The effectiveness bundling of zinc with Oral Rehydration Salts (ORS) for improving adherence to acute watery diarrhea treatment in Ethiopia: cluster randomised controlled trial

Caregivers' knowledge, practice, and associated factors toward oral rehydration salt with zinc to treat diarrhea among under 5 children in Burayu town, Oromia, Ethiopia, 2022: Cross-sectional study: An implication for action

Background

Diarrhea is the second leading cause of death in under 5 children of Ethiopia. Millions of young lives could be saved if mothers know and practice the three rules of diarrhea management: giving extra fluid (particularly oral rehydration salt [ORS]), zinc, and giving additional food during diarrhea illness.

Aim

The objective of this study was to determine mothers'/caregivers' Knowledge, Practice, and associated factors toward ORS with zinc to treat diarrhea among under 5 children in Burayu town, Oromia Region, Ethiopia, 2022.

Methods

A community-based cross-sectional study was conducted among 422 study participants from September 25 to October 10, 2022; in Burayu town, Ethiopia. Systematic random sampling technique was used to enroll study subjects from two randomly selected kebeles. Interviewer-administered structured questionnaire was used to collect data. Data were entered into Epi-info version 3.5.1 and exported to SPSS Version 21 for analysis. Binary and multivariable logistic regression was done to identify factors associated with knowledge and practice of ORS with zinc at p < 0.05% and 95% confidence interval (CI).

Results

The findings showed that 59% and 52% of the respondents had good knowledge and practice toward ORS with zinc, respectively. Being housewives (adjusted odds ratio, AOR = 0.407, 95% CI: [0.195, 0.848]), primary education (AOR = 3.246, 95% CI: [1.614, 6.530]), income of >4000 (AOR = 5.132, 95% CI: [1.947, 13.524]), health seeking behavior (AOR = 0.369, 95% CI: [0.139, 0.979]), being divorced (AOR = 0.275, 95% CI: [0.09,0.842]) were found to be significantly associated with knowledge toward management of diarrhea with ORS and zinc. Housewives in occupation (AOR = 0.084, 95% CI: [0.029, 0.243]), secondary and above education (AOR = 6.26: 95% CI: [1.51, 25.86]), health seeking behavior (AOR = 6.885, 95% CI: [2.29, 20.67]), having good knowledge of ORS and zinc (AOR = 22.14, 95% CI: [8.44, 58.07]) were found to be significantly associated with practice of managing diarrhea with ORS and zinc.

Conclusion

This study revealed low level of knowledge and practice of caregivers toward ORS with zinc. The more mothers/caregivers are knowledgeable, the more they are active to practice the use of ORS with zinc. Thus, health education and awareness creation for the mothers/caregivers on management of diarrhea is very crucial. Special attention should be given to enhancing income for mothers/caregivers.

Acute gastroenteritis-changes to the recommended original oral rehydrating salts: a review

The World Health Organization recommended a formulation of oral rehydration salts as the intervention of choice for the treatment of acute gastroenteritis. While of value for the replacement of fluids and electrolytes, the formulation does not reduce stool volume, frequency, or symptom duration. This may prevent wide acceptance. To increase tolerability, shorten the duration of diarrhea and improve parental quality of life, several modifications to the original formula have been proposed. These include; low osmolarity, rice-based, glucose polymers as an alternative to glucose, the addition of probiotics, prebiotics and/or zinc, and various other ingredients. Here we summarize evidence regarding such changes and additions.

Sociodemographic and institutional determinants of zinc bundled with oral rehydration salt utilisation among under-five children with diarrhoeal diseases in East Wallaga zone, western Ethiopia: a community-based cross-sectional study

OBJECTIVE

This study aimed to assess the sociodemographic and institutional determinants of zinc bundled with oral rehydration salt (ORS) utilisation among under-five children with diarrhoeal diseases in East Wallaga zone, western Ethiopia, in 2022.

METHODS

A community-based cross-sectional study was conducted among 560 randomly selected participants from 1 to 30 April 2022. Data were entered into EpiData V.3.1, then exported to the Statistical Package for Social Science (SPSS) V.25 for analysis. An adjusted OR (AOR) along with a 95% confidence level was estimated to assess the strength of the association, and a p value <0.05 was considered to declare the statistical significance.

RESULTS

About 39.6% of the participants had used zinc bundled with ORS for their children with diarrhoea at least once in the last 12 months. Being aged 40-49 years for mothers or caregivers (AOR 3.48, 95% CI 1.41, 8.53); merchant (AOR 4.11, 95% CI 1.73, 8.12); mothers or caregivers able to read and write (AOR 5.77, 95% CI 1.22, 11.67); visited secondary level (AOR 2.82, 95% CI 1.30, 6.10) and tertiary level health facilities (AOR 0.016, 95% CI 0.03, 0.97); degree and above (AOR 0.06, 95% CI 0.03, 0.12) and doctorate (AOR 0.13, 95% CI 0.04, 0.44) holder healthcare professionals were statistically associated with utilisation of zinc bundled with ORS.

CONCLUSION

The study found that about two in five of the participants had used zinc bundled with ORS for their under-five children with diarrhoeal diseases. Age, occupation, educational status, level of health facilities visited and level of health professionals provided care were determinants of zinc bundled with ORS utilisation. So, health professionals at different levels of the health system have to enhance the maximisation of its bundled uptake.

Predictors of Under-Five Caregivers’ Utilization of Co-Packaged Zinc and Oral Rehydration Salts for Childhood Diarrhea in East Wollega Zone, Western Ethiopia

Introduction

Diarrhea morbidity and mortality remain child health and economic burdens in low resource settings. In Ethiopia, diarrheal disease treatment service utilization remains very low. However, evidence on the level of utilization of zinc bundled with ORS among under-five caregivers' was not addressed.

Objective

The study aimed to identify predictors of under-five caregivers' utilization of co-packaged zinc and oral rehydration salts for childhood diarrhea in East Wollega Zone, Western Ethiopia, in 2022.

Methods

The study design used was a community-based cross-sectional study that was conducted among 540 randomly selected participants from April 1 to 30, 2022. Data were collected using interviewer-administered semi-structured questionnaires. It was entered into Epi-data version 3.1 and analyzed using SPSS version 26. An adjusted odds ratio along with a 95% confidence level was estimated, and a P value <0.05 was considered to declare the statistical significance in the multivariable analysis.

Results

About 39.6% of under-five caregivers' had utilized co-packaged zinc and oral rehydration salts for their childhood diarrhea at least once in the last 12 months. Having family size less than 5 [AOR and 95% CI = 5.72 (2.93,11.15)]; heard about the co-pack [AOR and 95% CI = 9.52 (4.95,23.68)]; perceived health status for the recent episode as poor [AOR and 95% CI = 5.90 (2.58, 15.96)] and medium [AOR and 95% CI = 2.20 (1.02, 4.83)]; perceived severity for recent episodes [AOR and 95% CI = 4.48 (1.36, 14.76)] and being community-based health insurance non-member [AOR and 95% CI = 2.28 (1.34, 6.90)] were statistically associated with co-packaged zinc and ORS utilization.

Conclusion

The study found that co-packaged zinc and oral rehydration salt utilization was low. Family size, heard about the co-pack, perceived health status, perceived severity, and CBHI membership were predictors of co-packaged utilization of zinc and ORS. Hence, concerned bodies in the health system should have devoted to maximize its uptake.

Measurement of benefits in economic evaluations of nutrition interventions in low‐ and middle‐income countries: A systematic review

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority‐setting. However, there are unique challenges to synthesizing the findings of multi‐sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost‐effectiveness, cost‐utility and benefit‐cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low‐ and middle‐income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty‐seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty‐one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non‐health and multi‐sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

Current economic evaluations often underestimate the total sum of benefits that can arise from nutrition interventions. Comprehensive benefit measurement of some nutrition programmes may require further methodological research.

In the near‐term, economic evaluations of multi‐sectoral nutrition interventions should include potential cost savings from improved nutrition in their calculations and assess the potential for benefits unrelated to nutrition. If the range of benefits is diverse and can be monetised, benefit‐cost analysis may be the preferred evaluation method.

Economic evaluations of nutrition‐sensitive interventions from agriculture, water, sanitation and hygiene (WASH), and gender empowerment sectors, are needed to fill an evidence gap on costs and benefits of multisectoral approaches to improved maternal and child health and nutrition.

Educational interventions using a primer and motivational interviewing: randomized clinical trial

BACKGROUND

Many educational technologies have been used to promote the health of the population. Thus, the objective was to assess the effect of using an individual educational primer along with the Brief Motivational Interviewing (BMI) for increasing maternal self-efficacy for preventing childhood diarrhoea.

METHODS

Randomized clinical trial, conducted in Fortaleza/Ceará-Brazil, composed of 181 mothers and/or guardians of children under five years, who were randomized into three groups: experimental group A (EG A)-who read the primer, experimental group B (EG B)-application of the primer and BMI and the control group (CG). The participants' assessment was based on the Maternal Self-Efficacy Scale for Preventing Childhood Diarrhoea and the diarrhoea Investigation Form at the beginning of the intervention and then 30 and 60 days after the first contact with the participants.

RESULTS

There were 60 participants in EG A and CG and 61 in EG B. It was noted a greater incidence of participants with high self-efficacy in EG B after applying the technologies. All groups manifested diarrhoea among children after the interventions, although with a lower number in EG B, one-month post-intervention (P = 0.025).

CONCLUSIONS

The combined use of the primer and the BMI contributed significantly over time to increase maternal self-efficacy in preventing childhood diarrhoea and reduce cases of this disease.

Barriers and facilitators to implementation of oral rehydration therapy in low- and middle-income countries: A systematic review

BACKGROUND

Oral rehydration therapy (ORT) is an effective and cheap treatment for diarrheal disease; globally, one of the leading causes of death in children under five. The World Health Organization launched a global campaign to improve ORT coverage in 1978, with activities such as educational campaigns, training health workers and the creation of designate programming. Despite these efforts, ORT coverage remains relatively low. The objective of this systematic review is to identify the barriers and facilitators to the implementation of oral rehydration therapy in low and middle-income countries.

METHODS

A comprehensive search strategy comprised of relevant subject headings and keywords was executed in 5 databases including OVID Medline, OVID Embase, OVID HealthStar, Web of Science and Scopus. Eligible studies underwent quality assessment, and a directed content analysis approach to data extraction was conducted and aligned to the Consolidated Framework for Implementation Research (CFIR) to facilitate narrative synthesis.

RESULTS

The search identified 1570 citations and following removal of duplicates as well as screening according to our inclusion/exclusion criteria, 55 articles were eligible for inclusion in the review. Twenty-three countries were represented in this review, with India, Bangladesh, Egypt, Nigeria, and South Africa having the most representation of available studies. Study dates ranged from 1981 to 2020. Overarching thematic areas spanning the barriers and facilitators that were identified included: availability and accessibility, knowledge, partnership engagement, and design and acceptability.

CONCLUSION

A systematic review of studies on implementation of ORT in low- and middle-income countries (LMICs) highlights key activities that facilitate the development of successful implementation that include: (1) availability and accessibility of ORT, (2) awareness and education among communities, (3) strong partnership engagement strategies, and (4) adaptable design to enhance acceptability. The barriers and facilitators identified under the CIFR domains can be used to build knowledge on how to adapt ORT to national and local settings and contribute to a better understanding on the implementation and use of ORT in LMICs. The prospects for scaling and sustaining ORT (after years of low use) will increase if implementation research informs local applications, and implementers engage appropriate stakeholders and test assumptions around localized theories of change from interventions to expected outcomes.

REGISTRATION

A protocol for this systematic review was developed and uploaded onto the PROSPERO international prospective register of systematic reviews database (Registration number: CRD420201695).

Mapping geographical inequalities in oral rehydration therapy coverage in low-income and middle-income countries, 2000-17

BACKGROUND

Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs.

METHODS

We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000-17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws.

FINDINGS

While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000-7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910-68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average.

INTERPRETATION

To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage.

FUNDING

Bill & Melinda Gates Foundation.

A Half Century of Oral Rehydration Therapy in Childhood Gastroenteritis: Toward Increasing Uptake and Improving Coverage

Termed by the Lancet, as "potentially the most important medical advance of the twentieth century," therapy with oral rehydration solutions (ORSs) has been essential to reducing mortality in children less than 5 years (under five) with infectious gastroenteritis and diarrhea. The target of the diarrhea-control programs in the 1990s was to achieve ORS use in 80% of diarrhea cases by the year 2000. Nevertheless, nearly 20 years later, global uptake remains limited to only a third of the cases. Our analysis shows that from 1990 to 2017, mean ORS coverage in Countdown countries [the 81 Countdown-to-2030 priority countries, which together account for 95% of maternal deaths and 90% of under-five deaths] increased from ~ 30% to nearly 40%. Flawed government policies, inadequate supplies, and lack of awareness among health workers and communities all contributed to this shortfall in coverage. Moreover, imperfect measurement methodology is implicated in questionable coverage data. A multipronged approach focusing on the manufacture, supply, training, and behavioral change is essential to ensure that ORS is used in all epidemic diarrhea cases globally, especially in the under-five population.

An evaluation of a national oral rehydration solution and zinc scale-up program in Kenya between 2011 and 2016

Background

In Kenya, diarrheal disease is the second leading cause of death among children under five. The Government of Kenya launched a national plan to increase coverage of oral rehydration solution (ORS) and zinc by addressing demand and supply-side barriers. This study evaluates progress of ORS and zinc uptake in Kenya according to the national plan from 2011 to 2016.

Methods

In 2016, we conducted a nationally representative population-based household survey to estimate coverage of ORS and zinc for treatment of diarrhea cases among children under five. We also used ORS and zinc coverage data from the two most recent Kenya Demographic and Health Surveys in 2008/09 and 2014 to estimate annual changes in coverage rates during the program period. Based on these inputs, we used the Lives Saved Tool to estimate the number of diarrhea deaths averted between 2011 and 2016 due to increased use of ORS and zinc.

Results

The 2016 survey results showed that ORS coverage was 42% (95% confidence interval (CI) = 38%, 47%) and zinc coverage was 18% (95% CI = 15%, 23%). The estimated coverage for the combined use of ORS and zinc was 15% in 2016 (95% CI = 12%, 19%). Compared to 2011, an additional 3340 (sensitivity bounds = 2 670, 3 920) diarrhea deaths among children under five were averted due to increases in ORS and zinc coverage.

Conclusions

Kenya was successful in catalyzing uptake of combined treatment with ORS and zinc, which rose from 0.8% in 2011 to 15% in 2016. Ongoing efforts are necessary to further build on these gains.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF).

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, mRCT, and reference lists up to 30 September 2016. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using either a fixed-effect or random-effects model) and assessed heterogeneity.We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Thirty-three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoeaThere is currently not enough evidence from well-conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized (very low certainty evidence).In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD -11.46 hours, 95% CI -19.72 to -3.19; 2581 children, 9 trials, low certainty evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD -26.39 hours, 95% CI -36.54 to -16.23; 419 children, 5 trials, high certainty evidence).Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, 2 trials, moderate certainty evidence), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, moderate certainty evidence).None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence). Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, 5 trials, moderate certainty evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well-nourished children, and in settings where children are at low risk of zinc deficiency.