Differential response at the village level to introduction of combination therapy for malaria and zi

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Differential response at the village level to
introduction of combination therapy for malaria
and zinc for diarrhoea in Sikasso Region, Mali
SCALING UP ZINC THE WAY FORWARD Sasakawa
Auditorium, ICDDR,B, 6-7 May 2007

• Peter Winch, pwinch_at_jhsph.edu

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Overview

• Background on principles of Diffusion of
  Innovations
• Contrast experiences with introduction of ACTs
  for malaria and zinc for diarrhoea in rural Mali
• Relate these experiences to principles of
  Diffusion of Innovations

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Diffusion of Innovations
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Diffusion of innovations

• Zinc for diarrhoea is an innovation
• There is a large body of literature on diffusion
  of innovations
• Why some innovations diffuse and others do not
• Factors that affect how quickly innovations are
  adopted
• Who is likely to adopt quickly or slowly
• Everett M. Rogers is most well-known scholar in
  this field

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A nutritional intervention that diffused slowly

• 1601 Captain Lancaster tests lemon juice (Vit.
  C) as treatment for scurvy in sailors
• 1 intervention and 3 comparison ships sailing
  from England to India
• Sailors on the intervention ship got 3 teaspoons
  of lemon juice daily
• By halfway through voyage, 100 of 278 sailors on
  comparison ships had died

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A nutritional intervention that diffused slowly

• 1601 Captain Lancaster tests lemon juice as
  treatment for scurvy in sailors
• 1747 James Lind, British Navy physician, does
  confirmatory study on effects of orange and lemon
  juice vs. 5 other treatment regimens
• 1795 British Navy adopts policy for preventing
  scurvy on long sea voyages
• 1865 British Board of Trade adopts same policy
  for the merchant marine

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We are working to not repeat experience with
Vitamin C for scurvy

• On-going research and dissemination of results
• Dialogue with policymakers and incorporation of
  zinc into official policies
• Collaboration with manufacturers on production
• Social marketing
• Distribution through many provider types
• Monitoring and evaluation

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S Curve Cumulative adoption of the intervention
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S Curve Cumulative adoption of the intervention
Proportion of children with diarrhoea treated
with zinc
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Question 1 about S Curve How long does it take?
t ?
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Question 2 about S Curve Where does it level
off?
20? 80?
Final population coverage ?
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Characteristics of innovations that affect their
diffusion/adoption

• Relative advantage Is it better than what is
  used currently?
• Compatibility with values and needs of potential
  adopters
• Complexity How difficult is it to understand and
  use?
• Trialability Can people try it out before
  deciding to adopt it?
• Observability Can the benefits be readily
  observed?

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Two innovations being introduced in Africa ACTs
and Zinc
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Two innovations being introduced in Africa ACTs
and Zinc
Artemisinin Combination Therapy (ACT) for malaria
e.g. Coartem
Dispersible zinc tablets for diarrhoea
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Introduction of zinc and ACTs at community-level
in Mali
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Contributors to different phases of this work

• Save the Children Eric Swedberg, Dian Sidibe,
  Houleyemata Diarra, Modibo Kante, Aïssata Male
• University of Bamako Adama Diawara, Seydou
  Doumbia
• Johns Hopkins University Kate Gilroy, Robert
  Black
• WHO/Geneva Olivier Fontaine
• Funding USAID and WHO

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Introduction of zinc and ACTs at community-level
in Mali

• CCM infrastructure throughout Sikasso Regional
  put in place by Save the Children by several
  projects, most recently CS-20
• Save the Children in collaboration with
  University of Bamako and JHU conducting
  operational research on
• ACT introduction at community level in Kolondieba
  District (USAID/GRA funds)
• Zinc introduction at community level in Bougouni
  District (WHO USAID/GRA)

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Effect of introduction of new treatments at
different levels

• Introduction of new treatments has much greater
  effect at community level (village drug kits)
  than at first level facilities (community health
  centers)
• Distance is major factor
• 48 lt10 km from health center
• 40 11-25 km from health center
• 12 gt25 km from health center

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Effects of introduction of new products on
careseeking

• ACT gt Zinc Effect of ACT introduction on
  careseeking is greater than zinc at both
  community level and first-level facilities
• Effect of ACT on careseeking is sustained, while
  effect of zinc tends to decrease after a few
  months

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Zinc in Bougouni vs ACTs in Kolondieba

• ACTs in Kolondieba
• Initial round of community meetings and radio
  announcements was sufficient to lead to large,
  sustained increase in careseeking

• Zinc in Bougouni
• Similar initial round of meetings, home visits,
  radio etc. was insufficient, only modest
  increases in careseeking
• Needed second more intensive round to achieve
  objectives

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First round of zinc promotion

• Meetings with village leaders
• Meetings at neighbourhood level
• Home visits by CHWs to promote zinc and ORS
• Counselling at time of visits to village drug kits

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Second round of zinc promotion

• Large all-day community events
• Banners, posters
• Music
• Diarrhea riddles and prizes
• Effective, but questions about whether this
  approach can be taken to scale due to effort
  required

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Diarrhea day in zinc project
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Prizes for winners of diarrhea riddle
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Monthly zinc sales at first-level health
facilities in Bougouni District, Mali
2nd round of promotion
1st round of promotion
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Monthly zinc sales at village drug kitsin
Bougouni District, Mali
2nd round of promotion
1st round of promotion
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Why the differences in community response to
introduction of ACTs and zinc?
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Why the differences in community response?

• Differences in
• Perceptions of the disease problem
• Perceptions of the innovation

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Differences in perceptions of the disease problem
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Characteristics of innovations that affect their
diffusion/adoption

• Relative advantage Is it better than what is
  used currently?
• Compatibility with values and needs of potential
  adopters
• Complexity How difficult is it to understand and
  use?
• Trialability Can people try it out before
  deciding to adopt it?
• Observability Can the benefits be readily
  observed?

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Where are the differences between ACTs and Zinc?

• Relative advantage Is it better than what is
  used currently?
• Compatibility with values and needs of potential
  adopters
• Complexity How difficult is it to understand and
  use?
• Trialability Can people try it out before
  deciding to adopt it?
• Observability Can the benefits be readily
  observed?

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Relative advantage ACTs Zinc versus existing
products

• ACTs
• Comparison is to Chlorquine (CQ)
• CQ has been discredited in the mass media and
  withdrawn by MOH
• General consensus it no longer works
• Chloroquine is becoming less available

• Zinc
• Comparison is to antibiotics and ORS
• Antibiotics are a major treatment for diarrhoea
  (38), especially tetracycline
• General consensus that antibiotics are effective
• Antibiotics widely available

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Antibiotic sales in a local market
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Where are the differences between ACTs and Zinc?

• Relative advantage Is it better than what is
  used currently?
• Compatibility with values and needs of potential
  adopters
• Complexity How difficult is it to understand and
  use?
• Trialability Can people try it out before
  deciding to adopt it?
• Observability Can the benefits be readily
  observed?

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Observability

• Artemisinin compounds are very fast acting
  (within few hours), so fast that there is concern
  people will only take one day of treatment
• Zinc takes longer to exert its effects, and the
  effects of a course of zinc treatment continue
  over months
• Very difficult for people to appreciate
  everything that zinc is doing

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Implications

• We need to recognize that community may find it
  more difficult to appreciate the benefits of zinc
  than we do
• Need to plan for some level of continuing
  promotion of zinc and ORS

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Implications

• Advantages to coordination of introduction of
  ACTs and zinc
• More efficient use of funds for implementation
• Integrated treatment of children with multiple
  conditions (fever, diarrhoea)
• Promotion likely more effective if zinc and ACTs
  promotion coordinated ? Experience of IRC in 4
  African countries (K. Haxall tomorrow AM)