Abt Associates Inc.

SHOPS is funded by the U.S. Agency for International Development.Abt Associates leads the project in collaboration withBanyan GlobalJhpiegoMarie Stopes InternationalMonitor GroupO’Hanlon Health Consulting

Results and lessons learned from household surveys in Nepal, Benin, Madagascar, and Pakistan

Kathryn Banke, Ph.D.Abt Associates

June 1, 2011

Overview

• USAID-funded Social Marketing Plus for Diarrheal Disease Control: Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project

• Background/Methods• Nepal• Benin• Madagascar• Pakistan

• Main findings/results that will be covered:• How do caregivers treat pediatric diarrhea?• Where do caregivers go for treatment?• Are caregivers using zinc correctly?• Is message recall associated with zinc knowledge or use?

Programs

• Nepal• Public sector pilots: 2006• POUZN (w/MOH) pilot in Kathmandu: Jan-Aug 2007• POUZN in 30 districts (out of 75 total): April-August 2008

• Benin• Public sector pilot (2 departments): April 2008 • Pharmaceutical (private & public) & FMCG launch: July 2008

• Madagascar• Limited MOH zinc program began June 2007• ViaSur launched April 2009 (communities)• Hydrazinc launched December 2009 (commercial)

• Pakistan• Pharmaceutical firms marketing pediatric zinc nationwide since 2008• Public sector program through Lady Health Workers began 2009• POUZN demand creation focused on seven districts in two provinces in

2010

Household survey details

Nepal Benin Madagascar Pakistan

Dates Aug-Sept 2008 Nov 2009 March-April 2010 July, Sept. 2010

No. of Households

3550 2912 1200 1725 (pre) and 1713 (post)

No. of children 4211 3854 1200 1725 (pre) and 1713 (post)

No. with diarrhea

289 307 1000 1725 (pre) and 1713 (post)

Age range 0-59 months 0-59 months 6-59 months 0-59 months

Design Cross-sectional Cross-sectional Cross-sectional; programs vs. comparison

Program vs. comparison, pre-and post-intervention

Baseline DHS 2006 DHS 2006 (no zinc)

DHS 2009 July 2010 survey

Household survey methods

Structured questionnaire• Diarrhea treatment practices

• Zinc use, source

• Exposure to messages and media• Knowledge, perceptions related to diarrhea and zinc

Administered to caregivers of children under 5• Nepal & Benin: youngest & next-youngest (if any) child in

house (0-59 mos)• Madagascar: youngest child in house (6-59 mos)• Pakistan: one child in house (0-59 mos)

Weighted analysis (complex sampling designs)

A large number of caregivers in Benin and Madagascar do not seek advice or diarrhea treatment outside the home

010

2030

4050

6070

80

Nepal Benin Madagascar Pakistan

Per

cen

tag

e (%

)

No advice/treatment outside home No treatment

POUZN succeeded in increasing zinc use in Nepal and Benin in a short time

0.4

54

15

31

7

01

23

0

20

40M

adag

asca

r

Nep

al

Ben

in

Pak

ista

n

% o

f c

hild

ren

wit

h d

iarr

he

a

in p

as

t 2

we

ek

s t

rea

ted

wit

h z

inc

Baseline

Survey

Apr ‘08–Nov ‘09Apr ‘07 – Aug ‘08

Dec ‘09 – Apr ‘10July ‘10–Sept ‘10

Among zinc users, zinc with ORS/ORT use high; correct zinc use for 10 days still needs attention

Note: analysis restricted to respondents who used zinc for diarrhea episode in past 2 weeks

0%10%20%30%40%50%60%70%80%90%

100%

Nepal

Benin

Mad

agas

car

Pakis

tan

Pe

rce

nta

ge

(%

) o

f re

sp

on

de

nts

Used zinc with ORS/ORT

Used zinc for at least 10days

Caregivers use other treatments, regardless of zinc/ORS promotion and marketing

0%10%20%30%40%50%60%70%80%90%

Pe

rce

nta

ge

(%

) o

f re

sp

on

de

nts

ORS/ORT

Antibiotics

Antidiarrheals

Homefluids/increasedfluids

Unknown pill orsyrup

Greater reliance on public sector for zinc in Benin & Madagascar, private sector for Nepal and Pakistan

Note: In Nepal and Benin, POUZN supplied product to the public sector.

0%10%20%30%40%50%60%70%80%90%

100%

Nepal

Benin

Mad

agas

car

Pakis

tanP

erce

nta

ge

(%)

of

resp

on

den

ts

Public health clinics/ posts

Private sector

Hospitals

Community healthworker/ female volunteer

Community sales agent

Other

Nepal: Message recall associated with zinc knowledge

86%

98%

39%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Knows zinc is anappropriate

diarrhea treatment

Knows zinc needsto be taken for 10

days

% w

ith

sp

ecif

ic k

no

wle

dg

e

Recalled message

Did not recallmessage

Benin: Message recall associated with zinc knowledge

83%82%

28% 31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OraselZincmessage

Diarrheatreatment withzinc message%

of

care

giv

ers

agre

ein

g t

hat

zin

c is

an

ap

pro

pri

ate

or

effe

ctiv

e d

iarr

hea

tr

eatm

ent Recalled message

Did not recallmessage

Benin: Message recall associated with zinc use

74.1

21.8

68.4

19.2

0

10

20

30

40

50

60

70

80

Heard zincmessage

Did not hearzinc message

HeardOraselZincmessage

Did not hearOraselZincmessage

Per

cen

tag

e (%

) o

f re

spo

nd

ents

wh

o

use

d z

inc

41%

2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Heard zinc message Did not hear zinc message

Pro

po

rtio

n o

f ca

reg

iver

s w

ho

use

d z

inc

(%)

Pakistan: Message recall associated with zinc use

Pediatric diarrhea treatment – summary

• Zinc use low but growing• Caregivers go to public sector in Benin and Madagascar,

private sector in Nepal and Pakistan• No evidence that zinc displaces ORS/ORT• High proportion of zinc users also use ORS/ORT, but

many do not use zinc for full 10 days• Mean: 6-8 days of use

• Use of antibiotics, antidiarrheals, other pills/syrups requires more understanding

• Exposure to zinc messages associated with zinc knowledge and use

Abt Associates Inc.

SHOPS is funded by the U.S. Agency for International Development.Abt Associates leads the project in collaboration withBanyan GlobalJhpiegoMarie Stopes InternationalMonitor GroupO’Hanlon Health Consulting

Kathryn_banke@abtassoc.com

www.shopsproject.org