers of children under five

Improve provider knowledgeImprove provider knowledge: Training : Training or sensitization of private sector providers or sensitization of private sector providers and pharmacists and pharmacists

Generic Campaign Logos

Research DesignsResearch Designs

Household surveys conducted after at Household surveys conducted after at least one year of implementationleast one year of implementation

Comparison with DHS in countries with no Comparison with DHS in countries with no previous zinc program and no useprevious zinc program and no use

Pre- and Post-program surveys in Pre- and Post-program surveys in countries with zinc available in marketcountries with zinc available in market

Operations research comparing different Operations research comparing different delivery systems with control districtsdelivery systems with control districts

IndicatorsIndicators

Zinc Use:Zinc Use: % children under five who had % children under five who had

diarrhea in the preceding 2 weeks diarrhea in the preceding 2 weeks who were treated with zinc who were treated with zinc

Correct zinc use:Correct zinc use: % children under five who had % children under five who had

diarrhea in the preceding 2 weeks diarrhea in the preceding 2 weeks who were given the correct who were given the correct amount of zinc for age for a full 10 amount of zinc for age for a full 10 daysdays

ORS/ORT use:ORS/ORT use: % of children under five who had % of children under five who had

diarrhea in the preceding 2 weeks diarrhea in the preceding 2 weeks who were given ORS/ORT in who were given ORS/ORT in conjunction with zinc conjunction with zinc

IndicatorsIndicatorsCaregiver Knowledge:Caregiver Knowledge: % of caregivers of children under five who know that % of caregivers of children under five who know that

zinc needs to be administered along with ORS/ORT zinc needs to be administered along with ORS/ORT % of caregivers of children under five who are aware % of caregivers of children under five who are aware

that zinc is an appropriate treatment for diarrheathat zinc is an appropriate treatment for diarrheaKnowledge/accessKnowledge/access:: % of caregivers of children under five who know % of caregivers of children under five who know

where to obtain zincwhere to obtain zinc %/# of consumers residing within a specified distance %/# of consumers residing within a specified distance

of a zinc treatment product of a zinc treatment product Source of Supply (Private vs Public)Source of Supply (Private vs Public) % children under five who had diarrhea in the % children under five who had diarrhea in the

preceding 2 weeks who were treated with zinc by preceding 2 weeks who were treated with zinc by source of supply source of supply

IndicatorsIndicators

Correct Provider Behavior:Correct Provider Behavior: % of drug sellers who recommend zinc treatment along % of drug sellers who recommend zinc treatment along

with ORS/ORT as the first line treatment for diarrhea with ORS/ORT as the first line treatment for diarrhea before antibiotics or anti-diarrhealsbefore antibiotics or anti-diarrheals

Not Available from HH survey – need Mystery Client SurveyNot Available from HH survey – need Mystery Client Survey

Purpose of Qualitative ToolsPurpose of Qualitative ToolsPharmacists/ProvidersPharmacists/Providers

Formative PhaseFormative Phase How they get information about new productsHow they get information about new products Background on distribution systemBackground on distribution system Inputs into materials development (point of Inputs into materials development (point of

sale, counseling tools, detailing materials)sale, counseling tools, detailing materials) Reactions to new productsReactions to new productsImplementation PhaseImplementation Phase

Feedback on sales and client reactionsFeedback on sales and client reactionsReactions on zinc marketing (cost/margins)Reactions on zinc marketing (cost/margins)Actual behaviors (mystery client surveys)Actual behaviors (mystery client surveys)

Qualitative ToolsQualitative ToolsCaregiversCaregivers

Formative PhaseFormative Phase Attitudes about diarrhea/terminologyAttitudes about diarrhea/terminology Motivators/demotivatorsMotivators/demotivators Experience with ORS/other medicationsExperience with ORS/other medications Sources of medical adviceSources of medical advice

Experience with zinc useExperience with zinc use Ease of Use/Attitudes on effectivenessEase of Use/Attitudes on effectiveness Problems (including access and affordability)Problems (including access and affordability) Source of ZincSource of Zinc

Feedback on Media messagesFeedback on Media messages

Qualitative ToolsQualitative Tools Community Sales AgentsCommunity Sales Agents

Background (role in community health)Background (role in community health) Experience in diarrhea case managementExperience in diarrhea case management Reaction of caregivers to Zinc and ORSReaction of caregivers to Zinc and ORS Sales experienceSales experience

Health FacilityHealth Facility Background information on area and prevalenceBackground information on area and prevalence Program status in public and private sectorsProgram status in public and private sectors Social safety netSocial safety net Training of clinic staff and community agentsTraining of clinic staff and community agents Supplies and stock-outsSupplies and stock-outs

Research ResultsResearch Results

Initial levels of zinc use are encouraging Initial levels of zinc use are encouraging and use of ORS remains high, even in and use of ORS remains high, even in countries where the products are not co-countries where the products are not co-packagedpackaged

Compliance with the full 10 day regimen is Compliance with the full 10 day regimen is not as goodnot as good

Zinc Utilization ResultsZinc Utilization Results(NEPAL August 2008)(NEPAL August 2008)

% all children % all children with diarrheawith diarrhea

% zinc users% zinc users

Treated with zincTreated with zinc 15.4%15.4%

Treated with zinc and Treated with zinc and ORS/ORTORS/ORT

12.1%12.1% 79%79%

Treated with zinc for Treated with zinc for 10 days or more10 days or more

10.1%10.1% 66%66%

ORS use: 68% RHF use: 56%**

Zinc Utilization ResultsZinc Utilization Results(Benin November 2009)(Benin November 2009)

% all children % all children with diarrheawith diarrhea

% zinc users% zinc users

Treated with zincTreated with zinc 30.9%30.9%

Treated with zinc and Treated with zinc and ORS/ORTORS/ORT

27%27% 87.5%87.5%

Treated with zinc for Treated with zinc for 10 days or more10 days or more

14.1%14.1% 45.7%45.7%

ORS use: 40%, RHF: 18%

Knowledge about ZincKnowledge about Zinc(Nepal: all respondents)(Nepal: all respondents)

51.7%

28.3%

41.1%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Knows that zinc is anappropriate diarrhea

treatment

Knows that need to givezinc for 10 days

Knows where to getzinc

Lessons Learned from Lessons Learned from ResearchResearch

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

Cross Country TableCross Country TableNepal

(2006 - 2008)Benin

(2008 – 2010)Cambodia

(2006 - 2007)

Baseline Endline Baseline Endline Baseline Endline

ORS/RHF/SSS 61% 6868 3030 57.7 33 72

Zinc 0.40% 15.40% ----- 30.9 ----------

ORS + Zinc ---------- 12.10% ----- 27 ----------

Diarrhea treatment kit ---------- na ----- 14.5 ------------

Zinc for 10 full days ---------- 10.10% ----- 14.1 ----------

Lessons LearnedLessons Learned Zinc promotion through mass media has been Zinc promotion through mass media has been

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

Impact of Communications:Impact of Communications:Nepal:Nepal: Knowledge of Zinc by Exposure to Relevant Knowledge of Zinc by Exposure to Relevant

Messages through Radio and TelevisionMessages through Radio and Television

98.2%85.8%

39.3%

20.7%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Know s zinc is an appropriate diarrheatreatment

Know s zinc needs to be taken for 10days

Exposed Not exposed

Nepal: Impact of Behavior Change Nepal: Impact of Behavior Change Communications on Zinc Use BehaviorsCommunications on Zinc Use Behaviors

25.6%33.3%38.5%

7.1%8.0%9.2%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Used zinc along withORS/ORT

Used zinc for 10 days Correct zinc use(ORS/ORT+10 days)

Exposed Not exposed

Benin – Impact of CommunicationsBenin – Impact of Communications

Zinc Use Behavior by Message Exposure - Benin

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

Heard/Saw message aboutdiarrhea treatment with

zinc

Heard/Saw message aboutOrasel-Zinc

Used Zinc

Did not use

ChallengesChallenges

Assuring compliance with 10-14 day Assuring compliance with 10-14 day regimen is extremely challenging.regimen is extremely challenging.

Nepal: 15% zinc use but only 66% of Nepal: 15% zinc use but only 66% of those treated for the full 10 daysthose treated for the full 10 days

Benin: 30% use rate but only 46% of those Benin: 30% use rate but only 46% of those treated for the full 10 daystreated for the full 10 days

ChallengesChallenges

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

Results of Mystery Client Results of Mystery Client SurveySurvey

(Kathmandu Valley – September 2008)(Kathmandu Valley – September 2008)

Treatment Recommendations by ChemistsTreatment Recommendations by Chemists PercentPercent

Provided counseling before recommending Provided counseling before recommending treatmenttreatment

97%97%

Recommended anti-diarrhealRecommended anti-diarrheal 82%82%

Recommended ORSRecommended ORS 63%63%

Recommended ZincRecommended Zinc 31%31%

Recommended another pill/syrupRecommended another pill/syrup 10%10%

Recommended an antibioticRecommended an antibiotic 3%3%

Treatment by Source of CareTreatment by Source of Care(among caregivers with children having diarrhea in last 2 weeks)(among caregivers with children having diarrhea in last 2 weeks)

  Home Home

(25.0%)(25.0%)

Public Public sector sector (42.0%)(42.0%)

Private Private sector sector (13%)(13%)

Pharmacy Pharmacy (19%)(19%)

Traditional Traditional healer healer (1%)(1%)

ZincZinc 5.3%5.3% 25.7%25.7% 10.2%10.2% 10.4%10.4% 0.0%0.0%

ORSORS 49.8%49.8% 85.2%85.2% 54.8%54.8% 61.7%61.7% 45.2%45.2%

AntibioticsAntibiotics 7.3%7.3% 12.0%12.0% 27.1%27.1% 7.1%7.1% 0.0%0.0%

AntidiarrhealAntidiarrheal 2.1%2.1% 21.9%21.9% 25.3%25.3% 24.3%24.3% 0.0%0.0%

Recommended Recommended home fluidhome fluid 32.8%32.8% 67.3%67.3% 68.1%68.1% 54.9%54.9% 68.5%68.5%

Other unknown Other unknown pills/syrupspills/syrups 44.3%44.3% 49.8%49.8% 82.2%82.2% 87.9%87.9% 45.2%45.2%

Home Home remedy/traditionalremedy/traditional 13.4%13.4% 23.4%23.4% 7.0%7.0% 14.8%14.8% 76.7%76.7%

NothingNothing 21.7%21.7% 2.8%2.8% 0.0%0.0% 0.0%0.0% 23.4%23.4%

Thank you!Thank you!