Zinc Treatment for Childhood Diarrhea in Bangladesh - Recent Advances and Issues in Environmental Science - page 214

the failure to adhere to a 10-days course of treatment as evidenced by the fact over
50% of caregivers were sold seven or fewer days of zinc treatment.
A potential source of bias and limitation of this study is the populations surveyed,
which may not be representative of hard to reach, more remote sites in Bangladesh.
These sites were chosen because ICDDR,B researchers were known in these com-
munities, support structures were in place, and local approval to conduct the surveys
could be more rapidly obtained. The purpose of these surveys was to document trends
in the use of zinc and changes in other practices within the stratifi ed populations de-
scribed. The fi ndings may not, with confi dence, be extrapolated to accurately estimate
zinc coverage in all districts of Bangladesh. The sites chosen within each population
strata are, nevertheless, typical Bangladeshi communities and we are confi dent that
the observed trends in zinc coverage and reductions in disparities are indicative of
what is occurring in Bangladesh as a whole. Bias in estimates of zinc treatment aware-
ness may also have been introduced by repeatedly surveying in the same sub-districts.
Those caretakers interviewed may have discussed the experience with relatives or
neighbors, including the mention of zinc treatment. Households with a repeated case
of diarrhea were not replaced because it was concluded their exclusion would lead
to a biased selection of healthier children in subsequent surveys. The sites surveyed
contain an estimated population of nearly 1.5 million children under 5 years of age.
This was felt to be a large enough population base to minimize biased estimates of
zinc awareness and would not have affected zinc coverage estimates. A strength of the
surveys was the selection of households where a child had an active or recent diarrhea
episode of at least 2-days duration. This eliminated transient, less important episodes
and responses were based upon actual practices.
Promotion among health providers followed two strategies: half-day diarrhea
training workshops and product promotion by drug salesmen. There are estimated
to be over 200,000 health providers in Bangladesh, thus the challenge of reaching
them all through workshops is not realistic. We therefore placed an early emphasis
on sensitizing and training recognized leaders, such as pediatricians and educators.
Less well-trained providers tend to look up to pediatricians and copy their practices.
Among the unlicensed providers a training of trainers approach was used. While this
set of surveys cannot document the proportion reached, it is likely the majority of
health providers remain poorly informed about zinc treatment. Reliance on drug sales-
men also has limitations. These individuals and the systems within which they work
are profi t oriented and based upon prescription medications. Zinc is cheap and it is an
over-the-counter product. Not surprisingly, drug salesmen will be more inclined to
promote higher priced products. Promotion and distribution of zinc through alternative
systems, for example bottled water distribution networks, would reach a far greater
number of outlets and increase its availability within rural or urban communities,
Rogers' diffusion of innovation theory is useful for understanding progress with
scaling up health interventions in the general population over time. The theory de-
scribes the adoption of new innovations as passing through fi ve stages of decision
making—awareness, interest, evaluation, trial, and adoption [17]. At any stage a con-
sumer, in our case providers or caretakers, can choose to reject the innovation. The