Background: Diarrhoeal diseases are still one of the majors causes of childhood morbidity and mortality, especially in low- and middle-income countries. Clinical trials show that zinc, as part of a treatment for childhood diarrhoea, not only helps to reduce the severity and duration of diarrhoea but also reduces the likelihood of a repeat episode in the future. In 2004, the WHO/UNICEF revised their clinical management of childhood diarrhoea guidelines to include zinc.

The “Scaling Up of Zinc for Young Children” (SUZY) project was established in Bangladesh in 2003 to provide zinc treatment for diarrhoea in all children under the age of five. The project was supported by public, private and nongovernmental organizations, as well as multinational agencies. The scale-up campaign included production and distribution of zinc tablets, training of health professionals to provide zinc treatment and creation of media campaigns (TV and radio) to raise awareness and promote the use of zinc for diarrhoea treatment. To establish the effectiveness and success of the national campaign, and to highlight any potential problems during the implementation of health care initiatives in areas with deprived health systems, four survey sites were set up to monitor results from the first two years of the SUZY campaign. Each of the survey areas represented a different segment of the population across Bangladesh: urban slums, urban non-slums, municipal (small city) and rural settings. The study population across these sites was approximately 1.5 million children under the age of five years. At each site, seven surveys were conducted between September 2006 and October 2008. During each survey, about 3200 children with diarrhoea were studied from randomly selected households.

Findings: At baseline, awareness of zinc treatment was less than 10% in all communities. 10 months later, this peaked at 90%, 74%, 66%, and 50% in urban non-slum, municipal, urban slum, and rural sites, respectively. After 23 months, only 25% of urban non-slum, 20% of municipal and urban slum, and 10% of rural children under the age of five were using zinc for treatment of childhood diarrhoea. Use of zinc was shown to be safe, with few side-effects, and did not affect the use of traditional treatments. However, many children were not given the correct ten-day course of treatment and 50% of parents were sold seven or fewer zinc tablets. The findings further showed that although the first national campaign to promote zinc treatment for childhood diarrhoea in Bangladesh generated some success, the high awareness of zinc did not translate into high use. The scale-up campaign did not have any adverse effect on the use of oral rehydration salts (ORS). However, there were disparities in zinc coverage favouring higher income, urban households.

Conclusions: The study identified areas where more work was needed to ensure higher levels of coverage. For example, there was a need to link mass media messages with information from health care providers to help reinforce and promote understanding of the use of zinc. A change in focus of media messages from awareness to promoting household decision-making aided the adoption of zinc treatment for childhood diarrhoea and improved adherence.

Lessons: Long-term monitoring of scale-up programmes can identify important gaps in coverage and provide the necessary information about both intended and unintended outcomes, which consequently guides further decision-making.