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Trends and opportunities in Zinc & ORS

for diarrhea treatment

across multi-country formative assessments
Kendra Siekmans 1, Marion Roche 2, Jacqueline Kungu 2, Rachelle Desrochers 1,
Abdul Aziz Adish 2, Deepika Chaudhery 2, S. Kaushik 2
1 HealthBridge; 2 Micronutrient Initiative

INTRODUCTION RESULTS Caregivers & Family Members

Diarrhea remains the second greatest cause of childhood mortality in developing Behaviour: Seek treatment for all types of diarrhea within 2 d of diarrhea onset
Revised diarrhea treatment guidelines (WHO 2004): ORS + Zinc supplements
Internal Practical/logical to first treat child at
Need for higher coverage & utilization: currently 1/3 receive ORS & 5% zinc (UNICEF 2012) home Previous positive experience with case
Belief that different types of diarrhea resolution (i.e. treatment believed to have
based on local typology need different worked)
OBJECTIVES treatment
External Distance to facility, time, cost
Free medicines for diarrhea treatment
To identify global and context-specific challenges and opportunities to inform the Accessibility of local pharmacies/CHWs
design and implementation of zinc & ORS programs for the treatment of Relational Family members strong influence to
diarrhea. treat at home or traditional healer Positive experience previously with HCP
Low support & encouragement
To identify key barriers at the caregiver, health care provider, community and
institutional levels that need to be overcome and existing enabling factors that can be Behaviour: Use Zinc & ORS for 10 days to treat child diarrhea
built upon to increase coverage, utilization and adherence of zinc & ORS for BARRIERS ENABLERS
treatment of child diarrhea. Internal Belief: mild cases are best treated with home
Understand importance of replenishing
fluids & traditional /herbal medicines
Low to no awareness of zinc for diarrhea
Mod-high level of awareness for ORS
METHODS Belief: antibiotics/anti-diarrheals required
Zinc users recall positive impression of
to stop the diarrhea
Belief: stop treatment when diarrhea stops
STEP 1: Conduct formative research in 9 countries
External Lack of access to zinc & ORS distance, Community-based sources of Zinc & ORS
ASIA: Afghanistan, Bangladesh, India, Indonesia, Nepal stockouts, insufficient number given more convenient

AFRICA: Ethiopia, Kenya, Nigeria, Senegal Relational Varied level of trust in HCP
Dependence on others for purchase of
prescribed amount and instructions Broad social support for ORS
Multiple research methods Different messages from different sources
Qualitative inquiry in-depth interviews, Focus Group Discussions, observation (nurse vs. pharmacist vs. CHW)
Household & health facility surveys

Multiple target groups: Caregivers of children <5 y, Fathers, Grandmothers, Example of local typology of child diarrhea, Indonesia (adapted from Fahmida and Wibowo, 2011)
Community health workers, Formal & informal health care providers Actual health Perceived Perceived Perceived Pattern of
problem cause(s) problem health need care-seeking

STEP 2: Review & synthesize data Childhood Health care for No care-seeking
Not illness
Identify internal, external and relational barriers and enablers for key behaviours to development diarrhea not necessary (until severe stage)

increase zinc & ORS use Single treatment

Child Health care (traditional or modern)
diarrhea Illness
for diarrhea
RESULTS Coverage Natural Mixed treatments

Sign of Health care No optimal treatment for

Care-seeking (any source) for child diarrhea Other illness diarrhea but
other illness for other illness
100% single/mixed treatment
% reported seeking care

for other illness





Bangladesh India Indonesia Nepal Ethiopia Kenya Nigeria Senegal
Data confirm inadequacy of child diarrhea treatment practices in all countries
DHS/MICS (Hodgins 2013) MI Research (2011/12)
Care-seeking behaviour motivated by different things in different contexts
Important to understand local typology of beliefs
ORS & Zinc Use for Child Diarrhea Influential family members need to be included in promotion efforts
(Based on caregiver reported action taken during childs most recent diarrhea episode; recall period varied by country) Teething & supernatural causes most difficult to address but essential; prevalent belief in all countries

80% Interventions must target all settings where care & decision-making are made (cf. Colvin 2013)
% used ORS or Zinc

60% Risks & benefits of pairing Zinc & ORS

40% Low use & negative perceptions of ORS
Adding zinc supplements may improve caregiver perception of treatment effectiveness
Confusion re different dosing
0% Mismatch in sources of each in many countries & ongoing basic supply issues
Afghanistan Bangladesh India Indonesia Nepal Ethiopia Kenya Nigeria Senegal Effectiveness to STOP diarrhea is important factor motivating medicine given

Consider role played by middle layer of health care providers (e.g. CHWs);
community-based distribution addresses many of the current barriers
RESULTS Health Care Providers Need for strengthening formal health system function
Provider skills, including counseling
Behaviour: Provide Zinc & ORS as 1st line treatment for child diarrhea Continuous supply of zinc & ORS

Professional opinions & prescribing practices Treating diarrhea with ORS (and in some cases, Zn) REFERENCES
Desire to be responsive to patient demands is the norm in their work environment Colvin CJ et al. (2013) Understanding careseeking for child illness in sub-Saharan Africa... Soc Sci Med 86, 66-78.
Lack of adequate training & supplies Broad access to zinc & ORS at community level Fahmida U. & Wibowo L. (2011) Formative Research on Diarrheal Disease Control Program in East and West Lombok Districts,
West Nusa Tenggara Province. SEAMO Regional Center for Food and Nutrition: Indonesia.
Hodgins S et al. (2013) Understanding where parents take their sick children...Global Health: Science and Practice 1, 328-358.
Behaviour: Counseling to improve adherence UNICEF (2012) Pneumonia and diarrhoea: tackling the deadliest diseases for the world's poorest children.
BARRIERS ENABLERS WHO (2004) Clinical Management of Acute Diarrhoea: WHO/UNICEF Joint Statement.

Inadequate training for counseling skills Currently counsel mothers to give fluids & ORS ACKNOWLEDGEMENTS
Different messages given to different providers Active follow-up at household level
Inadequate info transfer: care-seeker to caregiver Broad population-level knowledge & buy-in We are indebted to the organizations and individuals who conducted the formative research in each country. HealthBridges work was
funded by The Micronutrient Initiative. The Micronutrient Initiatives work is undertaken with the financial support of the
Government of Canada through the Department of Foreign Affairs, Trade and Development (DFATD) and other generous donors.