Addition of Zinc to the Current Case Management Package of Diarrhea in a Primary Health Care Setting
Condition: Diarrhea; Mortality; Hospitalization
MeSH terms: Diarrhea
Study type: Interventional

Summary: 
      Several studies have shown the beneficial effect of zinc treatment in acute diarrhea. There
      was a significant reduction in duration of the treated episodes and in their severity as
      measured by diarrheal stool output or frequency. Zinc is a potentially important
      immunomodulator or nutraceutical which may have great impact as therapeutic agent in
      conditions like diarrhea and pneumonia. The issue is whether and how zinc should be
      introduced in primary health care programs for treatment of acute diarrhea. A practical,
      sustainable intervention for introduction of zinc as treatment of acute diarrhoea in national
      programs is therefore required. This study aimed to address this issue.
    

Detailed description: 
      This cluster randomized trial aimed at evaluating in a community based controlled
      effectiveness trial whether addition of 2RDA zinc as a therapeutic modality to the current
      case management package for diarrhoea in children aged between 1 month and 5 years, delivered
      through existing channels at village level, resulted in reduction in care seeking from health
      care providers, antibiotic and other drug use and increase in ORS use rates.

      The intervention was being implemented in 6 PHCs; 3 intervention and 3 control.

      Based on the experience of a pilot study and the formative research findings, common sources
      visited by caregivers for care seeking during morbidity were identified. These sources were
      selected as channels in partnership with the local government, to distribute zinc strips and
      ORS packets in intervention sites and only ORS packets in control sites. These channels were
      physicians (at the PHC and private practitioners), the auxiliary nurse midwives (ANMs) and
      Anganwadi workers (AWWs) of the Integrated Child Development Services (ICDS) Scheme. All the
      channels were trained and supplies of zinc strips and ORS packets, and ORS packets only were
      distributed in each pair of PHC in intervention and control sites respectively.
      Recommendations were developed and translated into local vernacular. A poster, incorporating
      these recommendations and pictures of zinc strips and ORS packets, was designed and put up at
      various places in the intervention sites. For outcome measurements, cross sectional surveys
      were conducted at 6 monthly intervals.

      Process evaluation activities, which included observations of different channels and exit
      interviews with mothers after they had visited a channel were conducted.

      In the two groups, zinc was used in 36.5% and 59.8% diarrheal episodes and ORS in 34.8% and
      59.2% episodes in the 4 weeks preceding interviews in intervention areas. In control areas,
      ORS was used in 7.8% and 9.8% episodes. Care seeking for diarrhea, prescription of drugs of
      unknown identity and antibiotics for diarrhea reduced in intervention communities.

      The study demonstrated that an intervention to improve diarrhea management with ORS and zinc
      is feasible and highly acceptable in rural Indian communities. The resulting health benefits
      were substantial and accomplished with a reduction in the cost to families for diarrhea
      treatment from current practices.
    

Intervention name(s): Zinc and ORS; ORS only
Intervention type(s): Drug; Drug
Intervention description(s): Government and private providers and village health workers were trained to prescribe zinc and ORS for use in diarrheal episodes in 1 month to 5 years old children in intervention communities; Promoted routine management of diarrhea in underfive with ORS
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: zinc; diarrhea; cluster randomization; hospitalization