Introducing Zinc through the Private Sector in Nepal for the Treatment of Childhood Diarrhea: Results and Lessons Learned

This 16-page report explores the implementation, in Nepal, of a global social marketing initiative for diarrhoeal disease control called Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project. POUZN aimed to create awareness of paediatric zinc treatment, together with pre-packaged oral rehydration salts (ORS) and oral rehydration therapy (ORT), for diarrhoea in children under 5 - and to convert that awareness into purchase and use behaviour. Consumers were also made aware of incorrect treatment for uncomplicated diarrhoea and encouraged not to purchase and use other pills or syrups, including antibiotic or anti-diarrhoeal treatments, without a prescription. POUZN was carried out by Abt Associates in partnership with Population Services International (PSI) and the Government of Nepal, through the Ministry of Health and Population (MOHP)'s Child Health Division. Funding was provided by the United States Agency for International Development (USAID).

As detailed here, during the first phase of the programme (December 2006-September 2007), the project introduced zinc in both the public and private sectors in the districts of Kathmandu, Bhaktapur, and Lalitpur. During Phase I, POUZN worked with 4 Nepalese pharmaceutical manufacturers in an effort to enable them to develop, register, manufacture, and bring to market for sale several paediatric zinc products. A total of 130,000 paediatric zinc treatments were distributed to public sector clinics and 700,000 treatments were sold to retail outlets in the private sector.

National scale-up of the programme to urban and peri-urban areas throughout the country began in October 2007. During Phase II (April-September 2008), the private-sector programme was expanded to an additional 27 public-sector, community-based Integrated Management of Childhood Illness (CB-IMCI) focus districts throughout Nepal.

Behaviour change communication (BCC) messages were developed and aired through mass media designed for public sector employees and private sector providers, pharmacists, and child caregivers in order to increase the use of ORS and paediatric zinc. Specifically, the following campaign materials were developed:

• Generic campaign logo: A number of prospective designs were tested with caregivers and the current logo selected, ensuring that a happy, healthy child was featured. The logo was used on all communication materials produced for the public and private sectors.
• Outdoor materials: POUZN developed large 1x1.5 meter flex boards - a job aid printed on flexible, longer-lasting fabric-based materials for use in outpatient department/clinic waiting rooms. In addition, billboards featuring the logo and the key message "Zinc tablets along with ORS/ORT - the most effective diarrhea treatment for children under 5" were prepared and installed near and/or on the side of district hospitals.
• Radio and television spots: Four radio spots and one television commercial were developed to convey the major messages through discussions featuring a physician, chemist, mother, and health worker. Research was conducted to determine the most popular stations and programmes listened to by caregivers around which to place the spots. Based on this information, POUZN's communications team negotiated contracts with various radio and TV stations.
  

"Provider education is another important key to successfully achieving the behavior change objectives of the program." This strategy reflects organisers' observation that chemist shops are important conduits of information and source of treatments for diarrhoea. Findings from the formative research study in 2006 indicated that chemists had no knowledge of zinc as a treatment for diarrhoea; rather they associated it with a range of nutritional supplements and multivitamins and consistently confused zinc with iron. So, using the zinc programme training curriculum developed by the MOHP, the POUZN team printed and provided to all training participants a manual and a range of informational materials.

Specifically, during Phase I (July 2007), 2,243 public sector personnel (physicians, nurses, and village health workers and volunteers) and 1,660 private sector chemists from the Kathmandu Valley districts were trained. During Phase II, 4,147 private sector chemists from the 27 other CB-IMCI focus districts were trained to understand the rationale behind recommending zinc with ORS/ORT as the first-line treatment for childhood diarrhoea. As part of this training, participants engaged in role playing sessions on how to counsel a mother requesting assistance in treating acute diarrhoea. Local zinc manufacturers also trained their own staff, who regularly meet and engage with both doctors and chemists, in the zinc programme approach and correct messages (including correct dispensing and incorrect dispensing practices) and in encouraging other positive provider behaviours.

Given that the private sector is the primary source of diarrhoea treatments, POUZN sought to ensure that paediatric zinc was available everywhere ORS and other diarrhoea treatments were sold. The programme worked closely with 3 local manufacturers to ensure that the 30 programme districts (the 27 CB-IMCI and the 3 Kathmandu Valley districts), were well covered. According to organisers, "The combination of a competitive market and high visibility communications campaign also led to a desire for manufacturers to ensure product availability." As reported here, an informal survey conducted in 2008 found that zinc products were widely available at outlets in 4 urban/peri-urban areas (Kathmandu, Pokhara, Dumre, and Besi Sahar).

In August and September 2008, POUZN funded a population-based survey among 3,550 households in 26 of the 30 districts. Research findings indicated that 15.4% of children with diarrhoea in the past 2 weeks were treated with zinc. Exposure to mass media messages was found to significantly increase consumers' knowledge of sources where they could obtain zinc (see Table 2, within the document.

Changes in consumer knowledge: 68% of respondents were found to have been exposed to at least one message about diarrhoea treatment. Fifty-three percent of respondents reported that they had heard or seen a message about a zinc product. Of these, 50% had heard a message about zinc on the radio, 85% via the television commercial, and 4% from friends or relatives. Only minimal exposure to zinc messages was received via education sessions, clinic or village health talks, sales agents, posters, newspapers, doctors, chemists, etc. Fifty-two percent of all respondents knew that they should give zinc to children experiencing bouts of diarrhoea. Those exposed to communications messages were more than twice as likely to know that zinc was an appropriate treatment for acute and persistent diarrhoea and/or dehydration and 4 times as likely to know that zinc should be used for 10 days.

Changes in consumer practices: Zinc use increased from 0.4% to 15.4% in the intervention areas. (Table 6 within the document shows the percentage of children with diarrhoea who were given zinc, given zinc along with ORS/ORT, and given zinc for the full 10 days). Data show that 79% of children who were treated with zinc were also given ORS/ORT, and 66% of zinc users correctly used zinc for the full 10 days. Fifty-four percent of caregivers treating with zinc correctly provided ORS/ORT and gave zinc for the full 10 days. While only 2.4% of caregivers from the economically poorest quintile used zinc to treat diarrhea, 27% and 38% of caregivers in the top 2 wealth quintiles used zinc. Eighty percent of caregivers mentioned that they would use ORS/ORT for persistent diarrhoea, 33% mentioned they would use ORS for acute diarrhoea, while only 15% mentioned ORS as a treatment for dehydration. ORS use was widespread among all income/socioeconomic categories - ranging from 58% among the economically poorest quintile to 74% among the richest segment of respondents. Eighty-five percent thought ORS was a "good medicine" and 67.5% actually provided ORS to their child during the bout of diarrhoea. In addition, 56.5% gave their child a recommended home fluid.

Changes in provider behaviour: Two other surveys provide information on the impact of both training and the media campaign on appropriate provider behaviours relative to counseling on and selling zinc and ORS. In September 2008, POUZN commissioned a mystery client survey that was conducted at 114 chemist shops in Kathmandu. During the same month, POUZN partner NPL conducted its own survey at 152 chemist shops in Kathmandu, Pokhara, Dumre, and Besi Sahar. Of these, 141 chemists agreed to be interviewed. The mystery client survey reported that 97% of chemists provided counseling before recommending treatment. In terms of treatments, 82% recommended an anti-diarrhoeal, 63% recommended ORS, 31% recommended zinc, 10% provided another pill/syrup, and 3% gave an antibiotic. The majority of chemists recommended multiple treatments. Only 10% recommended either zinc or zinc and ORS alone. The NPL study looked at knowledge and perceptions of zinc, finding that 65% of chemists knew about zinc either from the media (45%), training programmes (37%), or medical detailing visits (12%).

Based on this research, the organisers find that "Zinc programming (both public and private) shows great promise in improving diarrhea treatment practices." They offer the following lessons learned:

1. "Zinc treatment programs are most effective when public and private sector programs are coordinated, and the relationship between the public and private sectors is collaborative...
2. Local pharmaceutical manufacturers will independently produce high-quality, affordable zinc products and promote them through detailing and development and dissemination of promotional and IEC [information, education, and communication] materials when they see the market potential and government commitment.
3. 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....Several chemists reported having also seen and heard the media spots, motivating them to obtain stocks of the products.
4. Zinc can be successfully marketed as an accompaniment to ORS/ORT, without being co-packaged, in countries with relatively high ORS/ORT use...
5. Mass media is an effective means of changing caregiver and provider behaviors. Behavior change communication messages need to stress the reasons for taking zinc for the entire 10 days...
6. The combination of training and media reinforcement has been only partially effective in changing providers' behaviors....Ongoing reinforcement of the messages and rationale will be essential to long-term program success - particularly given the results of the mystery client survey conducted in Kathmandu in September 2008, which found the majority of chemists recommending anti-diarrheals and not fully conversant in the rationale for use of zinc."