1. Abt Associates Inc. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’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

2. 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?

3. 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

4. Household survey details NepalBeninMadagascarPakistan DatesAug-Sept 2008Nov 2009March-April 2010July, Sept. 2010 No. of Households 3550291212001725 (pre) and 1713 (post) No. of children4211385412001725 (pre) and 1713 (post) No. with diarrhea 28930710001725 (pre) and 1713 (post) Age range0-59 months 6-59 months0-59 months DesignCross-sectional Cross-sectional; programs vs. comparison Program vs. comparison, pre- and post- intervention BaselineDHS 2006DHS 2006 (no zinc) DHS 2009July 2010 survey

5. 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)

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

7. POUZN succeeded in increasing zinc use in Nepal and Benin in a short time Apr ‘08–Nov ‘09 Apr ‘07 – Aug ‘08 Dec ‘09 – Apr ‘10 July ‘10–Sept ‘10

8. 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

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

10. 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.

11. Nepal: Message recall associated with zinc knowledge

12. Benin: Message recall associated with zinc knowledge

13. Benin: Message recall associated with zinc use

14. Pakistan: Message recall associated with zinc use

15. 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

16. Abt Associates Inc. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Kathryn_banke@abtassoc.com www.shopsproject.org