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

Objectives

To evaluate whether co-packing of zinc with ORS using a plastic pouch can enhance the joint adherence to diarrhea treatment or not.

Methods

This cluster-randomised trial was conducted in 2015 in eight districts of Ethiopia. Thirty two HCs were randomly assigned to one of the following intervention arms: (i) ‘Central bundling’ (zinc and ORS bundled using a pouch that has instructional message distributed to HCs); (ii) ‘HC level bundling’ (zinc, ORS and a similar pouch distributed to the HCs and bundled by health workers); (iii) ‘Bundling without message’ (zinc, ORS and plain pouch distributed and bundled by the health workers); and, (iv) ‘Status quo’ (zinc and ORS co-administered without bundling). In each arm, 176 children 6-59 months of age with acute diarrhea were enrolled. Twelve days after enrollment, level of adherence was assessed. A composite scale of adherence was developed and modeled using linear regression analysis. The unit costs associated with the arms were estimated using secondary data sources and compared across the arms using Incremental CE analysis.

Results

The follow-up rate was 95.6%. As compared with the ‘status quo’ arm, the joint adherences in the ‘central’ and ‘HC level’ bundling arms raised substantially by 15.1 and 15.7 Percentage Points (PP), respectively (P<0.05). No significant difference observed between ‘bundling without message' and the ‘status quo' arms. The unit cost incurred by the ‘central bundling' is relatively higher (USD 0.658/episode) as compared with the ‘HC level bundling' approach (USD 0.608/episode). The incremental CE ratio in the ‘central bundling' modality was two times higher than in the ‘HC based bundling' approach.

Conclusions

Bundling zinc with ORS using a pouch with instructional messages increases adherence to the diarrhea treatment.