|Year : 2020 | Volume
| Issue : 1 | Page : 5-10
Diarrheal management approach among caregivers of under-5-year-old children in an Egyptian rural area
Taghreed M Farahat, Hala M Shaheen, Ayah M.A. Barakat, Safa H Alkalash
Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||26-Jan-2019|
|Date of Decision||19-Feb-2019|
|Date of Acceptance||02-Mar-2019|
|Date of Web Publication||25-Mar-2020|
Ayah M.A. Barakat
Shebin El-kom, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
The objective of this study was to assess the quality of diarrheal management practice and its relation to the sociodemographic characteristics of under-5-year-old children's caregivers.
Diarrhea among under-5-year-oldchildren is a serious public health problem in many developing countries, including Egypt. Adequate diarrhea management approaches including the increased use of oral rehydration solution (ORS), extra fluid intake, and continued feeding are cost-effective in reducing the child mortality associated with diarrhea and the overall burden of the disease.
Patients and methods
A cross-sectional study was conducted on 100 under-5-year-oldchildren's caregivers in Munshaat Sultan village. All the studied children were evaluated through a questionnaire that involved questions about the history of diarrhea within two weeks before the interview, sociodemographic characteristics, and questions to classify the quality of diarrheal management practices into good, fair, or poor on the basis of mothers' reports for children with diarrhea, using WHO/United Nations International Children's Emergency Fund recommendations for appropriate treatment.
Good diarrhea management practice was present among 36% of caregivers. About 24, 3, and 1% of children were given ORS and continued feeding, continued feeding and extra fluids, and ORS and extra fluids, respectively. There was a statistically significant difference between the quality of diarrheal management practice and mother's education, number of children in the family, socioeconomic standard, and child age. Children were given ORS, antibiotic, antidiarrheal medicine, and zinc in 43, 67, 52, and 21%, respectively.
Too many children are not receiving adequate management for diarrhea. Hence, the efforts should be increased to improve the quality of care for childhood diarrhea in both health facilities and at the community level.
Keywords: caregivers, diarrhea, drugs, Egyptian, management
|How to cite this article:|
Farahat TM, Shaheen HM, Barakat AM, Alkalash SH. Diarrheal management approach among caregivers of under-5-year-old children in an Egyptian rural area. Menoufia Med J 2020;33:5-10
|How to cite this URL:|
Farahat TM, Shaheen HM, Barakat AM, Alkalash SH. Diarrheal management approach among caregivers of under-5-year-old children in an Egyptian rural area. Menoufia Med J [serial online] 2020 [cited 2020 Jun 6];33:5-10. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/5/281304
| Introduction|| |
Across the globe, the burden of mortality in children in poor developing countries has long constituted a big health concern. Diarrheal diseases remained to be the second leading cause of death among children under 5 years old, accounting for about 760 000 children deaths every year. WHO recommends the first-line management of diarrhea in children under 5 with continued feeding, increased fluids, and supplemental zinc for 10–14 days to prevent dehydration. In addition, the WHO guidelines state that children exhibiting nonsevere dehydration should receive oral rehydration solution (ORS) in a health facility. Antimicrobials are recommended only for the treatment of bloody diarrhea or suspected cholera with severe dehydration. Appropriate management of acute diarrhea with adequately validated treatments may help reduce the health and economic burden of acute diarrhea in children worldwide.
This study provides insights into the three main diarrheal management approaches used by the Egyptian government to be able to recommend the changes necessary for the successful implementation of the national diarrheal disease control program. Hence, the aim of the study was to assess the quality of diarrheal management practice and its relation with sociodemographic characteristics of the studied caregivers.
| Patients and Methods|| |
The study was approved by the Research Ethics Committee in the Faculty of Medicine, Menoufia University, and written informed consent was signed by the caregivers of children. This study was a cross-sectional study carried out in Munshaat Sultan village, Menouf district, during the period spanning from 1 November 2016, until the end of December 2018. Menouf district was selected by simple random sampling technique from districts affiliated to Menoufia governorate (13 districts), and, thereafter, Munshaat Sultan village was selected by simple random sampling technique from villages affiliated to Menouf district. Menouf district in Menoufia governorate consists of two cities 'Menouf and Sers-Ellayan' and eight big villages and number of 130 small villages (Kofor and Ezab). The target population was the caregivers of children under 5 years old (2–59 months) who had diarrhea within 2 weeks before the interview and within selected households. The sample size was calculated on the basis of the highest and the lowest prevalence of diarrhea among the under-5 children in Egypt, which were 19.5 and 14%, respectively,. Thus, the calculated sample was 100 children, considering the confidence interval of 95% and the margin of error at 5% (standard value of 0.05). The houses were chosen from those affiliated to the Family Health Center of Menoufia University Hospital, which were a total of 1750 houses. The houses were chosen through a systematic random sampling technique. Thus, one house was selected for every 17 houses until completion of the sample size of 100 houses. If there were more than one household in a house, one of them was selected by simple random sampling technique. Households in which an under-5 child resided but for which the child's caregiver was not present were revisited once. During the second visit, if the child's caregiver was absent, the child was excluded from the study, and the next eligible study participant from the next household was included in the study to complete the sample size. Moreover, the houses did not have an under 5-year child or a child with diarrhea within the past 2 weeks, and the houses that had an under-2-month-old child only were excluded from the study.
The study participants were interviewed through a predesigned structured questionnaire that included five main parts. The first part was for the assessment of the socioeconomic standard using Fahmy et al. socioeconomic scoring system. The second part was for the identification of child and caregiver characteristics including age and sex of the ill child, number of children at the household, caregiver's age, and caregiver's work. The third part was for the identification of the management approach of diarrhea among caregivers by asking them three questions including whether the child was given ORS packets during diarrhea and how much a child was given to drink (including breast-milk) or eat compared with the usual amount. If the child was given more liquids to drink, the caregivers were considered as those who practiced increased fluids. If a child was given more, same as usual, or somewhat less food, caregivers were considered as those who practiced continued feeding. Moreover, caregivers were asked about the medication given to the child during his illness.
The assessment approaches included: the use of ORS, increased fluids, continued feeding, the combination of all treatment approaches (ORS, extra fluids, and continued feeding), and the combination of any treatment approach (ORS or extra fluids or continued feeding) during the diarrheal episodes. The quality of diarrheal management practice was classified as good, fair, or poor on the basis of WHO/United Nations International Children's Emergency Fund recommendations.
Classification of diarrhea management in children under-5 into good, fair, and poor on the basis of WHO/United Nations International Children's Emergency Fund recommendations is illustrated as follows:
Data were collected, tabulated, and statistically analyzed using a personal computer with statistical package for the social sciences, version 21 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were presented in numbers and percentages and analyzed using a Fisher's exact test when more than 20% of cells have expected frequencies less than 5. A P value less than 0.05 was considered statistically significant.
| Results|| |
The Venn diagram shows all the three treatment approaches [Figure 1]. In the figure, 24, 3, and 1% of children were given ORS and continued feeding, continued feeding and extra fluids, and ORS and extra fluids, respectively. Eleven percent of children were given ORS, extra fluids, and continued feeding and 7% of children did not use any of the three treatment approaches. About 36% of caregivers had good diarrhea management practice and 56% had poor practice [Figure 2]. There was a statistically significant difference between the quality of diarrheal management practice and mother's education, number of children in the family, socioeconomic standard, and child age. About half of highly educated caregivers (52.9%) had good management practice. More than two-thirds of caregivers of high socioeconomic standard (78.6%) had a good practice. Less than half of the caregivers of a child aged 1–2 years (43.8%) and having less than three children (57.7%) had a good practice [Table 1]. Only 43% of children suffering from diarrhea were given ORS [Table 2]. Antibiotics were given for over three quarters (67%) of the children who had diarrhea, about half of the participants (52%) received antidiarrheal drugs, and only 21% of children were given zinc.
|Table 1: Relationship between the quality of diarrheal management and sociodemographic characteristics of the studied caregivers|
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|Table 2: Frequency and type of drugs used in under-5 children with diarrhea|
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|Figure 1: Percentage of children who received ORS, continued feeding, and/or extra fluids during diarrhea. ORS, oral rehydration solution.|
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|Figure 2: Percent distribution of children under 5 with diarrhea in the 2 weeks before the survey by type of diarrheal management practice (good, fair, or poor).|
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| Discussion|| |
Diarrhea remains a high-burden disease despite the availability of simple, affordable, and effective treatments. Recent studies have shown high levels of harmful practices during childhood diarrhea, including the curtailment of fluids and food during illness episodes.
This study showed that less than one-quarter of children with diarrhea received extra fluid [Figure 1]. This was similar to a study conducted in Kenya, which found that more than 70% of mothers decreased fluid intake during diarrhea episodes, and only 10.0% were reported to have drunk more than usual. Furthermore, a study conducted by Omore and colleagues found that only 15% of caregivers offered the child more fluids to drink than usual. Such findings have also been reported in a number of studies, and they are consistent with global trends in reductions in ORS use, and the practice of decreasing the amount of fluid given to children during their diarrheal illness.
Less than half of children ill with diarrhea received good diarrheal management practice [Figure 2]. It is consistent with a study conducted in India that showed that the prevalence of good practice was 38%. It is different from a study conducted in Sierra Leone, which showed that about two-thirds of children (67%) with diarrhea were provided with good management and that only about 10% of children were provided with 'poor' management.
This difference may be due to the fact that caregivers, in this study, had poor knowledge about appropriate feeding practice during diarrheal episodes. Caregivers believe that 'the more fluids a child drinks when he/she has diarrhea, the more frequent the loose stools.' This misconception could result in restriction of fluid. This also may be because the government of Sierra Leone abolished healthcare costs for children under 5 in April 2010. As a result, many young children are now coming to health centers. Therefore, appropriate care was sought and caregivers were provided with more information about good management practice for their children.
The majority of caregivers with high socioeconomic standard and about half of secondary educated caregivers had a good practice [Table 1]. It was similar to the results of studies conducted in Ghana and Ethiopia showing that mothers of higher educational background demonstrated more correct dietary practices in child care as compared with mothers of low educational background,. It can be explained by the fact that school education increases the mother's knowledge about common health problems, and healthy habits such as these are included in standard school curricula. Moreover, a study conducted in Nepal showed that good treatment approach was significantly higher among the family with middle household wealth index compared with low household wealth index. It can be explained by the fact that those from lower socioeconomic strata are also more likely to encounter other constraints, such as apathy from healthcare providers and corrupt practitioners, which inhibit their access to and utilization of services.
Less than half of caregivers to children aged 1–2 years and about half of caregivers in families having less than three children had a good practice [Table 1]. This result can be explained by the fact that the resource and time constraints associated with caring for multiple young children serve as a barrier for seeking care; it may also be due to parents perceiving younger children as being especially 'delicate', and due to the difficulty of allocating scarce resources to the younger age group whose care cannot be handled at home in comparison with the older age group who can be possibly cared for at home.
The current study showed that antibiotics were given for about two-thirds of children ill with diarrhea, and about half of children received antidiarrheal drugs [Table 2]. This is in line with a study that was conducted in Kenya, which revealed that more than half of the mothers frequently used antibiotics in managing diarrhea episodes. It is different from a study conducted in Nigeria which reported 28% inappropriate use of antibiotics in treating diarrheal episodes.
The high use of antibiotics and antidiarrheal drugs may be due to the following reasons: caregivers' belief that they were accessible and believed to be efficacious and multiple studies reported that the drugs were widely available and affordable in the public and private sector typically without prescription.
The current study showed that less than half of the children received ORS [Table 2]. It is similar to the result of a study conducted in Egypt showing that some form of ORS was used in treating 30% of the children. Moreover, studies conducted in Nigeria and Mesoamerica revealed that caregivers who used ORS to manage diarrhea were 49.5 and 33%, respectively,.
It is different from a study conducted in Ethiopia, which found that three-fourths of caregivers used ORS while their children started to experience diarrhea. Another study conducted in Bangladesh discovered that the majority of respondents (88.9%) gave ORS to their children, and there was a significant association between the education of mothers and the use of ORS.
In this study, less than one-quarter of caregivers administered zinc supplements to their children [Table 2]. It is consistent with a study conducted in Ghana, which showed that just about a quarter of the mothers (25.1%) used zinc tablets in managing diarrhea episodes. It is different from a study conducted in western Kenya, which showed that more than half of the mothers (67%) used zinc tablets. The disparity in the study findings between the current study and the study in Kenya might be due to the increased awareness created about the use of zinc tablets in western Kenya.
The study limitations included that the measure of diarrheal management practice was based on mother's recall of care provided to the child during the episode of diarrhea. This could have led to differential recall bias and may not entirely reflect the level of quality of care in the facilities or from community-based workers. For instance, mothers are more likely to recall ORS than, other treatments like zinc, which might be misremembered as an antibiotic or other medication. Further studies are needed to explore the role of local and cultural beliefs and practices in determining caregiver understandings of diarrhea; appropriate responses are also important and will require further study using qualitative methodologies.
| Conclusion|| |
Too many children are not receiving adequate management for diarrhea in Egypt. Thus, more efforts are required to improve the quality of care for childhood diarrhea in both health facilities and at the community level. Community-based complete intervention packages such as the use of ORS, extra fluids, and continued feeding are needed to further manage childhood diarrhea.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khatab K, Adegboye O, Mohammed TI. Social and demographic factors associated with morbidities in young children in Egypt: a Bayesian geo-additive semi-parametric multinomial model. PLoS One 2016; 11
World Health Organization. Diarrheal diseases. 2013. Available at: www.who.int/mediacentre/factsheets/fs330/en/
. [Last accessed 2018 Dec 25].
World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers
. Geneva: WHO; 2005. 1–50.
Carter E, Bryce J, Perin J, Newby H. Harmful practices in the management of childhood diarrhea in low-and-middle-income countries: a systematic review. BMC Public Health 2015; 15
Yassin K. Morbidity and risk factors of diarrheal diseases among under-five children in rural Upper Egypt. J Trop Pediatr 2000; 46
El-Zanaty and Associates (EDHS). Egypt demographic and health survey
. Egypt: Ministry of Health and Population Cairo; 2014.
Fahmy SI, Nofal LM, Shehata SF, El-Kady HM, Ibrahim HK. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90
WHO/UNICEF. Joint statement: clinical management of acute diarrhoea (WHO/FCH/CAH/04.07)
. Geneva/New York: World Health Organization, Department of Child and Adolescent Health and Development, and United Nations Children's Fund, Programme Division; 2004.
Othero DM, Orago AS, Groenewegen T, Kaseje DO, Otengah PA. Home management of diarrhea among under-fives in a rural community in Kenya: household perceptions and practices. East Afr J Public Health 2008; 5
Omore R, O'Reilly CE, Williamson J, Moke F, Were V, Farag TH, et al
. Health care-seeking behavior during childhood diarrheal illness: results of health care utilization and attitudes surveys of caretakers in western Kenya, 2007–2010. Am J Trop Med Hygiene 2013; 89
Walker CL, Taneja S, LeFevre A, Black RE, Mazumder S. Appropriate management of acute diarrhea in children among public and private providers in Gujarat, India: a cross-sectional survey. Glob Health: Sci Pract 2015; 14
Diaz T, George AS, Rao SR, Bangura PS, Baimba JB, McMahon SA. Healthcare seeking for diarrhea, malaria, and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey. BMC Public Health 2013; 13
Carvajal-Vélez L, Amouzou A, Perin J, Maïga A, Tarekegn H, Akinyemi A, et al
. Diarrhea management in children under five in sub-Saharan Africa: does the source of care matter? A Countdown analysis. BMC Public Health 2016; 16
Mahama S. Relationship between mothers' nutritional knowledge in childcare practices and the growth of children living in impoverished rural communities. J Health Popul Nutr 2014; 2
Nigatu M, Tadesse A. Knowledge, perception, and management skills of mothers with under-five children about diarrhoeal disease in indigenous and resettlement communities in Assosa District, Western Ethiopia. J Health Popul Nutr 2015; 33
Ghimire PR, Agho KE, Renzaho AM, Dibley M, Raynes-Greenow C. Association between health service use and diarrhea management approach among caregivers of under-five children in Nepal. PloS One 2018; 13
Zwisler G, Simpson E, Moodley M. Treatment of diarrhea in young children: results from surveys on the perception and use of oral rehydration solutions, antibiotics, and other therapies in India and Kenya. J Global Health 2013; 3
Okoh BA, Alex-Hart BA. Home management of diarrhea by caregivers presenting at the diarrhea training unit of a tertiary hospital in Southern Nigeria. Br J Med Med Res 2014; 4
Ekwochi U, Chinawa JM, Obi I, Obu HA, Agwu S. Use and/or misuse of antibiotics in the management of diarrhea among children in Enugu, Southeast Nigeria. J Trop Pediatr 2013; 59
Agbolade MO, Dipeolu IO, Ajuwon AJ. Knowledge and use of oral rehydration therapy among mothers of under-five children in a Military Barrack in Ibadan, Nigeria. Afr J Biomed Res 2015; 18
Colombara DV, Hernández B, McNellan CR, Desai SS, Gagnier MC, Haakenstad A, et al
. Diarrhea prevalence, care, and risk factors among poor children under 5 years of age in Mesoamerica. Am J Trop Med Hygiene 2016; 94
Desta BK, Assimamaw NT, Ashenafi TD. Knowledge, practice, and associated factors of home-based management of diarrhea among caregivers of children attending under-five clinic in Fagita Lekoma District, Awi Zone, Amhara Regional State, Northwest Ethiopia, 2016. Nursing research and practice, 2017.
Akhtaruzzaman M, Hossain MA, Choudhury AM, Islam MN, Dhar SK. Home management of childhood diarrhea by mothers presenting at a tertiary hospital in Bangladesh. J Nepal Paediatr Soc 2015; 35
Anim-Larbi MA. Management of diarrhoeal diseases in children under five years by market women: the case of Makola, Accra [Doctoral dissertation]. Ghana: University of Ghana. 2017.
Otieno GA, Bigogo GM, Nyawanda BO, Aboud F, Breiman RF. Caretakers' perception towards using zinc to treat childhood diarrhea in rural western Kenya. J Health Popul Nutr 2013; 31
[Figure 1], [Figure 2]
[Table 1], [Table 2]