Reducing Child Mortality through Effective Childhood Diarrhoea Management

Posted In:    Behaviour Change Research & Documentation    Delhi    IEC Campaign    India    UNICEF    WHO    Diarrhoea    knowledge    management    districts    modules    Zinc    ORS    mother    MI    radio jingles    jodi    manuals    antibiotics    blood    English    Hindi    Multi-Media    Health    Nutrition    Bihar    2012   

Reducing Child Mortality through Effective Diarrhoea Management: Understanding Demand

From 2010 to 2012, Micronutrient Initiative (MI) collaborated with the Government of Bihar to implement The Children’s Investment Fund Foundation (CIFF) supported project Reducing Childhood Diarrhoea through Sustainable Use of Zinc and Oral Rehydration Solution (ORS) in Bihar. The project aimed to increase the coverage of Zinc and Low-osmolarity ORS for the treatment of childhood diarrhoea and improve compliance to the recommended course of treatment by the caregivers through public health service delivery channels in the state. One of the key components is to develop demand and ensure treatment compliance of zinc and ORS by the caregivers.

New Concept carried out formative research in five intervention districts (2 blocks each in Munger, Saharsa, Supaul, Sitamarhi and Bhagalpur) to understand the knowledge, attitude and practices of various stakeholders with respect to diarrhoea.

The study brought out the following key issues. 

  • Knowledge levels among mothers on causes, symptoms, seasonality, vulnerability and feeding practices including breastfeeding are good with a few exceptions such as reduced breastfeeding during diarrhoea; 
  • Common understanding on the lack of general hygiene being the primary cause of diarrhoea; 
  • Association of hand washing (before and after food intake) with diarrhoea not reported by any respondent;
  • Community respondents did not have comprehensive knowledge on diarrhoea prevention, acknowledging little or no understanding on how to avert it;
  • Home treatment for diarrhoea encompasses a wide range of time-tested remedies;
  • Mixed opinions on community relationship with frontline health service providers (ASHAs, AWWs and ANMs);
  • Majority of mothers in intervention districts consider zinc as a new medicine for diarrhoea without correct information on its dosage and duration;
  • Barriers to use of zinc were access, cost, unpopularity and therefore less demand. 


Based on the findings, recommendations were provided on: 

  • Strengthening community knowledge and attitude towards diarrhoea; 
  • Strengthening diarrhoea treatment practices and use of ORS and Zinc; 
  • Overcoming barriers to ORS and Zinc demand and compliance at community level; 
  • Communication sources, messages and mediums; and 
  • Capacity building resources and training inputs for health service providers,


A total of 126 In-depth Interviews (IDIs) were conducted across a cross-section of study respondents that included mothers, caregivers, frontline health service providers (ASHAs, AWWs and ANMs), CDPOs, medical officers and chemists. These were supplemented by Key Informant Interviews (KIIs) with community influencers and Focus Group Discussions (FGDs) with card matching exercise among mothers.

In addition, NC also undertook secondary research on the prevalent communication interventions and strategies in Bihar which included review of DLHS data, revised diarrhoea management guidelines in 2006, and the new Zinc policy. 

The study covered the following areas of enquiry: 

  • Community norms and practices related to diarrhoea;
  • Identifying key issues (barriers to diarrhoea management); 
  • Practices of diarrhoea management at the household level;
  • Understanding the factors that favour early adoption of the right behaviours;
  • Understanding of illness recovery;
  • Exploring the different sources of information;
  • Identifying the appropriate medium and channel to reach the defined audience;
  • Treatment/prescription practices by the public health professionals and service providers;
  • Exploring the existing skills and area of capacity building of health service providers.


The results from the formative research fed into development of interpersonal and behaviour change communication tools to improve coverage and compliance of Zinc and Low-osmolarity ORS in Bihar.

Development of Training-cum-IPC Toolkit and Radio Jingles on Revised Childhood Diarrhoea Management

Health promotion and health education activities rely on a variety of well-designed and effective BCC and IPC materials to help ensure success. Every flip book, poster, audio-visual, radio jingle or other communication material is the product of a decision, supported by research, to deal with a specific health concern, and to be well received and persuasive among a specific audience.

NEW CONCEPT developed a set of training modules and Inter-Personal Communication (IPC) kits in Hindi covering the technical and programmatic aspects of the revised childhood diarrhoea management programme. The prime objective was to improve the use of Zinc and ORS as a treatment regime of childhood diarrhoea and also improve technical and programme management skills of all functionaries in Health and ICDS.

A comprehensive training toolkit for effective programme management and in-depth technical understanding was developed. The focus was on using ORS and Zinc as a “jodi” to manage diarrhoea and on stressing the importance of Zinc compliance for 14 days. 

Training modules that included facilitators’ guide and participants’ manuals were developed prior to giving training to the different functionaries. The key aspects covered by the training modules included: 

  • Technical information on the revised guidelines for childhood diarrhoea management 
  • Programme management
  • Roles and responsibilities
  • Monitoring and reporting
  • Importance of communication
  • Use of IPC tools developed


The training kit aimed at enhancing skills of various levels of cadres in Health and ICDS (Level 1: MOs/CDPOs, Level 2: ANMs/Supervisors; Level 3: ASHAs/AWWs) to communicate effectively to all the mothers and caregivers of children aged two months to five years suffering from diarrhoea. The IPC kit (to be used by frontline functionaries) was developed for increasing awareness on diarrhoea control and management; thereby reducing diarrhoeal deaths at the community level.

Radio jingle: Two radio jingles (1 minute duration, with 40 sec and 20 sec cutaways) were developed to reinforce the importance of 14-day adherence to the recommended course of Zinc tablets and use of ORS and zinc as a “jodi”. These may be played during VHND, and Health Melas, because while the message of Zinc supplementation is applicable to only caregivers of diarrhoea-affected children, it is very important to create general awareness as acceptability of any product increases when more people know, have heard about it and generate demand for the product.

Building Capacities of Health and ICDS Functionaries on Revised Childhood Diarrhoea Management 

In May 2004, UNICEF and WHO issued a joint statement recommending a new ORS formula and Zinc treatment for diarrhoea. Based on this recommendation, health workers should: 

  • Counsel mothers to begin administering suitable available home fluids immediately upon onset of diarrhoea in a child;
  • Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration);
  • Emphasise continued feeding or increased breastfeeding during, and increased feeding after the diarrhoeal episode;
  • Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or shigellosis, and abstain from administering anti-diarrhoeal drugs;
  • Provide children with 20 mg per day of Zinc supplementation for 14 days (10 mg per day for infants under six months old);
  • Advise mothers on the need to increase fluids and continue feeding during future episodes.


Capacity building and training of programme managers, medical staff, supervisors and frontline functionaries on revised childhood diarrhoea management guidelines was an essential component of the overall programme. NC facilitated the training in 11 districts of Bihar across three phases: 

  • Phase I covering five districts namely Bhagalpur, Banka, Sheohar, Samastipur and Sitamarhi 
  • Phase II covering three districts namely Munger, Khagaria, Saharsa
  • Phase III covering three districts namely East Champaran, Nalanda, Sheikhpura 


In this regard, a total of 36,554 Health and ICDS functionaries in 11 districts of Bihar were trained in 1220 batches on the technical and programme management aspects of the programme. As part of the capacity building, NC followed the cascade approach to training the functionaries:

  • Medical Officers & CDPOs; Block Health Managers (BHMs)/Block Community Mobilisers (BCMs) at district level (Level 1)
  • ICDS Supervisors; Staff Nurse, Lady Health Visitors (LHVs) and Auxiliary Nurse Midwives (ANMs) at block level (Level 2)
  • Accredited Social Health Activists (ASHAs) and Anganwadi Workers (AWWs) at block level (Level 3)


The medical officers have a key leadership and project management role in guiding the other field functionaries to undertake initiatives and interventions for childhood diarrhoea management. The highly participative, interactive training programme aimed at enhancing the knowledge, skills and experiences of medical officers, CDPOs, ANMs, ASHA and AWWs and providing them with tools and methods would help improve the overall implementation and performance of the revised childhood diarrhoea management programme in Bihar. 

AWWs and ASHAs played a pivotal role in the community and were trained on aspects like home management of diarrhoea, assessment of dehydration and danger signs at the community level, preparation of ORS and Zinc solution and its benefits. 

The key aspects covered during training included: 

  • Technical information on the revised guidelines for childhood diarrhoea management 
  • Programme management
  • Roles and responsibilities
  • Monitoring and reporting
  • Importance of communication
  • Use of IPC tools developed


This initiative would go a long way in accelerating positive behaviour change, increasing awareness of mothers/caregivers, families and communities on diarrhoea management thereby enabling better implementation of the revised childhood diarrhoea management guidelines.

Towards Better Understanding of Sanitation & Hygiene Behaviours among Excluded Communities in Bihar

There is no shortcut to working on behaviour change, without directly listening to and observing the reasons for prevailing hygiene practices in the contexts in which these are practiced. Hygiene behaviours in WASH need to be studied from a local context. UNICEF’s Child Environment Programme, together with Communication for Development (C4D) in Bihar, aimed to provide technical support to the State Government’s Public Health Engineering Department (PHED) and the Communication and Capacity Development Unit (CCDU) to conceptualise and implement community-based behaviour change approaches to sanitation and hygiene.

To inform such a design, NEW CONCEPT conducted a formative research to understand perceptions regarding Sanitation and Hygiene among different stakeholders with focus on excluded communities in four districts of Bihar - Vaishali, Gaya, Madhepura and Sitamarhi. A paper based on the Vaishali experience was also presented at the South Asia Sanitation and Hygiene Workshop at Dhaka in 2012.

The research explored toilet use, hand washing and safe disposal of child faeces from a disaggregated perspective of gender and social stratification, in the mixed caste rural context of Bihar. Given the population and social complexity of a single district in India and the fact that a district is a comprehensive administrative unit for all development and administrative programmes in India, the research findings provide inputs to prioritising behaviour change communication strategies.  These findings address key hygiene behaviours that may be applied to the particular district or used for developing a state strategy.

The following aspects for promotion of hygiene and sanitation were the focus of this formative research:

  • Demand for and use of toilets, leading to open defecation-free environment
  • Safe disposal of child excreta and other solid wastes
  • Personal hygiene and hand washing with soap or ash at critical times
  • Safe water handling, maintenance of water sources and water quality monitoring


Privacy, lack of open spaces for defecation and abuse suffered by mahadalit women and the motivational work done by the NGOs, were cited as the major demand generation factors for household toilet construction. Women in the mahadalit communities reported lack of open spaces to defecate, and abuse from upper caste men when they went out – as a motivator for building and using their own latrine.

The research framework focused on capturing the knowledge, attitudes, barriers, enablers and current status/practices related to four key behaviours (toilet usage, hand washing at critical times, safe disposal of child faeces and safe water handling) from both the primary stakeholders (caregivers and decision-makers at the household level) and secondary stakeholders (frontline health workers – ASHAs, AWWs, local school teachers, doctors and NGO representatives).

The study tools for primary research comprised a combination of three key tools, namely, In-depth Interviews (IDIs), Focus Group Discussions (FGDs) and Trials for Improved Practices (TIPS). In each district, a total of 50 IDIs were conducted amongst a cross-section of study respondents including women and men (32 IDIs), local teachers (5 interviews), local doctors (4 interviews), health service providers (5 IDIs) and NGOs (2 IDIs); these were supplemented by 2 TIPS and 3 FGDs.

The scope of the formative research included:

  • Defining current behaviour, practices and habits of sanitation and hygiene at household level.
  • Identifying key issues (barriers to improved sanitation and hygiene behaviour) that need to be addressed to improve the current status of household sanitation and hygiene.
  • Identifying decision making dynamics at household level in the practice of improved sanitation and hygiene norms.
  • Reviewing differential status (for economic poverty, gender and excluded categories of community), and impact if any, on hygiene and sanitation behaviour change
  • Exploring why selective hygiene behaviours are only practiced in some households, where household latrine usage is high.
  • Matching perceptions of primary and secondary stakeholders – identifying gaps if any and suggesting what needs to be done for promoting improved hygiene and sanitation behaviours.
  • Providing recommendations for each of the four behaviour change objectives (toilet usage, hand washing with soap, safe disposal of child faeces and safe water handling), around which behaviour change communication messages need to be built.


The study brought forward 

  • the level of awareness about the government-supported schemes and entitlements for families belonging to different economic classes
  • knowledge about water quality issues and demand for and participation in water testing
  • demand for delivery of services and provision of benefits as per entitlements
  • awareness about health hazards emerging from poor hygiene & sanitation and contaminated drinking water
  • motivation and enabling environment for construction & use of toilets; hand washing at critical times; safe water handling; maintenance of water sources and clean surroundings