Social Marketing Zinc to Improve Diarrhea Treatment Practices - Findings and Lessons Learned from Cambodia

This 29-page report details the design and implementation of, as well as the results and lessons learned from, an ongoing pilot project to introduce zinc, co-packaged with oral rehydration salts (ORS), through the private sector in selected districts of two provinces of Cambodia. Led by the United States-based Abt Associates’ Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project and funded by the U.S. Agency for International Development (USAID), this evaluation looked at a pilot private sector approach to addressing the health problem of diarrhoea, one of the main causes of childhood morbidity and mortality in low-income settings. This process evaluation was jointly conducted by the POUZN Project and the World Health Organization (WHO) from January 28 to February 9 2007.

As detailed here, in early 2004, WHO and the United Nations Children's Fund (UNICEF) published a joint statement recommending the use of a new formulation of ORS, along with therapeutic doses of zinc, for the treatment of children under the age of 5 during diarrhoea episodes. The new ORS formulation has a lower level of salt and glucose than the standard ORS, resulting in a lower osmolarity of the solution and thereby reducing stool output and vomiting and thus decreasing the likelihood of hospital admission for intravenous therapy due to dehydration. Based on this recommendation, the Cambodian Ministry of Health (MOH) and Population Services International (PSI) decided to introduce the new low-osmolarity ORS and zinc through private sector channels. In March 2006, the MOH and PSI, in coordination with WHO and with financial support from USAID, launched a demonstration project to introduce a diarrhoea treatment kit (DTK) containing both products, branded as OraselKIT®.

Specifically, PSI/Cambodia partnered with the Reproductive and Child Health Alliance (RACHA), a local non-governmental organisation (NGO), and CARE Cambodia in Pursat, and American Red Cross (ARC)/Cambodian Red Cross (CRC) and RACHA in Siem Reap, to distribute the Orasel KIT®. As of this writing, the kit is subsidised to ensure affordability to the vast majority of people, and includes a low-literacy insert designed to provide information to mothers whose children are suffering from dehydration and diarrhoea. To reach health providers, PSI/Cambodia developed a training curriculum in close collaboration with WHO and the Cambodian MOH. A training of trainers programme was launched with NGO partners (RACHA, Care Cambodia, ARC/CRC), who then trained health centre staff, village shop owners, and village health support groups. The programme also trained private healthcare providers, including members of PSI's Sun Quality Health Network clinics, pharmacists, and drug store owners on use of the Orasel KIT® and diarrhoea management. PSI also worked to expand its collaboration with the Cambodian Pediatrician Association to increase awareness of the new guidelines for treatment of diarrhoea among children under 5 years of age. Amongst the communication tools developed to raise this awareness were a television and radio commercial, mobile video shows, a karaoke song video compact disc (VCD), and point of sales materials to increase knowledge of the correct treatment of diarrhoea and to create demand for the Orasel KIT®.

To assess progress of this pilot programme, evaluators used the following methodologies: document review; interviews conducted at the central, provincial, and district levels; field visits; and focus group discussions (FGDs) with female users and nonusers of the kit. They identified the following key lessons:

1. "Packaging ORS and zinc together is an effective means of marketing these products and encouraging their combined use...The result anticipated by caregivers, that is, a decrease in stool output or full stop of diarrhea, is occurring earlier thanks to the new formulation’s lower osmolarity and the administration of zinc. Consequently, caregivers are more open to accepting the combined treatment..."
2. "Distributing the product through village shops and local NGO networks, located in rural and peri-urban communities, is an effective means of increasing access and use in rural communities...Village shops in particular have proved to be important in improving caregiver access to appropriate treatment. Village shopkeepers are also more easily persuaded to recommend the DTK than are clinicians or pharmacists, because they do not have a large variety of alternatives to recommend..."
3. "An ongoing challenge is to change the behavior of clinicians, pharmacists, and drug sellers who continue to sell inappropriate treatments...Continued training of providers along with reinforcement of key messages on the appropriate treatment of diarrhea among consumers, particularly for urban and peri-urban areas, is needed....Emphasis on avoiding unnecessary use of drugs for simple diarrhea needs to be addressed by MOH officials, regulatory agencies, and communication campaigns..."
4. "Without consumer education and regulatory enforcement the availability of dangerous anti-diarrhea products in the marketplace creates a high-risk situation...Given the extent of use of unnecessary drugs, messages for consumers and MOH and pharmacy staff should reinforce that products other than OraselKIT® or other ORS and zinc combinations, are not needed for simple diarrhea (unless it is the ORS alone)."
5. "Mass media combined with the IPC [interpersonal communication] of partners' volunteers, village shopkeepers, and others have resulted in high awareness, improved knowledge, and use of the DTK...Most frequently cited communication channels from which people learn about DTK are the TV spot, radio, village shopkeepers, and NGO volunteers and comedy groups. Partner NGOs developed IEC [information, education, and communication] materials (banners, pamphlets with graphic demonstrations on the use of the product) that are used by shop owners for promotion and education, and by trained provincial- and district-level public health staff, health center volunteers (members of the [village health support group, or] VHSG), village shopkeepers, and community-based care groups in their demonstrations, health days, and health education sessions. Improved health practices are also promoted through home visits and edutainment sessions..."
6. "A strong monitoring and evaluation system, coupled with timely quantitative research, is needed to fully assess the effectiveness of any program that socially markets a new health product...Ongoing monitoring of program progress through implementation of household surveys that actually measure the degree of DTK use, adherence to the recommended length of zinc use, whether zinc is effective in replacing unnecessary medicines, and whether caregivers continue providing recommended home fluids after the two packages of ORS have been used is advisable prior to scaling up a pilot program to the national level..."