Factors related to mothers home practicer on management of accute diarrhea in children under five years old, in nam dinh city, viet nam

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FACTORS RELATED TO MOTHERS’ HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER

FIVE YEARS OLD, IN NAM DINH CITY, VIET NAM THRO VYIEN Lsố,JV XS mg NGUYEN MANH DUNG ——ễˆ Fi ta, ete fiery; Wy Cau pane, ¥ TT pate on ¬ tP¬——- Ta LUBE spit j i TH a “FW Sở: 2 TT ——SễÂSŠSÂSÂSÂSỘ —

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF

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Thesis entitled

FACTORS RELATED TO MOTHERS’ HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE

YEARS OLD, IN NAM DINH CITY, VIET NAM

was submitted to the Faculty of Graduate Studies, Mahidol University

for the degree of Master of Primary Health Care Management on March 20 , 2002 VEE Mr Nguyen Manh Dung Candidate ` Asst Prof Nonglak Pancharuniti D.D.S., M.P.H., Dr.P.H Chair Kitti Shiyalap _ Lect Kitti Shiyalap B.Sc in Pharm., M.P.H., Ph.D Member Jt wv Prof J unya Pattaraarchachai Asst Prof Somsak Wot esawass B.Sc., M.Sc., M.S.P.H., Sc.D B.Sc., M.Sc., M.P.H Member Member Lyk Z—— OA Il, — Prof Liangchai Limlomwongse Prof Som-arch Wongkhomthong Ph.D M.D., D.H.Sc Dean Director

Faculty of Graduate Studies ASEAN Institute for Health Development

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Thesis entitled

FACTORS RELATED TO MOTHERS’ HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE

YEARS OLD, IN NAM DINH CITY, VIET NAM 5£ < Prof Liangchai Limlomwongse Ph.D Dean Faculty of Graduate Studies Mr Nguyen Manh Dung Candidate Asst Prof Nonglak Pancharuniti D.D.S., M.P.H., Dr.P.H Major-advisor Kitti Shiualap Lect Kitti Shiyalap B.Sc.in Pharm., M.P.H., Ph.D Co-advisor Asst Prof Somsak Wongsawass B.Sc., M.Sc., M.P.H Co-advisor Asst Prof Boonyong Keiwkarnka Dr.P.H Chair |

Master of Primary Health Care Mangement

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iti

ACKNOWLEDGEMENT

This thesis would not have been possible without the help and support of many people

First and foremost, it is my honour and pleasure to express my sincere gratitude to Asst Prof Nonglak Pancharuniti, my major-advisor, for her valuable guidance,

support and inspiration throughout the thesis period Her effort, assistance and commitment made the entire thesis process an enjoyable time that I will always live to

remember

I am also grateful to Dr Kitti Shiyalap and Asst Prof Somsak Wongsawass, my co-advisors, for their kindly advice, guidance and encouragement during the thesis

process More specifically, I appreciate their support and guidance with regard to

thesis analysis and general review of my thesis that led to its successful completion

Furthermore, I express my sincere thanks to Asst Prof Junya Pattaraarchachai, for her valuable suggestions and comments, especially during the last moments of my thesis

I will always be grateful to you all

Also, I express sincere thanks to the Vietnamese Ministry of Health, and the Namdinh Medical College for selecting me to participate in the Master of Primary Health Care Management course at ASEAN Institute for Health Development My

special thanks go to the Canadian International Development Agency (CIDA), and operated by the Association of Universities and Colleges of Canada (AUCC), a

partnership between the School of Nursing, Memorial University of Newfoundland,

Canada, and the Secondary Technical Medical School 1 (STMS1), Ministry of Health,

Vietnam The author would like to thank the project Director, Dr Lan Tran Gien,

Professor, Nursing, Memorial University, Dr Hoang Dien Phan and Dr Vu Dinh Chinh (project Co-Directors) for their encouragement and support that enabled me to

attend this course

I am also grateful to the leaders of Namdinh health center, all the health personnel and respondents for their cooperation and assistance during the time of data collection Their support and enthusiasm made the entire data collection process a memorable experience for me

I am also grateful to all the professors and staff of the AIHD, the MPHM office, the-computer department, the library center as well as my classmates for supporting me

to complete my thesis successfully I also thank the ASEAN house staff for their

facilities during my stay in ASEAN house

Last but not least, I express my gratitude to my family members, relative and friends for according me the moral support and motivation throughout my study at the ASEAN Institute for Health Development, Thailand

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đi ĐIINN Trường đại học tống hợp Mahidol Thái lan Tóm tắt đề tài/iv

SỐ 4437629: _ CHỦ ĐỀ: QUẢN LÝ CHĂM SÓC SỨC KHOẺ BAN ĐẦU

ĐỀ TÀI THẠC SỸ QUẢN LÝ CHĂM SÓC SỨC KHOẺ BAN ĐẦU

TUKHOA : BENH TIEU CHAY/ THUC HANH TAI NHA/ TRE EM/ VIET NAM CHU DE TAL NGUYEN MANH DUNG

TEN DE TAI: CAC YEU TO LIEN QUAN DEN THUC HANH TAI NHA CUA BA ME

TRONG VIỆC XỬ TRÍ BỆNH TIÊU CHẢY CẤP Ở TRẺ EM DƯỚI 5 TUỔI, TẠI THÀNH

PHỐ NAM ĐỊNH, VIỆT NAM NHŨNG NGƯỜI HƯỚNG DẪN:

PGS TS NONGLAK PANCHARUNITI, TS KITTI SHIYALAP PGS THS SOMSAK WONGSAWASS

MÃ SỐ XUẤT BẢN: 974-04-1355-2

Để tài nghiên cứu được thiết kế theo kiểu nghiên cứu cắt ngang, được thực hiện để xác định các yếu tố liên quan tới thực hành tại nhà của các bi mẹ trong

việc xử trí bệnh tiêu chảy cấp ở trẻ em dưới 5 tuổi, tại thành phố Nam Định, Việt

Nam

270 bà mẹ có con bị bệnh tiêu chảy trong vòng 6 tháng gần đây, đã được phông vấn trực tiếp (hông qua bộ câu hỏi) để thu thập các thông tin, sử dụng

trong nghiên cứu này Nó bao gồm: Các đặc điểm về nhân khẩu-xã hội học, nhận

thức về sự nhạy cảm, sự nguy hiểm của bệnh tiêu chảy ở trẻ em cùng với lợi ích,

những điều trở ngại cũng như các điều gợi ý giúp đỡ bà mẹ trong thực hành và việc

thực hành tại nhà của các bà mẹ trong xử trí bệnh tiêu chảy cấp ở trẻ em

Sự phân tích kết quả nghiên cứu đã chỉ ra rằng: Phần lớn các bà mẹ ở độ tuổi từ 26-34, có trình độ VH hết phổ thông trung học và có thu nhập ở mức thấp Các bà mẹ trong nghiên cứu này chủ yêú là: nội trợ, làm nghề tự do và có tổng số

người trong gia đình không quá 4 người Số đông trong họ đã nhận được các thông

tin về liệu pháp bù nước và điện giải từ nhân viên y tế Toàn bộ nhận thức của họ

đã được phân loại trung bình: 52.6%, mức cao: 33% Có 38% ba me dat mức cao

về điểm thực hành, mặc dù 50% bà mẹ đã thực hiện tăng lượng nước uống cho trẻ,

65.6% tiếp tục cho trẻ ăn, 54.8% đã không sử dụng bất kỳ loại thuốc nào, 55.2%

đã có được nhận thức về các dấu hiệu nặng của bệnh khi con họ bị tiêu chảy và

67.4% bà mẹ đã có được hành vi thực hành rửa tay đúng trong khi chăm sóc trẻ

Spearman correlation test di dua ra két qua: m6i lién quan có ý nghĩa

thống kê giữa điểm thực hành tại nhà của các bà mẹ với tổng số năm học (VH- GD), tổng số thành viên trong gia đình, tổng số trẻ dưới 5 tuổi trong gia đình, nhận

thức của bà mẹ về bệnh tiêu chảy, cũng như các điều gợi ý giúp đỡ bà mẹ trong

thực hành với giá trị r, mong đợi tương ứng, 0.334, 0.305, 0.444, 0.277 và 0.380 Kết quả nghiên cứu cũng chỉ ra rằng: Thực hành tại nhà của các bà mẹ trong xử trí bệnh tiêu chảy cấp ở trẻ em dưới 5 tuổi là cao hơn có ý nghĩa trong nhóm các bà

mẹ đang làm việc tại các cơ quan, xí nghiệp nhà nước (p=0.005)

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Fac of Grad Studies, Mahidol Univ Thesis /iv

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4437629 ADPM/M: MAJOR: PRIMARY HEALTH CARE MANAGEMENT M.P.H.M (PRIMARY HEALTH CARE MANAGEMENT) KEY WORDS: | DIARRHEA/HOME PRACTICES/ CHILDREN/VIETNAM

NGUYEN MANH DUNG: FACTORS RELATED TO MOTHERS' HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE YEARS OLD, IN NAM DINH CITY, VIETNAM

THESIS ADVISORS: NONGLAK PANCHARUNITI D.D.S.,M.P.H., DrPH, KITTI SHIYALAP B.Sc IN PHARM., MPH, Ph.D.,

SOMSAK WONGSAWASS B.Sc, M.Sc., M.P.H., 103p ISBN: 974-04-1355-2

This thesis is a cross- sectional study, conducted to identify factors related to mothers' home practices on management of acute diarrhea in children under five years old, in Namdinh City, Vietnam

The subjects were 270 mothers who had children with diarrhea in the lasf

six months A structured interview questionnaire was used to collect the information in this study This included their socio-demographic characteristics, perception to susceptibility, severity of childhood diarrhea in accordance with

benefit, barrier, cues to action to support mothers on home practices and mothers’

home practices on management of acute diarrhea in children

The analysis indicated that, the majority of mothers were with the age between 26-34 years, graduated at secondary school, and having low income Most of them were self-employed or housewives, and with small family size (< 4 people in the family) Most of them had received information of Oral Rehydration Therapy from health personnel Over all of their perception about childhood diarrhea and home practices on management of acute diarrhea was classified to be

moderate (52.6%) and up to high level (33%), About 38% of mothers had high

level of practice score, although 50% of them would feed the children with more fluid, 65.6% continue feeding, 54.8% didn't use any drugs, 55.2% recognize dangerous signs, and 67.4% had hygiene behavior of washing hands

Spearman correlation gave the statistical significant results of the relationship between mothers’ home practices and total years of education of mothers, total family members, family's income, total number children under five years old in the family, mothers' perception of diarrhea and cues to action of

mother with r, equal to, 0.334, 0.305, 0.444, 0.441, 0.277, and 0.380 respectively

It was also found that the score of mothers' home practices on management of acute diarrhea in children was significantly higher in the group of mothers working for the government (p= 005)

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CONTENTS Page ACKNOWLEDGEMENT cccccccsesssessecstecerereeeeenecesessseesteasaesseegenesseseneresseeenesiesss ili 1.5.2 (10010150 iv LIST OF FIGURES 0 ccceccccscsstesssseccsenceseceneessueeveneesaeseeesseeceaeesseessaeeseeaeseeearssserens ix i39) 1/).3:27.009) 105 X CHAPTER I INTRODUCTION 1.1 Rationale and justification of study .cccecscsssececceeeseeceeeseeveceeeveneeeraees 1 1.1.1 Magnitude of diarrhea among children Worldwide and Vietnam 1

1.1.2 Case management of acute diarrhea .::ccsccesesesssessesseeenes 2 1.1.3 Practice of mothers on management of acute diarrhea 83] BE 3 1.1.4 co na 4 1.2 Co 6 INN ' (c nha 6 1.2.2 Specifc objectives "¬ 6 1.3 Conceptual frame oi ch ốc 7 li co co on I1 c0 cà 11 1.6 Scope and limitatlons of the study HH re, 12 1.7 Hypothesis 12 H LITERATURE REVIE 2.1 Epidemiology of diarrhea Ánh HH0 tre 13 2.1.1 Present global situation of diarrheal disease 15

2.1.2 Present situation of diarrheal disease in Vietnam 17

2.2 Management of diarrhea in children at home rưnnhhhtntieeh 18 2.2.1 Give the children more fluid than as usual Seevanencaeueceaeanenees 19 2.2.2 Continue feeding the children eee eeeeeseeeectceeceseeneaeees 22 2.2.3 Take the child to a health worker iŸ cccccccsc<ec 2 2.2.4 Using antibiotic and antidiarrheal drugs - c c«ccccec 27 2.2.5 Behavior of hygiene practice of mothers ¬ 29

2.3 Health beliefs model - - HH“ H 11411 HH Hổ 31

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CONTENTS (Cont.)

Page

2.4 Factors related to mothers’ home practice 0.00 cccseeesesesereseetteenerens 36

2.4.1 Socio-demographic factors of mothers -sieee- 36

2.4.2 Perception of mother toward diarrhea in chiÌdren 37

2.4.3 Cues to action support mother on managing acute diarrhea 40

II RESEARCH METHODOLOGY KG sẽ 42

3.2 Study population na 42

3.3 Sample size estimatiOn Ác HH” HH HH HH HH HH Hai 42 3.4 Study area oo -a 43 3.5 Instrument 0.00 45 3.6 Data collection na 47 Ki nh 48 IV RESULTS ; 0 PP 49 V_ DISCUSSION e8 67 VI CONCLUSION AND RECOMMENDATIONS 0v: 01 75 Recommendation - ẤN HT TT HH Tà HT HT TH nưkn 77 ;422:32)/ 0.0057 80 APENDIX | A _ Questionnaires - sàn HH HH HH HH tr niên 87

B Theresult oftest normal distribution Sàn nnerteereke 98

C Summary Ofthe r€S(§ - SH HH2 HH vá ngư 99

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LIST OF TABLES

TABLES Page

1 The main types of diarrhea 0.0.0 13

2 Estimates of diarrhea associated death, 1995 ooo ecw cccessseeesecsseeeeenes 16 3 _ Selected communicable đisease in SEAR countries, 1995 l6

4 Summary offñndings about using ORS -.-.- Ăn vs 21

5 Summarized guideline of WHO/CDD about amount fluid supplied for

children with acute điarrlea -ó- chì HH 4121 re 22

6 Summary of findings about mothers' home practice on feeding children with bu m 25 7 Summary how to supply food for children with acute diarrhea 26 8 Number and percentage of respondents classified by socio-demographic

Characteristics 22.2 ccccseceseeseeseseeseeeeeceseesesaneseteneneeeeesaseateaesseeansecrsneuats 51

9 Percentage of respondents classified by mothers' perception toward

điarrhea In ChỈÏr€T ó- SH HH HH HH ke 53 10 Number and percentage of respondents! by level of perception 55° 11 Number and percentage of respondents classified by cues to action 57 12 Number and percentage of respondents' by level of cues to, action 58 13 Number and percentage of mothers by their practice on home care

management of acute điarrhea in children - - 5 cà Sc se +scxseeeee 60 14_ Number and percentage of mothers by their correct practice on home care

management of acute diarrhea in chiÏdren 61 15 Number and percentage of respondents by level of their practice score 62 16 Association between mothers’ home practice score and

their occupation by Kruskal-Waliss test 63 17 Correlation analysis between ee H2 2n 64 18 Correlation analysis between practice sore and perception score by

vii

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TABLES 19 20 21 22 23 24 ` 25 26 27 28 29 30 31 32 33 34 35 LIST OF TABLE (Cont.) Page

Correlation analysis between cues to action score and practice score by Spearman rank correlation 'Test - - HH HH 66

The result test normal distribution ( Kolmogorov-Smirnov test) 98

Correlation analysis between socio-demographic factors and susceptibility by Spearman rank correlation †€§E - cành re 99 Correlation analysis between other items of perception and BiSv2011011 880 99

Correlation analysis between susceptibility and cues to action 99

Correlation analysis between barrier and socio-demographic factors 99

Correlation analysis between barrier and others items of perception 100

Correlation analysis between and diarrheal episodes of children 100

Correlation analysis between benefit and socio-demographic factors ¬ 100 Correlation analysis between benefit and other items of perception — 100 Correlation analysis between cues to action and socio-demographic factors by Spearman rank correlatiort †©Sï - - ng Ho 101 Correlation analysis between cues to action and diarrheal episodes of children by Spearman rank correlatiori feSỂ Ác HH He 101 Correlatiion analysis between diarrheal episodes of children and scocio- demographic factors of mothers by Spearman rank correlation test 101

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tl tae gat ome Me ls ad ix LIST OF FIGURES FIGURES Page

1 Trend in diarrheal disease in Vietnam, 1992-1998 - LH 17

2 The Health Belief Model 0 cccssseeeceeceeessseeseesseeseseeessersaeeeseasansseasessaseceniees 35 3 Diapram for data collection prOC€SSỈng óc cà nen HH2 re 46

4 Percentage of respondents' by level of perception SCOr€ c.nnieenie 56

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H i J ị j a : CDD: CIDA: IMCI MoH: MPHM: ORT: ORS: SEAR: SSS: STMSI: UNICEF: USS: WHO: LIST OF ABBREVIATIONS

ASEAN Institute for Health Development

Control Diarrheal Disease

Canadian International Development Agency

Integrated Management of Childhood Illness

Ministry of Health

Master Primary Health Care Management Oral Rehydration Therapy

Oral Rehydration Sait

South East Asia Regions Salt-Sugar-Solution

Secondary Techniccal Medicine School No 1

United Nations Children's Fund

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VLG AOE Sn eee Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 1 CHAPTER I INTRODUCTION

1.1 Rationale and justification of the study

1.1.1 Magnitude of diarrhea among children worldwide and in Vietnam Each year, globally more than eleven million children die from the effects of many diseases and inadequate nutrition In some countries, more than one in five children die before they reach their birthday, and many of those who do survive are unable to grow and develop to their full potential Seven out of ten childhood deaths

in developing countries can be attributed to just one main cause, or often to a combination of diseases such as pneumonia, diarrhea, measles, malaria and

malnutrition (1)

Diarrheal diseases are a leading cause of childhood mortality in developing countries and an important cause of malnutrition On average, children below 3 years of age in developing countries experience three episodes of diarrhea each year In 1993, an estimated 3.2 million children below 5 years died from diarrhea (2) Diarrheal disease is related to more than 3 million deaths and more than 4 billion episodes in 1995, of which more than 80% were among children under five years old About 50% of deaths from diarrhea are due to acute watery stool, 35% to persistent diarrhea and 15% to dysentery (3.)

In 1999, causes of 10.5 million deaths among children under five years in

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ME aE a a ne ae

Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management)/ 2:

Dehydration caused by diarrhea is a major cause of death among children

in Vietnam In 1998, as recorded in hospitals among the children, diarrhea is the

second disease in ten leading causes of morbidity and it is the ninth in ten leading causes of death (5) Especially, in the Mekong delta diarrheal diseases are prevalent, ubiquitous and the mortality and morbidity rates are the highest compared to other areas in Vietnam Gastrointestinal diseases (including diarrhea diseases) represent 60% among the total number of cases for 24 communicable diseases reported to the Ministry of Health (MOH) Among gastroenteritis, diarrhea contributes approximately

90% of cases In 1998 there were 2701.6 diarrhea cases per 100 thousand children,

which was rather high (6) |

Diarrhea is not the only direct cause of death, but also the cause of malnutrition, especially in infants and children under five years old Repeated episodes of diarrhea contribute to malnutrition and are more likely to cause death in

children who are malnourished Therefore, diarrheal diseases and malnutrition

constitute a vicious cycle leading to increased rate of child morbidity and mortality Diarrhea also presents an economic burden for the developing countries In many of these countries, children with diarrhea occupy a large amount of hospital beds each year They also require expensive intravenous fluids, which in the long run affect the country's economy by reducing the health of its work force (7) ,

1.1.2 Case management of acute diarrhea

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= pes pane, ave tnd ME RAE cụ be fe at dea

Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) /3

World Health Organization's treatment guidelines are based on the major

features of the disease The following principles guide the treatment of the diarrhea include:

- Watery diarrhea requires replacement of fluids and electrolytes, regardless of the cause of the diarrhea For most patients, this can be accomplished with an Oral Rehydration Salt (ORS) solution or Sugar Salt Solution (SSS) Severely

dehydrated patients can be rehydrated intravenously with Ringer's Lactate solution

- Feeding should be continued during all types of diarrhea to the greatest extent possible It also should be increased after the diarrhea stops to avoid the effects of malnutrition

- Increase fluids as soon as diarrhea starts and continue feeding These

two keys can ensure that 90% of diarrhea cases can be treated successfully at home, without requiring the assistance of health workers (1)

- Drugs should not be used routinely Drug treatment does not help in most episodes of diarrhea, including severe diarrhea with fever The only exception to this is dysentery (with bloody stool), suspected case of cholera and some cases of persistent diarrhea The WHO recommendation is that antidiarrheal and antiemetic

drugs should never be used to treat diarrhea in children None of these drugs has

practical value and some are dangerous (2)

1.1.3 Practice of mother on management of acute diarrhea in children at home

Practice of mother on management of acute diarrhea in children at home

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Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 4

- Rule 1: Give extra fluids intake,

- Rule 2: Continuing food

- Rule3: Recognize danger signs and bring the child to the health worker for check up Six danger signs of acute diarrhea in children under five years old are: fever, repeated vomiting, bloody stool, not able to drink or breast-feed adequately,

a

does not better (the passage of many watery stool)(2)

And recommendation: do not give a child any antidiarrheal preparation,

antibiotic drugs and adopt significant preventive behavior

1.1.4 Problem statement

Many children die because their parents do not recognize warning signs

that indicate their children might be suffering from one or more of the above iliness

Changing family habits and the kinds of food offered to children is an important element of Integrated Management of Childhood Illness (MCI) approach, Correct management of diarrhea could save the lives of up to 90% of children who currently

die from the effects of the disease

An important element of IMCI approach is the encouragement of a healthier home life Through IMCI, health workers can counsel parents on how to improve care for their sick children Workers teach them how to administer drugs to combat pneumonia, how to follow the three rules of home care for diarrhea- increase fluids, continue feeding and recognize the danger signs that mean their children needs further treatment in a health facility (7)

More than 20 countries have begun to implement the IMCI strategy at

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-

Fac of Grad Studies, Mahidol Univ — ˆ M.P.HM HC Management) / 5

Acute watery diarrhea is the most common form and the most easily treated It may cause dehydration, which can usually be avoided by giving extra fluids and food with a little extra salt Oral Rehydration Salt solution can safely correct

‡

dehydration without the need for intravenous therapy in all but the most severe cases

(7)

The situation of diarrhea in Vietnam with a population of 78.7 million,

diarrhea in children is a major public health problem Although mortality rates

attributable to diarrheal diseases have been progressively decreasing in recent years Morbidity rate has been one of the most important health problems Mortality rate of children under five years old is 40 per 1,000 live births (9) Only 18% of rural households have access to proper sanitation facilities Poor environmental sanitation, lack of knowledge and failure to put knowledge into practice contribute significantly to this problem (10)

In Vietnam, mothers are mainly responsible in taking care of children

during the childhood and hence they are the ones who mostly influence the health of their children The health beliefs of mother toward diarrheal disease in children play a crucial role in their practice of child feeding, drinking, personal hygiene, sanitation and care of their children when they have acute diarrheal disease at home

Therefore, the study of factors related to mothers' home practice on

management of acute diarrhea among children under five years old, in Namdinh City, Vietnam is plausible and a priority

It is important to explore the factors related to correct and incorrect practice of mothers on management of acute diarrhea in children at home This

information can be used as baseline data for future diarrheal prevention and treatment

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1.2 Research objective

1.2.1 General objective:

‘To study factors related to mothers’ home practice on management of

acute diarrheal disease among children under five years old, in Namdinh City, Vietnam

1.2.2 Specific objectives

1.2.2.1 Determine Socio-Demographic factors of mothers who have children under five years old with acute diarrhea

1.2.2.2 Identify perception of mother about diarrhea in children

1.2.2.3 Identify the cues to action toward managing acute diarrhea-in children

1.2.2.4 Identify practice of mother on management of acute diarrhea in children at home

1.2.2.5 Determine association between Socio-Demographic factors of mother with their perception of diarrhea and their practice on managing acute diarrhea

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Fac of Grad Studies, Mahidol Univ

1.3 Conceptual frame work Independence Socio-demographic factors of mothers M.P.H.M (HC ManagemenÐ) / 7 Dependent Age Education Occupation Monthly income Family size Perception of mothers toward diarrhea in children

under five years old Susceptibility Severity Benefit Barrier Motivation Cues to action Mass media campaigns Advice from family member or other Experiences of mothers with diarrhea in children (diarrheal episodes of children in the last 6 months) Practices of mothers on management of acute diarrhea in children under five

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wie det ie dl En oo ea clk te Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 8 1.4 Operational definition

Diarrhea: Diarrhea is a group of signs and symptoms which describes how frequent “defecation” is and what are characteristics of the fecal matter It is a usually defined as the passage of three or more loose or watery stool in 24-hour period (11)

Classification of diarrhea, according to World Health Organization, there are

three main types of diarrhea ‹

1 Acute watery diarrhea is the most common form and the most easily treated (an episode of diarrhea lasts less than 2 weeks) It may cause dehydration, which can

usually be avoided by giving extra fluids and food with a little extra salt Oral

Rehydration Salts solution can safely correct dehydration without the need for

intravenous therapy in all but the most severe cases

2 Dysentery is diagnosed by the presence of blood in the stools and is treated with antibiotics

3 Persistent diarrhea is defined as an episode that lasts for more than 14 days”

Diarrheal episode: An episode of diarrhea of children is an interval in which

the definition of diarrhea is met and starts at the beginning to the end of the disease Two subsequent episodes of diarrhea are separated by an interval of normal stool at

least 3 days

Dehydration: During diarrhea there is an increased loss of water and electrolytes (sodium, chloride, potassium, and bicarbonate) in the liquid stool Water

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The classification of dehydration is graded according to the signs and

symptoms that reflect the amount of fluid lost:

- In the early stages of dehydration, there are no signs or symptoms

- As Dehydration increases, signs and symptoms develop These include: thirst,

restless or irritable behavior, decreased skin turgor, dry mucous membranes, sunken

eyes, sunken fontanel (infants), and absence of tears when crying vigorously

- In severe dehydration, these effects become more pronounced and the patient may develop evidence of hypovolaemic shock Death follows soon if rehydration is not started quickly

Oral Rehydration Therapy (ORT), This is method of rehydration by oral

administration of fluids, in order to correct and prevent dehydration, which is a

consequence of diarrhea

- Oral Rehydration Salt (ORS) refers to fluid for treatment of diarrheal disease

to reduce the severity of dehydration and to prevent deaths Universally recommended

formula containing of Sodium Chloride: 3.5 grams, Sodium Bicarbonate: 2.5 grams, Potassium Chloride: 1.5 grams, Glucose: 20 gram to be dissolved in one liter of drinking water

- Homemade Sugar Salt Solution (SSS): a special drink (salt, sugar and water) can be made to treat of diarrhea and prevent dehydration at home In one liter of drinking water add: sugar: 8 teaspoons (making level full of each), salt: 1 level teaspoonful (2)

Malnutrition in Diarrhea: during diarrhea, decreased food intake, decreased

nutrient absorption, and increased nutrient requirements often combine to cause

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HỆ RT BANDE TORRe Sk, UAE eS a triều

Use of antimicrobials drugs in diarrhea: antimicrobial drugs should be able to

fight effectively against bacteria like Shigella, Chorelra such as: Amoxycillin,

Metronidazole, chloramphenicol, Nitrofurans, Cephaleuxin.(2)

Use of " antidiarrheal" drugs: these agents, though commonly used, have no practical benefits and are never indicated for the treatment of acute diarrhea in

children Products in this category include adsorbents and antimicrobility drugs such

as: smectite, kaolin, loperamid hydrochloride, etc They do not prevent dehydration or

improve nutritional status, which should be the main objective of treatment Some have dangerous, and sometimes fatal, side effects These drugs should never be given to children below 5 years (2)

Beliefs of mothers following health beliefs model: means the result of repeated perception closely related to his/her own experiences, culture, customs and the age of the person in that society This study takes into consideration, the belief of the diarrheal disease related to management of acute diarrhea in children at home

Perceived Susceptibility: maternal believes or perception to the high or low opportunities of her child having acute diarrhea and its complicated symptoms

Perceived Severity: maternal believes or perception regarding seriousness of acute diarrhea in her child such as dehydration due to acute diarrhea causing death

Perceived Benefit: maternal believes or perception to the expected outcome of primary practices at home when her child having diarrhea

Perceived Barrier: maternal believes or perception to various factors under real situations which limit conditions in maternal practices when her child'having diarrhea

Health Motivation: maternal attention and concern to child health and her

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Cues to action are some things mass media campaigns, advice from family

member or other, experienced of mother about diarrhea in children, diarrheal episodes

of children in the last six months Those stimulate mother to take the recommended

actions on home care management of acute diarrhea in children under five years old

Home practices on management of acute diarrheal disease among children

under five years old are the performance of the duties and responsibilities of mother,

as practices toward management of acute diarrhea in children includes:

Increasing fluids means during episode diarrhea of children, mother have to give

him extra fluid (ORS, SSS) to correct or prevent dehydration In case infant,

increasing fluid means mother give children more milk or breasted than as usual

Continuing food means during episode diarrhea of children, mothers have to

continue to feed their children as usual to prevent malnutrition

Recognize danger signs means when children get diarrhea, mother observes and

take care of them recognize the signs fever, blood in the stool, vomits repeatedly, drink poorly, not able to drink or breast-feeding, do not better, to seek medical care

Using drugs means when children get acute diarrhea mother should not gives them any antidiarrheal preparation and antimicrobiotic drugs

Behavior of hygiene practice of mother on management of acute diarrhea at

home, in this study concern about hand washing of mother to limit transmission

diarrhea to another people |

1.5 Usefulness of the study

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: x z : THM SE ERD

Vietnam This study is also expected to provide information on the existing practice of mothers about management acute diarrheal disease in children This information can be used as baseline data information for future diarrhea prevention and treatment

program Furthermore, this study will also provide information about relationship

between socio-demographic factors of mother, their perception toward diarrhea and

mothers’ practice on management of acute diarrhea among children under five years

old at home, which will be helpful for health education program in the community of

Vietnam

1.6 Scope and Limitations of the study

The study was carried out in four villages in urban Namdinh City, Vietnam Therefore, it may not be generalized to the whole Namdinh City Since this study

needs to be completed in a short period of time, information about practice of mother was based on a set of questions given to them, rather than actual observation during their practice

1.7 Hypotheses

1) There is association between Socio-demographic factors of mother and their home practice on management of acute diarrhea in children under five years old

|

2) There is association between perception of mother toward diarrheal diseases in children and their home practice on management of acute diarrhea in children

3) There is association between cues to actions of mother toward diarrhea in

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Fac.of Grad Studies, Mahidol Univ : M.P.H.M.(PHC.Management)/13 CHAPTER II LITERATURE REVIEW 2.1 Epidemiology of diarrhea

In many countries, diarrheal disease remains a major cause of infant and child mortality Integrated Management of Childhood IIIness (IMCI) identifies the duration of diarrhea, assessing the severity of dehydration and the presence of blood in the

stools in order to categorize diarrhea and propose an appropriate treatment There are three main types of diarrhea (7)

Tablel: The main types of diarrhea

Type ofdiarrhea Case of Death dueto Death preventable by diarrhea(%) diarrhea(%) standard case ` management Acute watery 80 50 100 diarrhea Dysentery diarrhea 10 15 80 Persistent diarrhea 10 35 80

Source: WHO; fact sheet No.180 September 1997

Pathogens are most frequently associated with diarrhea in young children in developing countries Particular pathogens are Rotavirus, bacterias such as E.coli(the toxic form), Vibriocholera, Shigella, and Salmonella or protozoa like Crytosporidium, E.hystolytica, Giardia lambia(12)

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OR |

Nguyen Manh Dung Literature Review/14

Escherichia coli 14%, Campylobater 14.1%, Shigella 12.5%, Entamoba histolytica

7.8% and Salmonella 3.1% (13)

The incidence of rotavirus infection was studied among 704 children under five years old who were suffering from acute gastroenteritis in Tehran The frequency of

Rotavirus infection was significantly (p< 0.001) higher among patients under 24 months of age was19.7% as compare to children two years old or more (5.1%) (14)

According to an epidemiological study conducted in Vietnam in 2000, the Sentinel surveillance at 6 hospitals showed that disease burden of Rotavirus diarrhea as assessed by surveillance of children under 5 years old who were hospitalized for diarrhea at 3 centers in the North and 3 centers in the South., was identified in

56%(range 47%-60%) of 5768 patients between July 1998 to June 2000 (15)

Mode of transmission of acute diarrhea was mainly through the oral-fecal route, which included the ingestion of fecal contaminated water or food, and the spread of

infectious agent of diarrhea and direct contact with infected feces (12) The major

cause of death from acute diarrhea might have come from dehydration, which resulted in loss of fluids and electrolytes in diarrhea stools Other important causes of death were dysentery, malnutrition and serious infections, such as pneumonia But correct management could save nearly 1.8 million lives per year; IMCI reduces the death toll from diarrhea by promoting:

1 Rapid and effective treatment through standard case management

2 Prompt recognition and treatment of conditions that occur due to diarrhea 3 Improved home management

4, Improved nutrition

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Fac.of Grad Studies, Mahidol Univ M.P.H.M.(PHC Management)/15

2.1.1 Present global situation of diarrheal diseases

In the year 2000, World Health Organization and United Nations Children Fund announced three million children died of dehydration caused by

°

diarrhea

- Eighty percent of them in the first two years of their life

- Fifty-seven thousand (57,000) a week, 8,000 a day and six every minute

(16)

Diarrhea was estimated to account for 35.8% of deaths in children under five years old, in 1981 -1986 Based on this data and the demographic data from 1989,

young children in developing countries experience an estimated 1500 million episodes

of diarrhea per year and 9 million associated deaths (12.0 per 1000 children under five years old) (17) The incidence rate of diarrhea was found to be 3.6 episodes per child

semi annually and the point prevalence was 19.5% The average duration of current

episodes was 4.8 + or - 3.7 days, 33.6% of children had diarrhea more than three times (18)

I

In developing countries, diarrhea attributes to an estimate of 1.3 billion episode and 3.2 million deaths each year in children under five years old Overall, children experience an average of 3.3 episodes of diarrheal disease per years In some areas the average number of episodes per year is 9 (19) A study carried out by

Ryland S; RaggersII for 34 developing countries, The executive summary indicated

that prevalence of diarrhea was 16% for children under five years old Diarrhea prevalence peaked at 12 - 17 months and declined there after Prevalence was highest among children of young mother (20)

In the Southeast Asia Regions (SEAR), diarrheal disease is still a

problem, especially when occurring in children under five years old For instance, In Bangladesh, diarrhea was the leading cause of mortality and morbidity among children Similarly in Bhutan, DPR Korea, Myanmar, India, Indonesia, Siri Lanka,

and Thailand, diarrheal disease was one of the ten leading causes of morbidity and

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Table 2: Estimates of diarrhea associated deaths (1995)

Countries Total population §$ Total number of Diarrhea

- (aged <Syearsin under-five years associated deaths }

million) old deaths Bangladesh 17.46 500,218 123,554 Bhutan 0.26 6,730 1,662 DPR Korea 2.67 17,686 4,413 India 116.97 2,968,086 733/117 ` Indonesia 21.93 409,956 101,259 Myanmar 6.51 164,822 40,711 Nepal 3.550 101,384 25,042 Sri Lanka 1.80 6,915 1,708 Thailand 5.29 36,497 9015

Source: UNICEE, The state ofthe World's Chiidren, 1996

Every year, there are over one million deaths from diarrhea in children

one year of age Diarrhea accounted for about 25 percent of death of children less than five years of age in most of SEAR countries (see table 3) This is,a tragic because 90% of these deaths were preventable (21)

Table 3 Selected communicable disease in SEAR countries, 1995 Disease Estimated number of | Estimated number of deaths Acute respiratory 360,000,000 1,400,000 Diarrheal disease 318,000,000 1,000,000 Malaria 24,000,000 40,000 Measles 9,000,000 180,000 Tuberculosis 3,500,000 1,200,000 Hepatitis B 3,000,000 200,000 Source: WHO/ SEARO, Division of integrated control of disease, 1996 °

Study in Guatemala, Bangladesh and Indonesia found that 100-300

episodes of diarrhea occurred per 100 children per year during the first three years of

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Fac.of Grad Studies, Mahidol Univ M.P.H.M.(PHC.Management)/17

2.1.2 Present situation of diarrheal disease in Vietnam

In Vietnam, the situation of diarrheal disease is similar to the countries in SEAR Vietnam's diarrheal disease control program began in 1982 in four provinces and expanded over the last decade to cover the whole country Although the number

of deaths from diarrhea is on the gradual decline, but the number of cases had 10mœ0 — ot wa NTA — _— 2000 0 LU T T LU T ĩ ‹ wo #42 £#©4 #6 © £# #

Figure 1: Trend in diarrheal diseases in Vietnam, 1992-1998 Source: MOH of Vietnam, Health statistic yearbooks 1992-1998

According to the annual report of the Ministry of Health-Vietnam,, in

1998 diarrheal disease was placed second in the top-ten leading causes of morbidity

among children in almost all provincial and district hospitals The number of episodes of diarrhea per child per year is 1.4 and the rate of children under five years of age died of diarrhea was 19.11 percent (23)

In several studies that were conducted in Vietnam, children experienced

an average of 2.1 episodes of diarrheal diseases per year in Uong Bi district Another study in 3 villages in Ha Tay was found that an average of 3.5 episodes / child / year (24) In 1999, diarrhea was still the leading cause of child morbidity The report from

the general statistical office indicated that 11.32% of children under five years old

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higher, for instance, Northeast 17.72%, South Central Coast 14.68% Moreover, they

found that children from 6-11 months and 12-23 months had the highest prevalence of

diarrhea (25)

Since the World Bank's World Development Report 1993 described the Integrated Management of Childhood IlIness as the intervention is likely to have the greatest impact in reducing the global burden of disease It is also among the most

cost-effective health interventions in low and moderate-income countries Indeed,

adoption and implementation of this approach are now deemed essential to reaching

the goal set by the 1990 World summit for children for reducing childhood mortality

by 50% by the year 2000 (1)

2.2 Management of diarrhea at home

The children, who are seen at a health facility with mild diarrhea and dehydration have been successfully treated at the facility and are sent home to follow the plan A of the WHO / CDD chart for case management in the home (increase

fluids, continue feeding, and seek medical care when needed) Unlike many other treatments, which are provided by the health workers, case management in the home is entirely the responsibility of the mother or other child caretakers If correctly carried out, it can have a significant impact’on the health of children (26)

In many countries, diarrheal diseases remain a major cause of infant and child mortality Inappropriate treatment of diarrhea in this age group is a widespread problem in both the public and private sectors A survey on health centers in a South East Asian countries found that in some locations, less than half of children were

diagnosed with simple watery stool diarrhea, received Oral Rehydration Therapy

_ (ORT), while over 80% received hydroxyquinolone, a so-called antidiarrheal drug

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Correct management of acute diarrhea in children at home, should be done as the following (2)

2.2.1 Give the children more fluid than usual (increasing fluid)

In order to prevent dehydration in children with diarrhea should be

given fluids containing salts, such as ORS solution, salted drink (e.g salted rice water or a salted yoghurt drink), vegetable or chicken soup with salt, a home made solution contain salt and common sugar (SSS)

Some fluids are potentially dangerous and should be avoided during diarrhea as soft drinks, sweetened fruit drinks and sweetened tea because they can cause osmotic diarrhea and hypernatraemia

Other fluids to avoid are central nervous system stimulants, diuretics or

purgatives as for example coffee, some medicinal tea or infusions

Fluid should be given to the children according to the general rule, that is give as much fluid as the child ‘wants until diarrhea stops Or as a guide, after each loose stool, give children under 2 years of age 50-100 ml (quarter to half a large cup) of fluid, children aged 2 up to 10 years, 100-200m! (a half to one large cup) (27)

A Rao KV's study was carried out in India, through data from the 1992 - 1993 National Family Health Surveys The data set included 38,161 women who gave birth in 4 years The study found that children with diarrhea were twice as likely to receive decreased amounts of breast milk and another fluids than to be given increased amounts The low use of ORS is especially alarming since 61% of children with diarrhea in the previous 2 weeks were taken to a health facility, (28)

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markets in Ibadan, Nigeria The study took place between September 1996 and March

1997, 266 of mothers were interviewed in the first market and 260 in the other, 33% and 32% gave ORS at home for their child with acute diarrhea respectively (30)

Another study was designed to determine the fluid intake and feeding practice among under five years old children during episodes of diarrhea, in Nigeria

The findings showed that fluid in take (ORS or SSS) was low Only 43.3% of children

received more fluid respectively as compared to before the diarrhea (31) A study on

the management of diarrhea, in young children at community level in Thailand was reformed, among 15,466 children who were randomly selected from households of 30

clusters of twelve provinces from twelve regions of Thailand The results showed that the utilization of ORS was 25.6% while the rate of using sugar salt solution (SSS) and

the use of recommended home fluids was 2.8 and 33.8 % respectively Only 23.7% of

patients could correctly prepare the ORS (32)

An Indonesian study in West Lombok reported factors associated with the

use of oral rehydration solution among 293 mothers in six villages It was found that

more than 66% of mothers had used oral rehydration therapy for home management of diarrhea, either as packaged oral rehydration solution (ORS) or as salt-sugar solution (SSS) Fifty-six percent of mothers reported giving ORS and 10% reported

giving SSS Only 37% of mothers, however were able to prepare ORS properly, and 9% were able to prepare SSS properly (33)

A study on households in different parts of Vietnam during 1986 - 1987 revealed several areas of concern about a very low rate of ORS and SSS usage (7 per cent and 13 per cent respectively) Moreover, with only just over half of mothers (54

per cent) continued to feed children during diarrhea, slightly more than 45%

continued breast- feeding during diarrhea (34) Kim Sac, (Vietnam-1997) reported that among 50% of mothers using ORS at home, the amount of ORS solution given to the child with diarrhea was no more than 60 ml during 24 hours; and they do not give ‘fluid right away at the onset of diarrhea (35) These findings are similar to the finding

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A cross-sectional study was done in Tien Giang province, in Mekong

delta in 1998 The finding showed that the majority of mothers (95%) gave fluids

when children had diarrhea and they knew fluids would make the children better

Most of them (83%) used ORS solution, they thought ORS solution could stop diarrhea, but only half of them (50%) prepared the ORS solution correctly (36) Sixty- eight percent of mothers do not read the instructions printed on the ORS packets Some of them read but did not mix the whole packet, because they thought that one

liter of ORS solution was too much, so the children could not finish it Mothers liked to save ORS solution (37)

Table 4: Summary of findings about using ORS or other fluid for children with + MBG ET Bi diarrhea Year Author Study Finding of using ORS or other areas fluids 1992-1993 A Rao KV's India low use of ORS, decreased ORS and other fluid 1996-1997 Coatepec, Vera Nigeria ‘32% mother use ORS for children Cruz

1996 Edel EE Nigeria 43.3% of children received more fluid 1997 Wongsaroj T, Thailand 25.6% ORS 2.8% SSS, 33.8 % other

Thvornnunthj fluids

1994 Widarsa KT Indonexia 66% use ORS,SSS,

1986-1987 Nguyen Dung Vietnam low rate of ORS 7% and SSS 13%

1997 Kim Sac Vietnam 50% using ORS and no mofe

60ml/24hour

1998 Kin Tien ` Vietnam 50% used ORS correctly

2000 CDD program South 68% used ORS but most of them

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Table 5: Summarized guideline of WHO/CDD about amount fluid supplied for children with acute diarrhea at home

Method Standard of using fluids for children with acute diarrhea at home (based on guideline WHO/CDD)

Rule 1 - Give as much fluid as the children want Rule 2 As a guide:

+ Under 2 years old: 50-100ml after each loose stool + More than 2yeas old: 100-200ml after each loose stool

Source: The treatment of diarrhea WHO/CDD/80.2 R 2(1990)

2.2.2, Continuously feeding the children with diarrhea

In order to prevent malnutrition, feeding should be continued during

diarrhea and increased afterwards Food should never be withheld and the child's

usual foods should not be diluted Breast-feeding should always be continued The aim is to give as much nutrient rich food as the child can accept

Most children with watery diarrhea regain their appetite after dehydration

is corrected, whereas those with bloody diarrhea often eat poorly until the illness

resolves When food is given, sufficient nutrients are usually absorbed In contrast,

children whose food is restricted or diluted lose weight, have diarrhea for longer duration and intestinal functions are recovered more slowly

Therefore which food to give a child depends on the child's age, food preferences and pre-illness feeding pattern, cultural practices In general, food suitable

for a child with diarrhea is the same as required by healthy children Specific

recommendations are given below

Milk

-Breast fed infants should be allowed to take milk as often and as long as they want

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Fac.of Grad Studies, Mahidol Univ M.P.H.M.PHC.Management)/23

|

-Infants below 4 months of age who take breast milk and other foods

should receive increased breast-feeding As the child recovers and the supply of breast

milk increases, other foods should be decreased

Other foods

-If a child is at least 6 months old or is already taking soft foods, he or she should be given cereals, vegetables and other foods, in addition to milk

-If a child is over 6 months and such foods are not yet being given, they

should be started during a diarrheal episode or soon after it stops

-Recommendation: Food should be culturally acceptable, readily available, have micronutrients They should be well cooked, and mashed or grinned to make them easy to digest Food should be offered to the children every three or four

hour (six times a day) Small and frequent feedings are tolerated better than less

frequent and large ones

-After diarrhea stops, continue giving the same energy rich foods in

addition to an extra meal each day for at least two weeks (2)

Breast-feeding has a substantial role for protection of infectious diseases and diarrhea VanDerslice et al conducted a follow-up study in metropolitan Cebu City They showed that there was little difference in diarrhea prevalence between

mixed-fed and non-breasted group, after 6 months of age The study also indicated that full breast-feeding provided the highest effect in prevention of diarrhea among

children who lived in crowded family under low sanitation conditions (38)

To compare the difference between effective feeding frequencies and the speed of recovery from diarrhea, Chaomin Wan showed in his study that frequently

fed infants had a significantly greater weight gain and significantly lower fecal

frequency and fecal weight Frequently fed group had a significantly shorter duration

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|

Halliday K and his colleague carried out a study in 168 consecutive

patients admitted to the Royal Children's hospital, Brisbane They found that severity

and outcome varied with most cases requiring a defined formula diet (40) The results from study in’ Sudan: 45% mothers stopped breast-feeding and foods while their children had diarrhea (41)

¬ \

Perception of mothers towards diarrhea and taking care of children when

their child had diarrhea is very important In the study, " Feeding practices of mothers during childhood diarrhea in rural area of Nigeria " (1996), 335 randomly selected mothers with children under 5 years of age were interviewed The diets chosen by mothers reflected cultural perceptions of the etiology of illness and of the therapeutic

properties of local foodstuffs Raw cornstarch was believed to be an antidiarrheal

agent and therefore given for all types of diarrhea, while rice was avoided Sugar,

sweet foods and groundnut preparation, which were perceived as causes of bloody diarrhea and related illness, were proscribed (42)

Home management of diarrhea was studied in 1,638 children under 5

years of age whose 1,160 mothers were randomly selected in Suleja (Nigeria) local government area in 1994 by Babaniyi During episodes of diarrhea, almost all mothers continued breast-feeding and gave available home fluids, but 42% stopped feeding

solid food (43)

In Thailand 1997, a study on the management of diarrhea in young children at community levels Wongsaroj T and his colleague evaluated 15,466 young

children from randomly selected clusters in 12 provinces 84.3 % of mothers breastfed

their child during the diarrheal episodes (44) `

In Vietnam, Kin Hung pointed out that knowledge among mothers about

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Kim Sac ct al.-Vietnam indicated that the majority of mothers 91% abstained from animal and vegetable oil when their child had diarrhea, because they

thought that a child could not digest these One- fourth of mothers 25% abstained ˆ

from fish, shrimp, and crab when their child had diarrhea, because they thought seafood could cause the child to have more serious diarrhea Approximately 30% of

them gave only rice gruel with sugar or salt to their children when they had a diarrhea, Fifty-one (51%) of them reduced feeding and 12% stopped breast-feeding

the child The authors concluded that mothers lacked knowledge in feeding their children while having diarrhea (35)

Table 6: Summary of findings about mothers' home practices on feeding children with diarrhoea

year Author Study area Findings

1982 Halliday K Thailand Formula diet, more severity case

1994 Ahmed.Eltonet Sudan : 45% stop breast feeding when diarrhea 1994 Babaniyi Nigeria 42%stoppedsolidfood

1996 Jinadu MK Nigeria Raw corn is belied to be an antidiarrhea

Rice, groundnut were avoided

1997 Thailand Wongsaroj 84.3% continue feed

1997 Vietnam, Kin Hung Abstained from some common daily food

1997 Kim Sac 30% only rice gruel with sugar 25%

abstain from fish 51% of reduce feeding, 12% stop breast fed 1999 Chaomin Wan China Frequently feeding greater than weight

gain, lower fecal frequency

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Table7: Summary how to supply food for children with acute diarrhea (Following guide line of WHO/CDD)

Age of children Standard feeding for children with acute diarrhea at home (following guide line WHO/CDD)

Infant -Infant: breast feeding as long as they want -Infant below 4 months: increase breast-feeding

Children more -At least 6months: milk, vegetable other food with high energ

than 4 month mashed, well cooked `

-After diarrhea stop: continue the same energy rich food

Source: The treatment of diarrhea WHO/CDD/80.2 R 2(1990)

2.2.3 Take the child to a health worker if there are the signs of dehydration or other problems

Mothers are needed to know what signs to watch for, to decide whether the child needs medical care or not Since understanding and recognizing dehydration may be difficult, the CDD program suggests a few simple signs that most mothers can recognize easily These are

the child can not eat or drink

the child is very thirsty

the child passes many watery stools

the child is vomiting the child has a fever

there is blood in the child's stool

the child is not getting better

It is very important that the mother should understand these signs and can

practice when her child has a diarrhea (2)

A survey and non participant observation were conducted by Agbere AD

in late 1995, in rural Togo to evaluate the home care given by mothers to their undér -

five years old children with diarrhea One hundred mothers in 7 villages were questioned about signs of severe diarrrhea The mothers said would prompt them to

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sockets for 39%, duration for more than 2 days for 36%, fatigue for 6% and thirsty for

4%, (46)

In 1999, Sodemann M and his colleague carried out a study about the

management of childhood diarrhea and use of oral rehydration salts in a suburban West African community In household survey in Bandim, Guinea-Bissau, on 319 episodes of diarrhea in children of mean age 10.5 months old were followed by interviews every second day of episodes until the mother reported that the diarrhea

had stopped, the child was hospitalized, or 14 days had elapsed Children with diarrhea were considered to be caused by teething were less likely to receive ORS during the acute phase By univariate analysis it was found that there was relationship between the use of ORS for breast-fed children and the number of reported symptom, but mothers being the caretaker did not know how to recognize the symptoms and

lack of knowledge of ORS Although most mothers knew about oral rehydration salts, only 58% of diarrhea episodes were treated with ORS and inadequate amount was

given to the children (47)

Kim Sac in Vietnam had indicated that 87% of mothers could not recognize all 6 dangerous signs There were some dangerous signs that mothers did

not know such as: drink poorly and not able to drink or take milk (35) These findings

were consistent with study by Ahmed et al (1994) in Sudan who found that 90% of mothers could not recognize the dangerous signs

A study dealt with the issue of incorrect home care for children under five years of age in the Mekong delta, Vietnam Le van Tuan found that most of mothers (83.3%) did not know the dangerous signs of diarrhea in children (48)

2.2.4 Using antimicrobial and antidiarrheal drugs

Antimicrobials should not be used routinely This is because, it is not

possible to distinguish clinically which episode might respond well, such as diarrhea

caused by enteroxigenic Ecoli, from those caused by agents unresponsive to

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responsive infections, selecting an effective antimicrobial requires knowledge of

sensitivity of the causative agent, information that is usually unavailable

Antidiarrheal drugs have no practical benefits for children with acute

diarrhea They do not prevent dehydration or improve nutritional status, which should

be the main objective of treatment Some have dangerous and sometimes fatal side effects These drugs should never be given (2)

In many countries, diarrheal diseases remain a major cause of infant and

child mortality Inappropriate treatment of acute diarrhea in these age groups is a widespread problem in both the public and private sectors Furthermore, it is a problem with two dimensions: Under use of oral rehydration therapy (ORT),

including oral rehydration salts (ORS) and use of ineffective products such as antidiarrheal preparations and antimicrobial drugs in cases where their use is not

indicated ,

In a survey of health centers in South East Asian countries, it was found that: in some locations, less than half of children diagnosed with simple watery stool diarrhea received ORS, while over 80% received hydroxyquinoline, also called antidiarrheal drugs known to have dangerous side effects (27) A study in India, Rao

KV, Mishra VK and Retherford RD wete selected 38,161 women who gave birth in the 4 years preceding the survey and 4558 children born 1-47 months before survey who were sick with diarrhea at any time during the 2 weeks before interview 94% of these children were given antibiotic or other unnecessary drug (28)

A prospective epidemiological and clinical study of acute diarrhea,

among children under five years old was carried out by Suwatano O- Thailand One

hundred and five (105) cases of acute diarrhea were studied Causative pathogens