FACTORS AFFECTING THE USE OF ORAL REHYDRATION THERAPY IN THE HOME MANAGEMENT OF DIARRHOEAL DISEASE

• SUMMARY

 

Aim: To identify the factors affecting the use of oral rehydration therapy in the homemanagement of diarrhoeal disease.

Study period: The study was carried out between June and Number,2003.

Study design: Four hundred (400) consecutive children aged less than five years who presented with diarrhoea at Plateau State Specialist Hospital, Jos were seen and examined. Their mothers were interviewed. Their demographic data, duration of diarrhoea, level of dehydration and nutritional status were obtained. The usage rate of oral rehydration therapy (ORT) at home before presentation and mother’s knowledge of mixing and administration of oral rehydration solutions were assessed. The factors relating to the correct use of ORT were analysed.

Results: Diarrhoeal disease was more prevalent in the second half of infancy. A total of 237 (59.3%) patients had no dehydration, 150 (37.5%) had some dehydration, and

13 (3.3%) had severe dehydration. Malnutrition was present in 70 (17.5%) patients. The usage rate of ORT was 39%, oral rehydration salt (ORS) was 34%, and salt sugar solution (SSS) was 5%. There was a significant association between use of ORT and the degree of dehydration. There was no relationship between use of ORT and mothers’ educational status or parity. Of the 20 mothers who used SSS, only 10 (50%) prepared it correctly. Of the 136 mothers who used ORS, only 18 (12.5%) prepared it correctly. The rest prepared hypertonic solutions. There was no association between the ability to prepare ORT correctly and mothers’ educational status. The average volume of the correctly prepared and incorrectly prepared ORT administered in 24 hours were 600ml and 300ml respectively, and they were low. There was no relationship between the administrative skill of the mothers and their parity or educational status.

Conclusion: These findings showed that mothers were lacking in their knowledge of the work, the reconstitution and administration of oral rehydration solutions. The value of ORT in the home-management of diarrhoeal disease is therefore limited. There is a need to intensify effort at teaching mothers the correct way to prepare and administer  ORT at home so that its full impact and benefits will be realized.

TABLE OF CONTENTS Title -       -        -        - -         -         -         -         -         -         i

Declaration -          -         -         -         -         -         -         -         -         ii

Certification -         -         -         -         -         -         -         -         -         iii

Dedication -           -         -         -         -         -         -         -         -         iv

Acknowledgement -         -         -         -         -         -         -         -         v

Abbreviations         -         -         -         -         -         -         -         -         vi

Table of contents -           -         -         -         -         -         -         -         vii

List of tables and figures -          -         -         -         -         -         -         x

Summary     -         -         -         -         -         -         -         -         -         xii

CHAPTER ONE

1.1. Introduction     -         -         -         -         -         -         -         -         1

1.2. Statement of the problem    -         -         -         -         -         -         4

1.3. Aim and specific objectives -         -         -         -         -         -         5

1.4. Rationale for the study        -         -         -         -         -         -         5

1.5. Assumptions -           -         -         -         -         -         -         -         6

CHAPTER TWO: LITERATURE REVIEW

2.1. Definition and clinical types of diarrhoea -          -         -         -         7

2.2. Aetiology         -         -         -         -         -         -         -         -         8

2.3. Epidemiology -          -         -         -         -         -         -         -         9

2.4. Pathogenesis of infectious diarrhoeas     -         -         -         -         10

2.5. Degree of dehydration         -         -         -         -         -         -         12

2.6. Types of dehydration -         -         -         -         -         -         -         14

2.7. Electrolyte disturbances in diarrhoeal disease -           -         -         16

 

2.8. Diarrhoea as a cause and an effect of malnutrition      -         -         16

2.9. Evaluation of patients with acute diarrhoea        -         -         -         18

2.10. Evaluation of patients with chronic diarrhoea -           -         -         21

2.11. Management: Oral Rehydration Therapy         -         -         -         24

2.12. Formulation of oral rehydration salt       -         -         -         -         25

2.13. Salt sugar solution -          -         -         -         -         -         -         27

2.14. Prevention of dehydration  -        -         -         -         -         -         28

2.15. Treatment of dehydration -          -         -         -         -         -         29

2.16. Limitation of ORT    -         -         -         -         -         -         -         32

2.17. Cereal-based ORS formulation -           -         -         -         -         33

2.18. Dietary management of acute diarrhoea -        -         -         -         36

2.19. Anti-diarrhoeal and antimicrobial agents -        -         -         -         37

2.20. Intervention for the control of diarrhoeal disease        -         -         39

2.21. Child survival strategy       -         -         -         -         -         -         40

2.22. Evaluation of the programmes     -         -         -         -         -         41

CHAPTER THREE: MATERIALS AND METHODS

3.1. Location of the study -         -         -         -         -         -         --       50

3.2. Study area      -         -         -         -         -         -         -         -         51

3.3. Sample size    -         -         -         -         -         -         -         -         51

3.4. Study design -           -         -         -         -         -         -         -         52

3.5. Collection of data      -         -         -         -         -         -         -         53

3.6. Therapy -        -         -         -         -         -         -         -         -         56

3.7. Statistical method      -         -         -         -         -         -         -         57

CHAPTER FOUR: RESULTS

4.1. Characteristics of the subjects in the study        -         -         -         58

4.2. Characteristics of the children with diarrhoea. -            -         -         60

4.3. Degree of dehydration         -         -         -         -         -         -         61

4.4. Level of malnutrition - -        -         -         -         -         -         -         62

4.5. Usage of oral rehydration therapy- -        -         -         -         -         64

4.6. Preparation of Oral rehydration therapy -           -         -         -         67

4.7. Acceptance of ORT- -          -         -         -         -         -         -         68

4.8. Administrative skill of the mothers -         -         -         --       -         70

4.9 Knowledge of salt sugar solution    -         -         -         -         -         73

CHAPTER FIVE: 

5.1. Discussion       -         -         -         -         -         -         -         -         76

5.2. Conclusions    -         -         -         -         -         -         -         -         84

5.3. Recommendations    -         -         -         -         -         -         -         85

REFERENCES-     -         -         -         -         -         -         -         -         87

APPENDICES

INTRODUCTION

Diarrhoeal disease is a major health problem and one of the leading causes of childhood morbidity and mortality particularly in the developing countries¹. It is estimated that 1.4 billion episodes of diarrhoea occur annually in children under the

age of five years resulting in about four to five million deaths^1,2. Currently in Nigeria, diarrhoeal disease ranks among the first three causes of hospital admission and deaths among children under five years of age, accounting for about 25% of deaths in these children ³. A National household survey on control of diarrhoeal disease conducted in the country in 1993, showed an incidence rate of acute watery diarrhoea of 4.9 episodes per child per year. Annually in Nigeria, there are approximately 200,000 deaths from acute watery diarrhoea. This translates to approximately 500 deaths daily or no less than one death every three minutes³.

Diarrhoeal infections inhibit the body’s ability to absorb salts and water. Fluid is lost faster than it can be replaced thus leading to dehydration - the major contributor to mortality. Fortunately, dehydration can be prevented by the use of oral rehydration therapy (ORT), which simply means increased fluid intake and continued feeding instituted at the onset of diarrhoea³. Oral rehydration therapy is a simple, inexpensive and effective therapy based on the discovery that glucose greatly increases the capacity to absorb salt and water⁴. The benefits of ORT are clear. It is cheap. The materials are readily available in most homes. It does not require expert knowledge or manpower. It avoids most of the complications associated with the intravenous therapy. The mother is involved in the medical management of her child.

ORT campaigns are concentrating on teaching mothers to forestall dehydration by using household remedies at the onset of diarrhoea since effective early interventions can reduce complications and subsequently will result in fewer office or emergency room visits, hospitalizations and deaths.

The major components of the ORT campaigns in Nigeria are ^{5, 6}:

1. Recognition of diarrhoea by parents as a potential cause of death.
2. Prompt institution of management with salt-sugar solution and other homebased fluids.
3. Continuation of breast feeding and other feeds during and after diarrhoea.
4. Prompt recognition of simple clinical indicators of failure of homemanagement, such as the signs of dehydration, as an indication for seeking expert help.

Due to the high impact of diarrhoea on health, several countries have initiated a programme on control of diarrhoeal disease (NPCDD) to help co-ordinate

management of diarrhoea at all levels throughout the country^5,7. Its goals were to reduce the incidence of diarrhoea and prevent complications through oral rehydration therapy using oral rehydration salt. The programme also emphasizes on the prevention of diarrhoea by using interventions that are cost effective and easy to incorporate in the primary health care programmes. These interventions include improved nutrition through promotion of breastfeeding and proper weaning practices; adequate supply and use of safe drinking water; good personal, domestic and environmental hygiene; immunization, especially against measles; female education; improvement in socioeconomic status; safe faeces disposal and the provision of vitamin A.

Similarly, oral rehydration therapy has been recognized and inco-orporated as a strategy for child survival and development revolution (CSDR) in any country with a high incidence of diarrhoeal disease⁷. These are programmes aimed at curtailing the high rate of infant morbidity and mortality in these countries. At the world summit for children in 1990, over 150 countries under-took to attain 80% access to and usage of oral rehydration therapy by 1995 with a view to achieving a

reduction of 50% in mortality attributable to diarrhoea by 2000^5,7. This was to be achieved through health education of the public and establishment of health care facilities especially for oral rehydration salts.

The programme since its establishment, has shown both success and failure in its efforts to achieve its objectives. Case studies all over the world show positive trends in diarrhoea management⁸. ORT is now given to the majority of children with diarrhoea resulting in a significant reduction in the mortality rate due to diarrhoea. Nonetheless, several workers have found that less than half of women who knew

about ORT actually use it when their children have diarrhoea^8,9. It is estimated that world wide, oral rehydration is currently used by 23% of those who can benefit from the treatment, usually being given only for maintenance or to correct mild dehydration⁹.

There is a need for continuing education for healthcare providers and caretakers to become familiar with the benefits and applicability of ORT, so that in the long term, oral rehydration solutions would become more widely used both in the clinic and at home, and this would greatly reduce cost, and the rate of hospitalization and mortality attributable to diarrhoeal disease⁹.

 

Statement of the problem

Diarrhoeal disease is one of the leading causes of childhood morbidity and mortality, particularly in the developing countries. It has been shown that oral rehydration therapy is a very important and efficient tool in combating this scourge ⁹. Though, the level of awareness of ORT has been increasing, studies carried out both within and outside the country indicate a low usage rate of ORT (SSS and

ORS) in the management of diarrhoeal disease, both at home and in the clinic^9,10. Similarly, serious harmful errors in mixing the ingredients and administration of the

solution have commonly been reported^10,11. These have limited the potential benefits derivable from this innovation. There is a need to find out the factors affecting the knowledge, use rate and correct use of salt-sugar solution in the homemanagement of diarrhoeal disease. These were the motivation for this study.

 

Aim of the study

 

To identify the factors affecting the use of oral rehydration therapy in the homemanagement of diarrhoeal disease in children.

 

Specific objectives

 

To determine

1. The clinical presentation (Level of dehydration and Nutritional status) of diarrhoeal diseases in children presenting at Plateau State Specialist Hospital, Jos.
2. The use rate of oral rehydration solutions (salt sugar solution and oral rehydration salt solution) at home before presentation.
3. Errors regarding their use.
4. The level of mother’s awareness and knowledge of salt sugar solution.

 

Rationale for the study

Most of the studies on the knowledge and use of ORT so far reported were done in rural areas among the illiterates. It is pertinent to carry out a study in a relatively urban and literate environment to identify the factors affecting the use of oral rehydration therapy in the home-management of diarrhoeal disease. This will help to know the level of impact the ORT campaigns has achieved so far, and assist in redesigning the programme to a more efficient and effective intervention strategy.

 

Assumptions

For the purpose of this study, the following assumptions were made.

1. Mothers should be aware that diarrhoeal disease is a great killer disease of childhood, and that it chiefly does so by causing electrolyte and fluid loss.
2. Oral rehydration therapy (SSS and other recommended home fluids) is adequate and effective to be used in the home-management of diarrhoeal disease.
3. They should initiate the use of salt-sugar solution as a first line remedy to prevent dehydration at the onset of diarrhoeal disease.
4. They should be able to prepare and administer this solution correctly at home.
5. When signs of dehydration develops, the mother should be able to recognize this, and the child should be taken to a health care facility for management which may include the use of oral rehydration salt (ORS)

solution.

FACTORS AFFECTING THE USE OF ORAL REHYDRATION THERAPY IN THE HOME MANAGEMENT OF DIARRHOEAL DISEASE

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