Sarmila Mazumder Black Fischer Walker www.jogh.org [email protected] Baltimore, MD21205 615 N.WolfeStreet Department ofInternationalHealth of PublicHealth Johns HopkinsUniversityBloomberg School Laura Lamberti Correspondence to: 2 1 Laura MLamberti under–five inUttarPradesh, for thetreatmentofdiarrheaamongchildren Adherence tozincsupplementationguidelines   New ,India Development, SocietyforAppliedStudies, Centre forHealthResearchand Health, Baltimore,MD,USA of PublicHealth,DepartmentInternational Johns HopkinsUniversityBloombergSchool 1 • doi:10.7189/jogh.05.020410 1 , SunitaTaneja 1 , ChristaL 2 , RobertE 2 , oralrehydration salts(ORS),dailyand zincsupplementation 10–14for continuedincludefeeding,low–osmolarityto 2004 guidelines inment evidence, UNICEF and WHO revised the global childhood diarrhea treat yearsbeenhasagewell–documentedof [1-3].responseIn mountingto ducingtheduration andseverity diarrheaof amongchildren underfive Theefficacy and effectiveness of therapeutic zinc supplementation in re Background (standarddeviation (SD) Results associated with caregiver adherence to national guidelines. zinc therapy and built logistic regression models to assess the factors follow–up.tionat We quantified averagethe durationdose and of rial tracking form and were asked to retain all packaging for collec Caregivers were asked to record treatments administered on a picto treatmenttheinstructions onreceived data lectedfromproviders. advised zinc for the treatment of diarrhea. At the initial visit, we col Methods caregivers of zinc–prescribed children. monthsmg/day20agesand7–59formonthsdays) among14for 2–6 ages for mg/day 10 (ie, regimen treatment zinc advised ally UttarPradesh, India,soughtassesswetoadherence nation theto episodeschildrenin under five years age.of selectedIn districts of diarrheal for supplementation zinc of duration and dose mended acute diarrheal episode. anrecovered fromhave to appearschild a oncetreatment minate caregivers,addressingwhilealsotendency caregivers theofter to trainproviders successfullyto communicate dosing instructions to should diarrhea childhood for treatment zinc scale–up to aiming guidance in ensuring adherence to zinc dose and duration. Programs ruralIndia. Ourfindings also highlight the importance of provider nationalzinc treatment guidelines for diarrhea among caregivers in Conclusions with having received appropriate provider instructions. associated highly were days 14 for zinc of continuation and dose appropriateageAdherence 67.3%.to and 30.8% received by was ceiving zinc syrups and tablets respectively, the age appropriate dose continuedtreatment for the complete 14 days. Among children re 1 Caregivers administered zinc for an average of 10.7 days 10.7 of average an for zincadministeredCaregivers We identified and conducted follow–up visits to children There is limited evidence on adherence to the recom Ourresults indicate moderate–to–good adherence to

=

3.9 days;3.9median December 2015 •Vol. 5No. 2• 020410

=

13 days),1347.8%and global journal of health ------

VIEWPOINTSPAPERS PVIEWPOINTSapers for pines and India (Nagpur and ), adherence to zinc fromcRCTs conductedBrazil,Ethiopia,in Egypt, Philip total 14–day zinc dosage [7]. In a study drawing evidence residing in intervention villages received only 7 days of the diarrhea with children average on that reported gladesh 14].Acluster randomized controlled trial (cRCT) in Ban the regimen received by those actually treated with zinc [6- of supplementation have called into question the quality of assessingies adherenceadvisedtheduration anddoseto for diarrhea among children under–five years of age, stud In addition to concerns regarding access to zinc treatment most low– and middle–income countries [5]. in challenge a remainedhas ORS, as well as zinc, of age decadepastscaleattainingtheoverand improved cover countries, zinc treatment has failed to become available at tionaldiarrhea treatment policies ofagrowing number of recommendation and the incorporation of zinc into the na global the Despite [4]. months <6 aged infants for mg/d days with 20 mg/d for children aged 6–59 months and 10 Lamberti etal. giversof children under–five. While coverage surveys cap the zinc treatment protocol among both providers and care only gauge zinc coverage but also the level of adherence to not to designedtherefore be programstreatmentshould diarrhea implemented newly of Evaluations treatment. diarrhea adequate scaling–up of goal the toward pushes communityglobal the asaddressed be should that tions existingthe evidence highlights important research ques herence to therapeutic zinc supplementation for diarrhea, Though there are limited studies assessing the issue of ad istering more than the age appropriate daily zinc dose [13]. (38%)anddosage (55%), with32% caregiversof admin ancewiththe guidelines bothonzinc treatment duration ersofchildren under–five in Kenya reported low compli daily dose of zinc [14]. A cross–sectional study of caregiv (94%),one infant received more than the age appropriate goodgenerally instructionswasdosage compliancewith herence to 14 days of therapeutic zinc was 64% andscale–upzinc whichprojecta inMaliunderway, was though ad totalcommunitiesceived[10].daysin7–8Inzincfor in re childzinc–treated average the andtreatment, of tion project,only 55.8% adhered to the advised 10–day dura evaluation of the Scaling up zinc for young children (SUZY) common among both providers and caregivers. In a 2005 tice adherence to the zinc treatment guidelines may be less Evidence from observational studies suggests that in prac even under controlled research settings. treatmentadherencezinc of levelsmaintaininghigh and studieshighlight the challenges associated with achieving six months post–intervention, respectively [8]. These three decreased from 70% to 61.9% when assessed at three and tion of zinc–treated children receiving the full 14–day dose interventioninIndiafoundthatana, villages propor the December 2015 •Vol. 5No. 2• 020410 ≥ 10days was 83.8% [6]. cRCTA conducted inHary

------2 adherence sub–study Overview of the DAZT project and zinc METHODS tation in rural India. al study to assess adherence to therapeutic zinc supplemen (UP), India. To our knowledge, this is the first observation Zinc and ORS Treatment (DAZT) project in through Alleviation Diarrhea the of evaluation external der–five ruralin India, nested we sub–study a within the herence among caregivers of zinc–prescribed children un effortaddressanto questionInthetreatment zinc of ad appropriate daily dose may pose a risk for zinc toxicity. instructions is important, since ingesting more than the age term.Furthermore, monitoring adherencedosagezinc to on diarrhea morbidity and mortality outcomes in the long– extenttowhich increases incoverage translate into impact course. Therefore, the level of zinc adherence may affect the ment regimens do not confer the same anybenefits course asof zinc,the itadvised is possible that very minimalture theproportionzinc childrenof treatwithdiarrhea whoreceive ogy and assumed the true proportion of adherent zinc– adherent of proportion true the assumed and ogy rural India, we employed the most conservative methodol In the absence of published estimates of zinc adherence in Sample size tehsils of Badaun district in UP. and Badaun the and districtLucknow of tehsils Ganj lal from May through July, 2014 in the Lucknow and Mohan childrenby thispopulation.in studyTheconductedwas tify the average zinc treatment dose and duration received zinc therapy advised by their child’s provider; and to quan theproportion ofcaregivers that adhered tothe course of tional childhood diarrhea treatment guidelines; to estimate zinc dose and duration instructions in agreement with na fold: to estimate the proportion of caregivers who received three– wasobjective main Our India. rural caregiversin dearth of information on zinc treatment adherence among The zinc adherence sub–study was designed to address the censed providers. unli informal, and providers qualified both to zinc and ticalcompaniesORS wereemployedsolicit ofsaletothe arrhea. In the private sector, representatives of pharmaceu thoroughtraining adequatein treatment childhoodof di receivedalsoproviders sectorwhomunity–based public and zinc supplies were made available to facility– and com ORSbrief, publishedelsewhereresultsIn areation [15]. age. A complete description of the intervention and evalu zinc treatment of diarrhea among children 2–59 months of UP from 2011–2014 with the goal of scaling–up ORS and selecteddistrictsof conductedinproject was DAZT The www.jogh.org • doi:10.7189/jogh.04.020410 ------www.jogh.org ing following the diarrheal episode. tracking form and visit was tothe check of purpose on thethe child’sthat told were well–be they visit, follow–up modifyingtheir adherence behavior due to the scheduled caregivers of threat the To reduce process. tracking the generatedcouldbeassess to caregivers’ understanding of tivities (ie, feeding and bathing) such that dummy variables recordtowhichcommonacdailyincluded alsoinslots istered ORS and/or zinc syrup or tablets. The tracking form rienced diarrhea and days on which the child was admin rial tracking form to record days on which the child expe during this period and was also shown how to use a picto packagingfromtreatmentsany administered childtheto the retain to asked was caregiver The criteria. inclusion theinitial visit toall households inwhich childa metthe Interviewersscheduledafterdaysfollow–up 14 visits for received, and the dose/duration of treatment to date. the place of zinc procurement, zinc treatment instructions zinc–treated children were formally interviewed regarding sponses on the youngest. Consenting primary caregivers of hold,the primary caregiver was instructed to base her re rangemonth2–59residedagehousethethechildin in one than more If child. the to administered treatments availableanytreatmentssee packagingasking to orfrom ing, interviewers verified the third enrollment criterion by precedingthe visit. To ensure the accuracy of zinc report visit; 3) receipt of zinc treatment for diarrhea in the 3 days household the precedingdays 7 the in period) 24–hour sode of diarrhea (defined as ≥3 loose or watery stools in a following inclusion criteria: 1) aged 2–59 months; 2) epi within the selected villages to identify children meeting the (PPS) sampling. Trained interviewers visited all households inclusion in the study using probability proportional to size randomlytehsil,eachweselectedruralvillagesIn 12for Data collection remaining tehsils. practices, we allowed the sample size to be made up in the treatment stock–outs or lower than anticipated prescribing unforeseenzincto due tehsil given a childrenscribedin zinc–pre identifying difficulty encountered terviewers across the four included tehsils (ie, 30 per tehsil) but if in requiredthe zinc–prescribedsample120sizeof children sibilityloss–to–follow–up.of We aimedequallyto divide scribed children was inflated to 120 to account for the pos [16]. The resulting sample size requirement of 97 zinc–pre children within 10 percentage points with 95% confidence estimatepointprevalencetheof adherent of zinc–treated calculatesamplethesizerequired generateprecisionto a thispopulation. We used Stata 12.0 statistical software to given our limited knowledge on the outcome of interest in appropriate most the was and requirements size sample treatedchildrenapproachthis50%;be tomaximizes the • doi:10.7189/jogh.04.020410 ------3 days ( 14provider forwhethertheadvisedindicatorzinc of an log odds of continuing zinc for the complete 14 days onto In each of the three models, respectively, we regressed: the provider instructions as the primary explanatory variable. appropriateofreceipt with therapy zinc ofduration and tors associated with adherence to the GoI/IAP advised dose We built three logistic regression models to assess the fac (ie, tabletorsyrup). adherence by age and category zinc product formulation conducted portion of children receiving an age appropriate dose. We apy, the average duration of zinc treatment, and the pro- that adhered to the provider–advised course of zinc ther protocol. We also calculated the proportion of caregivers national the to according trained were providersproject DAZT since adherence of gauge appropriate most the from WHO/UNICEF in the age cut–offs for dose slightly but were differ guidelines these [17,18]; months) 7–59 with 10 mg/d for ages 2–6 months and 20 mg/d for ages Academy of Pediatrics (IAP) (ie, 14 days supplementation Indian the and (GoI) India of Government the by sued recommendationagreementthe in is- with duration and caregivers that received provider instructions on zinc dose of proportionWe the variables. calculated categorical of and medians of continuous variables and the proportions deviations standard means, the calculating by children all of characteristics treatment zinc and episode arrheal software [16]. We summarized the sociodemographic, di 12.0 Stata using analyses data statistical Weconducted Statistical analyses ment. discontinuing reasons for treatand zinc zinc benefits of givers regarding diarrhea treatment preferences, perceived allreserved packaging. Interviewers also questioned care caregiver’s responses by referring to the tracking form and the confirmed and days 14 preceding the during given questionschild’stheon diarrheal episodetreatmentsand interviewerfollow–upadministeredthevisit,theDuring gave such instructions ( provider the whether of indicator an onto dose zinc ate Stata 12.0 [16]. el, we employed the robust cluster estimator of variance in just for correlation in adherence behavior at the tehsil lev indicated by the possession of a BPL card ( of school vs no school), and poor socioeconomic status as sode in number of days, caregiver education (at least 1 year 59 months vs 2–6 months), duration of the diarrheal epi tion of therapy. All models controlled for age category (7– providerwhethertheduracorrectadvised andthedose theageappropriate dosefordays14 onto indicator an of model 1 –tests to assess the statistical equivalence of equivalence statistical the assess to z–tests ); the log odds of receiving the age appropri Zinc adherencefordiarrheatreatmentinchildren December 2015 •Vol. 5No. 2• 020410 model 2 ); the log odds of receiving Table 1 ). To ad ------

VIEWPOINTSPAPERS PVIEWPOINTSapers zinc course procured from the private sector were syrups. from the public sector were in tablet form, and all but one Figure 1. givers were advised to give zinc for 13.8onthe daily daysdose toadminister (SD (100%). Onaverage, care how long to continue the zinc treatment coursetionshowprepareonto andadminister(90.3%), zinc(96.5%), on and ment, but the majority reported receiving provider instruc instructional pamphlet from the provider who advised Onlytreat a small proportion of caregivers (3.5%) received a zinc Reported zinc treatment instructions (89.3%; mulation product(90.2%)tabletsand were mostcommonthe for was purchased. Zinc sulfate was the most commonly used tainedfree charge,of whereas private sector zincproduct 2 Accredited Social Health Activists (ASHAs) (85.8%; community–basedfromacally provider as cadreknown specifiandprocured(88.5%)sector publicthrough the used at the initial household visit. The majority of zinc was Allcaregivers were inpossession ofthezinc supplements Details of zinc treatment characteristics of these children are described in ( criteriainclusion the meetingchildren of caregivers120 theFollow–up (94.2%)ofvisitscompletedwere113 for RESULTS Lamberti etal. December 2015 •Vol. 5No. 2• 020410 Figure1 ). All product procured through the public sector was ob Data collection profile. ). The sociodemographicThe). diarrhealand episode Table 2 Table ). All zinc products obtained obtained products zinc All ).

=

1.2 days); Table 1 Table . ------4 rupees per month [ †Antyodaya cards are issued to the poorest BPL families *Governmentwith of India–issuedincome ration<250 cards for subsidized food and fuel. SD – standard deviation, APL – above poverty line, BPL – below poverty line but one zinc product procured from the private sector was in syrup form. productszincAll obtainedpublicthesectortabletvia wereform; inall syrupformulations.tabletobtainedbothandwascase,zincin one †In *In one case, zinc was procured from both the public and private sectors. Table 1. Table 2. of children with completed follow-up (n (n Family possesses an Antyodaya card† Family possesses a BPL card Family possesses an APL card Socioeconomic indicators:* Median (range) Mean±SD Never attended school Caregiver years of schooling: General Other backward castes Scheduled tribe Scheduled caste Ethnic group: Median (range) Duration (days, mean±SD) Dehydration/ Sunken eyes Lethargic/irritable Vomiting Fever Blood in stool Episode characteristics: Female Male Sex: Median (range) Mean±SD Aged 7–59 months Aged 2–6 months Age of child (in months): Tablets Syrup Zinc formulation:† Zinc gluconate Zinc acetate Zinc sulfate Zinc product: – Chemist – Private provider Private sector place of procurement: – Anganwandi worker or center – Accredited social health activist (ASHA) Public sector place of procurement: Place of zinc procurement:*

=

113) Sociodemographic and diarrheal episode characteristics Description of zinc product and place of procurement Pani ki kami 18 ]. www.jogh.org • doi:10.7189/jogh.04.020410

=

113) 101 (89.3) 13 (11.5) 3 (2.7) 8 (7.1) 102 (90.2) 5 (4.4) 9 (8.0) 14 (12.4) 3 (2.7) 97 (85.8) 100 (88.5) N 13 (11.5) 25 (22.1) 47 (41.6) 5 (0–15) 4.8 44 (39.0) 9 (8.0) 36 (31.9) 2 (1.8) 66 (58.4) 3.0 (1–15) 4.4 71 (62.8) 54 (47.8) 84 (74.3) 40 (35.4) 83 (73.5) 13 (11.5) 65 (57.5) 48 (42.5) 13 (2–59) 17.7 90 (79.7) 23 (20.3) N umber umber

± ±

± 4.5 3.0 (%)

(%) 13.9 www.jogh.org and 47.8% (n 10–14 days and for the complete 14 days by 63.7% (n days, median On average, children received zinc for 10.7 days (SD Reported zinc treatment adherence (n tionzincoftreatment [17,18]. additionIn zinc,to 76.1% according to the GoI/IAP guidelines on both dose and durasyrups.total,In 55.8% (n receivedby 69% treated with tablets and 20% treated with propriate dosage instructions (ie, 1 tablet/d or tablets10mL/d)and syrups, wererespectively. In the older age group, ap 5mL/d) were received by 65% andor tablet/d 33%1/2 of(ie, instructions thosedosage appropriate age,treated with 85.8% for exactly 14 days. Among children 2–6 months of 89.4% were told to continue treatment for 10–14 days and duration of zinc therapy for diarrhea* ¶As indicated by possession of a Below Poverty Line card. §Statistically significant: ‡Statistically significant: dose to be continued for 14 days. †Model 1: provider advised zinc for 14 days; Model 2: provider advised zinc dose appropriate for child’s infantsage; agedModel 2–6 months3: providerand 20 mg/10 advisedmL for childrenage appropriateaged 7–59 months. *Government of India/India Academy of Pediatrics guidelines advise zinc supplementation for 14 days in the daily tablet/syrup dose of 10 mg/5mL for Table 3. stratified by age, 92.9% of caregivers of children ≤6months caregivers72 receivedwho appropriateage advice; when the among87.5% instructions wasdosage Adherence to difference was not statistically significant ( with tablets (53.3%) compared to syrups (40.0%) but this to the advised 14 days was higher among children treated tion of treatment by the child’s age ( statistically significant difference in adherence to the dura no was There adhered. 52.6% days, 14 for therapy zinc continuecaregiversprovidersinstructedto97by the Of children. tablet–treated 101 the of 67.3% to and children treated propriate dose was administered to 30.8% of the 13 syrup– Appropriate provider instruction† Outcome Household below poverty line¶ Never attended school ≥1 year schooling Caregiver education: Episode duration (days) 2–6 months 7–59 months Child age:

=

86) were also advised to administer ORS. Factors associated with adherence to Government of India and the Indian Academy of Pediatrics guidelines on the dose and • doi:10.7189/jogh.04.020410

=

=

13 days). Zinc treatment was continued for

54) of caregivers, respectively. The age ap P P

< <

0.05. 0.001.

=

63)caregiversof were advised 6.43 (3.09–13.37)‡ 1.01 (0.39–2.58) 1.0 1.07 (0.77–1.50) 1.07 (0.99–1.14) 1.0 1.44 (0.65–3.18) Zinc continued for 14 days P

=

0.996). Adherence P M

= odel

0.563). 1

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72) 3.9 Adjusted odds ratio (95% confidence interval) - - - - 5 32.46 (8.06–130.66) ‡ 0.57 (0.24–1.39) 1.0 1.08 (0.47–2.47) 1.00 (0.82–1.22) 1.0 0.29 (0.03–2.54) Age appropriate zinc dose priate provider instructions ( to age appropriate dose were highly associated with appro Continuation of zinc treatment for 14 days and adherence adherence Factors associated with zinc treatment days (adjusted odds ratio, aOR and other factors, the odds of continuing treatment for 14 sessed as separatesessedasoutcomes ( as when duration and dose on guidelines to adherence ucation and household BPL status were not associated with 4.10–24.25). Age category, episode duration, caregiver ed receivedsuch advice from providers (aOR both dose and duration were higher among caregivers on who guidelines GoI/IAP the to adhering of odds the tion, caregiversinstructedamongaccordingly.evated addi In dose for age (aOR terval(CI) group ( weredose–adherent comparedoldertheage86.2% in to syrups (88.2%, syrups to compared (75.0%) tablets of formulation product by ference in adherence to age appropriate dosage instructions and duration,(n 46.0%and caregiversdoseappropriatelyadvised63 both the on Of age category. receivedthedaily doseintended forchildren theinolder months 2–6 agedtablet–treated children(66.7%) 4 and syrup–treated(20.0%) 2 but but, day per dose zinc one so at least once during the episode. instructions.All 86 caregivers told to administer ORS did P M

odel =

0.500). There was no statistically significant dif = 2

3.09–13.37)and of administering the correct P

= = Zinc adherencefordiarrheatreatmentinchildren

0.437). No child received more than more received child No 0.437). 32.46, 95% CI 8.06–130.66) were el December 2015 •Vol. 5No. 2• 020410

= 9.97 (4.10–24.25) ‡ 0.45 (0.22–0.92)§ 1.0 0.86 (0.50–1.48) 1.05 (0.92–1.21) 1.0 0.44 (0.22–0.87)§ Age appropriate zinc dose for 14 days

29) complied with both sets of setsbothcomplied with29) Table 3 Table3

=

6.43; 95% confidence in ). Controlling for age M ; odel Models 1 and 2 andModels 1 3

=

9.97,95% CI ), ------

VIEWPOINTSPAPERS PVIEWPOINTSapers Table 4. Table 5. (18.6%) and severity (5.3%) ( (56.6%) and volume (5.3%), as well as decreased duration of zinc among caregivers included reduced stool frequency syrups (81.4%) and tablets (92%). The perceived benefits for childhood diarrhea (29.2%) compared to ORS (58.4%), Zinc was not frequently reported as the preferred treatment Caregiver perceptions of zinc treatment over vomiting or dislike of taste were not reported at all. tioned by only a small proportion of caregivers,inability(5.1%)theandafford to (3.4%)zinc weremen and concerns zinc was not working (17.0%). Running out of zinc productistering another treatment (27.1%) and the perception that Table 4 asthe main reason for discontinuing zinc therapy (69.5%; thefull 14 days reported the child’s recovery from diarrhea The majority of caregivers who failed to administer zinc for erty line (aOR CI caregivers of children aged 7–59 months (aOR but adherence to both dose and duration was lower among Lamberti etal. (n=113) among caregivers who administered zinc for <14 days (n=59) *Column totals exceed 113 as more than one response was permitted. advised number of days. actuallydayscontinuedmendednumberofthe treatmentthan less for low–up shows the 4 respondents who said they gave zinc for the recom initialvisit tothe total number ofdays zinc was given asassessed atfol †Comparison of the advised duration of treatment as reported during the *Column totals exceed 59 as more than one reported reason was permitted. December 2015 •Vol. 5No. 2• 020410 No benefit reported Acts as a tonic after diarrhea Reduces stool volume Reduces severity of diarrhea Reduces duration of diarrhea Treats/reduces risk of disease or illness Makes child stronger/healthier Good for diarrhea/acts as drug for diarrhea Reduces frequency of stool Child did not like taste of zinc Child vomited Could not afford more zinc supplies Ran out of zinc supplies Zinc was not working Child was given other treatment Child recovered Gave zinc for the advised number of days† Reported reason zinc given for <14 days*

0.22–0.87)and those from households below the pov Reported benefits of zinc among enrolled caregivers Reported reasons for shortened duration of treatment ). Commonly reported reasons also included admin

=

0.45, 95% CI 0.22–0.92) ( Table 5 ). Caregivers also re

Model 3

N 0 0 2 (3.4) 3 (5.1) 10 (17.0) 16 (27.1) 41 (69.5) 4 (6.8) = umber N 18 (15.9) 5 (4.4) 6 (5.3) 6 (5.3) 21 (18.6) 46 (40.7) 46 (40.7) 54 (47.8) 64 (56.6)

0.44, 95% umber (%) ). (%)* ------6 continuingafterdiarrhealzinc symptoms subsided.have for rationale the explain also to but supplementation of to not only counsel caregivers on the appropriate duration ment. In addition, it is important that providers are trained healthbenefits zinc that extendof beyond diarrhea treat general the emphasize should community the in nated appears to have recovered. To this end, messages dissemi clination of caregivers to terminate treatment once a child treatmentregimen, futureprograms mustaddressin the zinc full the receiving children of proportion the crease was discontinued when diarrhea halted [9]. In order to in treatment of both placebo– and zinc–randomized children because analysesper–protocol in included be not could cently published RCT, the majority of participants (73.7%) tionof illness and the advised therapeutic course. In a re days), there is considerable discordance between 3–7 thetypically dura (ie, acute are under–five children among ered from diarrhea. Since the majority of diarrheal episodes to terminate treatment once a child appears to have recov difficultmadedays,numberwhichis oftendency the by lesschallenging thancontinuation zincoffortheadvised Our data indicate that for caregivers, compliance to dose is issues. formulation and are perhaps less likely to encounter recall structions tailored to their child’s specific age and product in dosage of set one only remember to requiredare ers mulation (ie, tablet vs syrup). On the other hand, caregiv complicated by age cut–offs and differences by product for communicatingand/orinstructions,dose zincare which planning.Providers mayexperience difficulty in recalling providers and caregivers and thus critical to future program differentforare challengesadherence zinc the that gests thoseonageappropriate dose (87.5%). This finding sug 14–day duration of zinc treatment (52.6%) was lower than givers for whom adherence to provider instructions on the than syrups. We observed the opposite trend among care ofproviders offered correct dosage instructions on tablets appropriate dose (63.7%). In addition, a higher proportion zinc for 14 days (85.8%) was higher than that advising age Among providers, the proportion advising continuation of tions by caregivers. zinc therapy protocol by providers and to provider instruc GoI/IAPillustratingmoderate–to–good the adherenceto diarrhea in rural India. The overall results are encouraging, to the national guidelines on zinc treatment for childhood Our study sheds light on provider and caregiver adherence DISCUSSION of caregivers were unable to list any benefit of zinc. children healthier and stronger (40.7%). However, 15.9% diarrheaforgood(47.8%) makesisportedzinc andthat www.jogh.org • doi:10.7189/jogh.04.020410 ------www.jogh.org ORSand zinc in rural India. Moreover, provider trainings tureprograms shouldcontinue simultaneous scale–upof reported being instructed to administer ORS complied. Fu interfere with adherence to ORS [6,8], as all caregivers who Our findings confirm reports that zinc treatment does not tion to caregivers. ofagecut–offs andability tocommunicate such informa approachcould potentially maximize providers’ retention This doses. syrup/tablet zinc four the of each of ration sualdemonstrations andhands–on practice theinprepa infants.youngciallyProvidersfor benefit mightfrom vi ofproviders inthe complex zinc dosage guidelines, espe rheatreatment programs should ensure adequate training children.intendedolderdoseforceivedtheFuture diar re age of months 2–6day, infantsper six dose but zinc not find any evidence of children receiving more than one well–trained.Weprovidersareensuring did of portance the diarrhea treatment advice of providers and thus the im underscoresitcalas thewillingness caregiversof heedto theage appropriate dose for 14 days. This finding is criti er zinc treatment instructions and the odds a child received We observed a strong correlation between receipt of prop child’s overall health. fordiarrhea treatment and perceive zinc asbeneficial a to in increasing the proportions of caregivers who prefer zinc and convalescence [6,19]. These strategies should succeed messages that promote the use of zinc during both diarrhea Formative research should be conducted to identify salient • doi:10.7189/jogh.04.020410 no conflict of interest. mje.org/coi_disclosure.pdf (available on request from the corresponding author). The authors report Competinginterests: script. CFW and REB designed the study and contributed to the analysespreparation.designedstudy,SMtheand ST and oversawcollectiondatacontributed manuscriptmanu and the to preparation. Authorshipdeclaration: questions and concerns. addresscouldcontactswho study local fornumbers phone of list a and formconsent the of copy caregivers,a fingerprint in the presence of a witness. All consenting caregivers were provided with a ceduresconsisted readingof theconsent document aloud andobtaining signaturea or, forilliterate questions to ascertain whether the child met the study’s inclusion criteria. The informed consent Trainedprocaregiversadministeringfrombeforeconsentscreeninginformedcollectorsobtained data accuracy.ensureback–translatedto and to Englishtranslatedfromwere forms consent and stitutionalReviewBoard Societytheand Appliedfor Studies Ethical Review Committee. surveyAll Ethical approval: of this publication. Fund for UNICEF. The funding organization did not have any part in data analysisFunding: or the preparation ing organization did not have any part in data analysis or the preparation of this publication. funded by a grant from the Bill and Melinda Gates Foundation Acknowledgments:via the US Fund for UNICEF. The fund This research was funded by a grant from the Bill and Melinda Gates Foundation via the US We received ethical approvals from the Johns Hopkins School of Public Health In The authors would like to thank the data collection team. This researchwas This team. collection data the thank to like would authors The Allauthors havecompleted theUnified Competing Interest form www.icat LML designedstudy,LMLthe conductedmanuscripttheanalysesledthe and ------7 erally high albeit with room for improvement. DAZT program areas, the quality of zinc treatment is gen select within zinc prescribed children among that gest ingsadd to the evidence base on zinc adherence and sug certainpublic–sector outlets[15].Nonetheless, findour to advise zinc treatment in the private–sector and through propensitylowlimitedavailabilitythe stocksand zinc of highlightslargerprogrammatic questionsconcerning the ity of zinc was advised by ASHAs (85.8%). This limitation whichzinc was procured, since the overwhelming major of adherence by the sector or specific provider cadre from This study is also limited by an inability to stratify estimates toring treatment of the episode. employedwe tracking formsassistto caregivers moniin hood of misreporting. To prevent recall issues at follow–up,ative to the timing of the visit, thereby lessening the likeli and thus receipt of zinc instructions occurred recently rel at the first household visit suggests that zinc procurement zinc products and packaging among all enrolled caregivers of Possession visit. household initial the preceding days ring in the last 7 days who were treated with zinc in the 3 ers by restricting inclusion to children with diarrhea occur ration. We reduced the threat of recall bias among caregiv gauge provider instructions on zinc treatment dose and du This study is limited by the reliance on caregiver report to supply chain sustainability and prevention of stock–outs. ucts while program implementers concentrate on ensuring shouldemphasize importancethe advisingof bothprod Zinc adherencefordiarrheatreatmentinchildren December 2015 •Vol. 5No. 2• 020410 ------

VIEWPOINTSPAPERS PVIEWPOINTSapers Lamberti etal. December 2015 •Vol. 5No. 2• 020410

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