Impact monitoring of the national scale up of zinc treatment for childhood diarrhea in Bangladesh: repeat ecologic surveys

Abstract

Background: Zinc treatment of childhood diarrhea has the potential to save 400,000 under-five lives per year in lesser developed countries. In 2004 the World Health Organization (WHO)/UNICEF revised their clinical management of childhood diarrhea guidelines to include zinc. The aim of this study was to monitor the impact of the first national campaign to scale up zinc treatment of childhood diarrhea in Bangladesh.

Methods/findings: Between September 2006 to October 2008 seven repeated ecologic surveys were carried out in four representative population strata: mega-city urban slum and urban nonslum, municipal, and rural. Households of approximately 3,200 children with an active or recent case of diarrhea were enrolled in each survey round. Caretaker awareness of zinc as a treatment for childhood diarrhea by 10 mo following the mass media launch was attained in 90%, 74%, 66%, and 50% of urban nonslum, municipal, urban slum, and rural populations, respectively. By 23 mo into the campaign, approximately 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural under-five children were receiving zinc for the treatment of diarrhea. The scale-up campaign had no adverse effect on the use of oral rehydration salt (ORS).

Conclusions: Long-term monitoring of scale-up programs identifies important gaps in coverage and provides the information necessary to document that intended outcomes are being attained and unintended consequences avoided. The scale-up of zinc treatment of childhood diarrhea rapidly attained widespread awareness, but actual use has lagged behind. Disparities in zinc coverage favoring higher income, urban households were identified, but these were gradually diminished over the two years of follow-up monitoring. The scale up campaign has not had any adverse effect on the use of ORS. Please see later in the article for the Editors' Summary.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1. Summary of the cluster sampling framework for the surveys.

Figure 2. Caretaker awareness of zinc treatment for childhood diarrhea before and up to 23 mo following the onset of the mass media campaign.

Figure 3. The proportion of children receiving zinc treatment by location of household before and up to 23 mo following the onset of the mass media campaign.

Figure 4. Changes in zinc coverage over time by household wealth asset quintile (1 lowest, 5 highest).

Figure 5. Income disparities in receiving zinc treatment as measured by concentration index curves 1–3 mo and 19–23 mo following the onset of the mass media campaign.

Distribution of use of zinc is equal among income levels if the concentration curve coincides with diagonal. During the 1–3 month interval the 60% of poorest households accounted for 28% of the zinc treatments received, while from 19–23 mo they accounted for 46%.

Figure 6. Number of zinc tablets purchased by caregivers during the final survey interval 19–23 mo following the mass media launch.

Figure 7. ORS utilization prior to and over the first 23 mo of the mass media zinc scale-up campaign.