Knowledge, Attitude and Practice Regarding Diarrheal Disease and the Use of Oral Rehydration Therapy among Mothers Attending Outpatient at a Tertiary Care Hospital –A Descriptive Cross Sectional
Study
Santosh Kumar K
1*, Sankavi Santosh Kumar
2, Subramanian V
31
*Associate professor, Department of Neonatology, Saveetha medical college and hospital, Thandalam, India
2
Assistant surgeon, Tamilnadu medical service, India
3
Assistant professor, Department of Pediatrics, Saveetha medical college and hospital, Thandalam, India
ABSTRACT
Acute diarrheal disease is the second most common cause of mortality among children under five years of age and next only to Acute respiratory tract illness. Oral rehydration therapy is a lifesaving intervention which can prevent mortality and morbidity associated with diarrheal illness. This descriptive cross- sectional study was conducted at Saveetha medical college and hospital, India from March 2018-March 2020. The awareness and knowledge, attitude and practices of mothers of children under 5 years of age with diarrheal illness was evaluated through a questionnaire. A total of 240 mothers were included in the study, of the 240 mothers who were included in the study 96 mothers were aware of the correct meaning of diarrhea. Majority of the mothers (196 of 240) knew about the oral rehydration therapy. But of the 196 mothers only 86 mothers knew the correct way of preparing the ORS. Majority of the mothers (96 of 240) did not know how to assess for dehydration and how to look for signs of dehydration. A strong association between maternal education and socio-economic status and ORT was noticed in the study. No association was established between age of the mother gender of the child and religion and ORT usage.
There is limited knowledge among parents regarding diarrheal illness. Every opportunity of contact with the parents should be utilized by the doctors for imparting health education regarding preparation of ORS and how to identify signs of dehydration.
Keywords: ORS, ORT, Under 5 Mortality, Acute diarrheal episode, Dehydration, Knowledge, Awareness.
Citation: Santosh Kumar. (2020). Knowledge, Attitude and Practice Regarding Diarrheal Disease and the Use of Oral Rehydration Therapy among Mothers Attending Outpatient at a Tertiary Care Hospital –A Descriptive Cross Sectional Study. Journal of Clinical and Translational Neonatology, 1(1), 11-16. http://dx.doi.org/10.33702/jctn.2020.1.1.2
Author for correspondence: Santosh Kumar, Saveetha medical college and hospital, Thandalam, India Email: [email protected]
Copyright: Santosh Kumar
License: This open access article is licensed under Creative Commons Attribution 4.0 International (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0
INTRODUCTION
Acute diarrhea is one of the common reasons for outpatient visits among under-five children. It is also the second most common cause of under-five mortality in India second only to acute respiratory tract infections. It contributes to around 20 % of all deaths among under-five children globally [1]. It also creates anxiety among parents as its usually associated with vomiting .Diarrheal deaths are easily preventable by following the World health organization guideline on management of diarrheal illness which recommends Oral rehydration therapy and Zinc .Probiotics have also been found to be useful when administered at the correct dose by reducing the purging episodes and improving the consistency of stools and reducing the duration [1,2].
Revision received: July 25, 2020
Accepted: July 30, 2020 www.joctn.com
DOI:10.33702/jctn.2020.1.1.2 Research Article
There is generally poor knowledge and awareness among parents about diarrheal illness among under- five children who usually attribute it to teething etc. Knowledge, awareness and attitude of the parents especially the mothers play a key role in preventing diarrheal death. Diarrheal deaths are usually due to loos of fluid leading to severe dehydration, shock and electrolyte imbalance. When associated with malnutrition, immunosuppressed conditions like splenectomy, AIDS it can be life threatening. Diarrhea can be infective or non-infective. Infective diarrheal episodes are more common among children and usual pathogens are viruses though bacterial infections, parasitic infections can also be the cause. Among viruses the most common cause in children is Rotavirus followed by Adenovirus Calcivirus and Norwalk viruses. Among the bacterial pathogens E.coli, Salmonella and Shigella are the common causes though vibrio can occur during epidemics. Parasitic and fungal causes are quite are and occur usually among immunocompromised children [1-3].
Usual mode of infection is by contaminated food or water and is as a result of poor hygiene. Maternal knowledge plays a key role in health promotion, disease prevention, early identification and management of a child with diarrhea. Strategies targeting diarrheal illness center around washing hands with soap which is one of the most cost-effective public health interventions, scaling up the use of ORT, zinc supplementation, and education regarding its appropriate usage for those in need with focus on cultural/hygienic factors. ORS is considered as one of the most important lifesaving medical advances of our centaury. Low-osmolality ORS is preferred because it reduces stool output by 20%, vomiting by 30%, and the need for intravenous fluid administration by 33% when compared with regular ORS. Zinc supplementation by improving epithelial regeneration reduces the duration of diarrheal episodes by 25%
and treatment failure and death by 40 % in persistent diarrhea.
However only one third of the children with diarrhea in developing countries receives ORT and continued feeding. And only one fifth of the children drink more fluid s during episodes of diarrhea .Further most of the diarrheal death are not due to lack of intervention but due to poor knowledge and attitude of the caregiver4. Global Action Plan for Prevention and control of pneumonia and diarrhea (GAPPD) 5was launched by WHO and UNICEF to take control of these two major killers of children and WHO is commitment to ensure 80% of world’s children having access to interventions and immunizations. These interventions will ensure elimination of diarrheal deaths by 2025.
This effort consists of a seven-point program was launched with two elements relating to treatment and five elements toward prevention. Two elements in treatment of diarrhea were fluid replacement with low-osmolality ORS to prevent dehydration and zinc treatment to prevent severity and duration of diarrhea in addition to continued feeding, including breast-feeding and use of appropriate fluids available at home if ORS is not available. Preventive elements included Rota viral and measles vaccination, promotion of early and exclusive breast-feeding with vitamin A supplementation, promotion of hand washing with soap, improvement of water supply including treatment and safe storage of household water, and promotion of community-wide sanitation.4,5 In India, Integrated Management of Neonatal and Childhood Illnesses (IMNCI) gives guidelines for management of acute diarrhea. There are very few studies which have actually asses the caregiver’s knowledge, attitude and the practices that they follow when their child is having diarrheal episodes. This study was done to determine the awareness and knowledge regarding diarrhea and its management among parents/caretakers and understand their perception, to determine the association of knowledge and perception of parents with selected demographic variables, and to identify the solutions to address the knowledge gap.
MATERIALS AND METHODS
A prospective descriptive study was conducted in the Department of Pediatrics, Saveetha medical college and hospital, teaching hospital located in suburban part of Chennai between March 2018 and March2020.
The hospital is visited by children from all socioeconomic strata. All those mothers who satisfy the inclusion criteria were included in the study. Data was collected from mothers by standard questionnaire method as per case record format.
Study population
• Parents/attendees of children under five years who visit the hospital for diarrheal illness.
• Parents/attendees of in-patient children under five admitted with diarrheal illness.
All the parents who enrolled in the study consented to be a part of the study. A questionnaire was given to all the parents which collected data on the demographic profile of the parents (age, religion, urban/ rural, education, income), data about the child which included age, sex, birth order, number of siblings and also data regarding the parenteral knowledge and attitude about diarrheal illness which included questions on ORT, Zinc supplementation, foods that are given during diarrhea, causes of diarrhea, hygiene practices etc. were studied.
Statistical analysis
Statistical analysis was done with SPSS-21 and mean, and standard deviation and proportions were analyzed.
Categorical variables were presented as bar diagrams, pie charts, frequency and percentage
• The Chi-square test was used to measure associations between nominal variables
• Test was considered significant where p value is < 0.05
• Level of significance was obtained using T test.
RESULTS Demographic data
A total of 240 mothers were included in the study around 196 mothers were from rural background and 44 were from urban background. Majority of the mothers were illiterate or had school education (192) .Very few mothers had completed graduation (44) and post-graduation (4) .Majority of them were Hindus followed by Muslims and Christians .More than two third were from nuclear family .Mean age of the child presenting with diarrhea was 2 years 1 month .There was no major sex preponderance with male children being slightly higher than female children.
Table 1: Demographic characteristics
Parameter n% (n -240 )
Place of stay Rural
Uraban 81.67%(196)
18.33%(44) Mothers education
School education Graduate Post graduate
80%(192) 18.33%(44) 1.67%(4) Religion
Hindu Muslim Christians Others
82.5%(198) 11.6%(28) 4.6%(11) 1.3%(3) Type of family
Joint family
Nuclear family 27.5%(66) 72.5%(174) Sex of the child
Male
Female 53.75%(129)
46.25%(111) Per capita income
< Rs 70069
Rs 70,137 to Rs 2,73,098 Rs 2,73,167 to Rs 8,45,955
>Rs 8,46,023
37.5%(90) 45%(108) 16.3%(39) 1.67%(3) Birth order
1st 2nd 3rd
19.17%(46) 66.25%(159) 14.58%(35) Level of knowledge among parents
Parents were provided with questionnaire which consisted of questions relating to the Definition of diarrhea, possible causes of diarrhea, what are the preventive measures which can be taken to prevent diarrheal episodes, what are the treatment options for diarrhea, are there any vaccines which can be used to prevent diarrhea and how to identify if the child has dehydration and what are the home based remedies that can be used. The knowledge level and awareness of the parents were assessed using these
parameters. Less than half of the mothers knew the correct meaning of diarrhea. Majority of the mothers did not know the correct cause of diarrhea. Most of them attributed it to teething (31.25%), Poor sanitation (33.3%), poor hand hygiene (18.33%) indigestion (9.16%), dosha (2.08%),taking food outside (6.25%).
Table 2: Cause of Diarrhea Cause of Diarrhea n% (n -240 ) Teething
Poor sanitation Poor hand hygiene Indigestion Outside food Dosha Others
31.25%(75) 33.3%(80) 18.33%(44) 9.16%(22) 6.25%(15) 2.08%(5) 3.75%(9)
Nearly three fourth of the mothers knew that diarrhea can be prevented and said the ways in which it can be prevented include proper sanitation(38%), hand hygiene (18.75%), boiling of water (20%),avoiding outside food(7.92%),covering of food containing utensils(10%).
Table 3: Preventive measures for diarrhea Ways to prevent of Diarrhea n% (n -240 ) Don’t know how to prevent
Proper sanitation Proper hand hygine Boiling water Avoiding outside food Covering of food
18.33%(44) 38%(72) 18.75%(45) 20%(36) 7.92%(19) 10%(24)
Table 4: Knowledge about dehydration Knowledge about dehydration n% (n -240 ) Don’t know how to look for it
Child asks for more water Child does not pass urine Child appears dull
Abdomen and eyes look sunken
40%(96) 18.75%(45) 8.33%(20) 25%(60) 7.92%(19)
Majority of the mothers did not know how to look for signs of dehydration (40%) Among mothers who knew about how to look for dehydration most of them said child asks for more water(18.75%),child is not passing urine (8.33%), child appears dull (25%), abdomen and eyes looks sunken (7.92%).
Table 5: Knowledge about ORS, Zinc and Probiotics Knowledge about ORS/Zinc and Probiotics in
Diarrhea n% (n -240 )
Heard about ORS Heard about Zinc Heard about Probiotics Child should be given IV fluids
81.66%(196) 12.08%(29) 24.16%(58) 60 %(144)
Majority of the mothers heard about ORS but most of them did not know how it has to be prepared correctly. Most of the mothers did not know about alternative home based ORS or foods that can be used as an alternative. Most of them said they were giving plain boiled water or some juices. Information regarding ORS was predominantly obtained from pharmacy and nurses and doctors.
More than half of the mother knew about rotavirus vaccines but did not know how it is given. Most of the mothers did not know about zinc .Some of the mothers knew about probiotics and how it is given.
Relationship between education of the parent and knowledge about ORS preparation
Preparation of ORS was found to be associated with education of the mother (p=0.04), proving that better knowledge is among those mothers with formal education. However no relationship was established between socio-economic class and preparation of ORS.
Relationship of parental age and knowledge about ORS
No association was found between ORS preparation and age of the mother (p=0.229), religion (p=0.342), and gender of the child (p=0.061).
Table 6: Source of information about ORS
Knowledge about Vaccine and other alternate foods n% (n -240 ) Medical shop
Nurses Doctors Friends Relative
45.83%(110) 33.33%(80) 13.33%(32) 4.16%(10) 3.33%(8)
Discussion:
Our study is one of the few studies which have been done to assess the knowledge of the caregiver and their practices while managing a child presenting with diarrheal illness. Results of our study are similar to previous reports by Uchendu UO et al [6] and Renjith RN et al [7]. In these previous studies teething and infections were perceived to be the major cause of diarrhea which is similar to our reports. Though most of the mothers knew about ORT However, the full benefits of ORT for acute gastroenteritis not been achieved, One of the main reasons for this low usage might be the the perception that use of intravenous (IV) therapy is superior to oral therapy and there is a reduced appeal to a technologically simple solution like ORS among caregivers [8,9]. This needs to be changed by use of health education and imparting knowledge to the mothers about the use of ORS in resource limited settings. Another worrisome observation of from our study was most of the caregivers were not aware of the correct way of preparing ORS nor were aware of the use of other home based ORT solutions that can be used. Most of the mothers preferred to give some form of fruit juices or plain water rather than ORS. These findings are similar to previous reports by Uchendu UO et al [6], Renjith RN et al [7], Pahwa S et al [10] and King CK et al [8].
With regards to the caregivers ability to identify signs of dehydration, majority of the mothers were aware of one or more of the signs of dehydration of which child appearing dull seemed to be the most important sign according to the caregivers in our study. Similar findings were observed in studies conducted by Ahmed IS et al [11] and Renjith RN et al [7].
Regarding use of other feeds during diarrheal episodes around 23% of the caregivers in our study said they will continue breastfeeding which is similar to reports by Omore R et al [12]. About 40 % of the mothers had perception that during episode of diarrhea child should be kept nil per oral which is similar to the findings in a study carried out by Ahmed IS et al .Studies conducted by Pahwa S et al [10], Kadam DM et al 13 showed similar results with respect to caregivers knowledge about ORS, zinc and use of intravenous fluids during diarrheal episosdes . With regards to the the source of information on ORS fluids and preparation of ORS majority of them had heard about the same from the pharmacy or the Staff nurses and other health care workers. A very few had received this information from friends and relatives. These findings are similar to previous reports by Uchendu UO et al [6], Renjith RN et al [7] and Pahwa S et al [10]. Association was found between ORT knowledge and maternal education status in our study which is contrary to the reports by Uchendu UO et al [6] who demonstrated no association between the use of ORS and maternal education status or socioeconomic class .Neither was any difference in the way the mothers prepared ORS when they had previous exposure to preparing ORS which is again contrary to our finding where mothers who previously used ORS had better knowledge about preparation of ORS and use of Zinc and probiotics. Knowledge about the use of Rotavirus or measles vaccination and Vitamin supplementation as a preventive measure for diarrhea were similar to previous reports.
CONCLUSION
The finding of our study indicates that there is still lot of misconception and lack of knowledge when it comes to management of diarrheal episode among caregivers. This knowledge gap not only is related to etiology but also management of diarrhea. The gravity of this lack of awareness stems from the fact that mothers are the immediate care takers in the event of diarrheal disease in the child and there is an increased risk of diarrheal episodes among children living in poor socioeconomic and living conditions in most of the places in our country .
There is an urgent need to educate the mothers regarding the importance of preventive and treatment measures in diarrheal diseases. In general, most mothers have lack of experience, knowledge and awareness for practice of ORS preparation.
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