Home Management of Childhood Diarrhoea by Mothers Presenting at a Tertiary Hospital in Bangladesh

Address for correspondence: Dr. Muhammad Akhtaruzzaman Medical Officer Paediatric Out Patient Department, Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Tel: +8801715560902 E-mail: dr_md_akhtar@yahoo.com 1Dr. Muhammad Akhtaruzzaman, Medical Officer, Paediatric Out Patient Department. 2Dr. Md. Anwar Hossain, Associate Professor, Department of Neonatology, 3Dr. Ahmed Murtaza Choudhury, Associate Professor, Department of Paediatrics, Hemato-oncology. 4Dr. Md. Nazrul Islam, Assistant Professor, Department of Neonatology. 5Dr. Sonjib Kumar Dhar, Thesis part student of MD paediatrics, Department of Paediatrics, All from the Mymensingh Medical College, Mymensingh, Bangladesh. Abstract


Introduction
D iarrhoea is defi ned as the passage of three or more loose or watery stools in a 24-hours period 1 .Diarrhoeal disorders in childhood account for 18% of childhood deaths, with an es mated 1.5 million deaths per year globally, making it the second most common cause of child deaths worldwide 2 .In Bangladesh, diarrhea accounts for 11% of under-fi ve mortality 3 .Each episode deprives the child of nutrients necessary for growth, thus diarrhoea is a major cause of malnutri on and malnourished children are more likely to die from diarrhoea 4 .
The pivotal role of oral rehydra on therapy (ORT) in the management of diarrhoeal diseases is well established 5 .Approximately, 90% cases of diarrhoea can be successfully managed with oral rehydra on therapy and con nued feeding without use of drugs.Oral rehydra on therapy is a well established therapy for the preven on and treatment of dehydra on.This is as eff ec ve as intravenous therapy and in most cases can be carried out at home, thus avoiding hospital stay 6 .
Since 1979 ORT has been the cornerstone of diarrhoea management worldwide 7 .In May 2004, WHO and UNICEF released a joint statement to decrease diarrhea deaths among the worlds most vulnerable children.This statement recommended the use of low osmolality oral rehydra on solu on (ORS) that reduces the need for intravenous fl uids, and Zinc supplementa on as an adjunct therapy that decreases the dura on and severity of the diarrhoea episode and the likelihood of subsequent infec on in 2 to 3 months following treatment 8 .Despite the evidence of benefi ts, there has been li le progress on the widespread use of ORS and Zinc for diarrhoea treatment 9 .It is a common observa on that some mothers s ll cannot mix commercially available ORS properly nor can they make sugar-salt solu on at home or realize the importance of giving more fl uids during acute diarrhoea of their children 10 .A recent review suggests that barely 39% of children with diarrhoea in developing countries receive the recommended treatment 11 .Addi onally, inappropriate feeding prac ces by the mothers may contribute to worsen diarrhoeal morbidity and mortality 12,13,14 .
This study aimed to assess the current level of knowledge and prac ces of mothers with regard to home management of childhood diarrhoeal diseases in Mymensingh region of Bangladesh.

Materials and Methods
This was a non-experimental descrip ve, cross sec onal hospital based study carried out on 360 mothers of children with diarrhoea a ending the Pediatric Out Pa ent Department (OPD) of Mymensingh Medical College Hospital (MMCH) from September 2014 to February 2015.People from all strata of the society receive care at the Pediatric unit of MMCH which holds rou ne outpa ent services, primary care and specialized clinics.Mothers who had a child less than 5 years of age suff ering from acute watery diarrhoea with or without any other symptoms were included in this study.Pa ents who had earlier consulta ons at any other health facility for the current diarrhoeal illness were excluded from the study.
The mothers who were willing to give relevant informa on were enrolled in the study by systema c random sampling.Sample size es ma on was determined using the formula 15 ) for es ma ng minimum sample size for descrip ve studies when studying propor ons with an en re popula on size <10,000.It was found from OPD records that everyday on an average 33 mothers having under-fi ve children with diarrhoeal diseases a ended in OPD of MMCH.So, in six months excluding the day-off s and other holidays about 4851 mothers having children with diarrhoeal diseases were expected to a end the OPD.It was assumed that 50% of the mothers would have adequate knowledge of home management of diarrhoea at a 95% confi dence level with a 10% margin of error.This gave a sample es mate of 356 mothers.Thus every 13 th mother presented with a child suff ering from diarrhoea was selected for the study.
Data was collected using a structured, pretested interview schedule containing informa on on sociodemographic characteris cs of the pa ents and their mothers, medical history of the current diarrhoeal illness, mothers knowledge on diarrhoea ae ology, home management of diarrhoea by the mothers.
There were 11 ques ons on knowledge and awareness and 11 on prac ce of home management of diarrhoea.The ques ons on knowledge and awareness included causes of diarrhoea, prepara on and preserva on of ORS, con nued feeding, use of recommended homemade fl uid, increased fl uid intake and the use of zinc for home management of diarrhoea.The prac ce ques ons included treatment given for the present diarrhoea episodes, the use of ORS and zinc, feeding and hand washing prac ces.A correct response was given a score of one (1), and an incorrect one, a score of zero (0).The level of knowledge and the level of prac ce both were classifi ed as poor for score 0-5 (i.e.<50%) and good for score 6-11 (i.e.>50%).
Data was collected by principal author himself.A er each interview, interview schedule was checked for inconsistency and incompleteness.Data was analysed by using computer so ware Sta s cal Package for Social Sciences (SPSS) version 21.0.Bivariate analysis involved the use of Chi-Square for tes ng the signifi cance of associa ons between categorical variables.Logis c regression was carried out for mul variate analysis.The level of signifi cance was set at p<0.05.
This study was approved by the research ethical commi ee of MMC and informed consent was obtained from all par cipants prior to enrolment.

RESULTS
A total of 360 mothers of pa ents aged less than 5 years presen ng with diarrhoea to the MMCH were selected for the study.The ages of the pa ents ranged from 2 to 59 months with a mean age of 18.01 months ±14.6 standard devia on (SD).Non-bloody diarrhoea was present in 322 (89.44%) and bloody diarrhoea occurred in 38 (10.56%) pa ents.Two hundred and sixty-two (72.78%) mothers came from low income group, 73 (20.28%) mothers came from middle income group whereas 25 (6.94%) mothers came from upper income group.Fi y-six (15.56%) mothers were illiterate, 107 (29.72%) had primary school educa on (incomplete), 97 (26.94%) had primary school educa on (complete), 71 (19.72%) had secondary school educa on (incomplete), while 29 (8.06%) had secondary (complete) or higher educa on (Table 1).In terms of occupa on, 330 (91.67%) mothers were housewives, while 20 (5.55%) mothers were service holders and 10 (2.78%) mothers had other occupa ons (day labourer, student etc).
Three hundred and twenty (88.88%) mothers gave ORS to their children during acute diarrhoea (Fig. 1).Zinc was used in 128 (35.56%) children.Out of 360 cases 38 (10.55%) had dysentery but an bio cs, an protozoal and an eme c besides ORS and zinc was used in 225 (62.50%) cases (Fig. 2).
On the ques on of the most common cause of diarrhoea in children, 265 (73.61%) answered correctly, contamina on of food or water by germs or infec ous organisms.Table 2 and Table 3 show the responses to ques ons on knowledge and prac ce of home management of childhood diarrhoea.The highest scored knowledge based ques on was the awareness of use of ORS in the home management of diarrhoea (100%) while the lowest scored was the knowledge of correct amount of ORS to be given a er each purging (26.11%).The highest scored prac ce ques ons were hand washing a er cleaning child's faeces and a er self use of the toilet (100%) while the lowest scored was the use of recommended homemade fl uid in the home management of diarrhoea (14.72%).
Five (1.39%) of the 360 respondents scored the maximum of 11 out of 11 points for the knowledge based ques ons.Six (1.67%) of the 360 respondents scored the maximum of 11 out of 11 points for the prac ce based ques ons.Of the 360 mothers, 164 (45.55%) had a good level of knowledge, while 122 (33.89%) had good level of prac ce (Table 4).
Table 5 shows the rela onship between the level of knowledge and some sociodemographic characteris cs of the respondents.A higher knowledge score was associated with mother's age, educa onal level and occupa on and father's educa onal level, occupa on and income.All were sta s cally signifi cant with p<0.001.
Table 6 shows the rela onship of level of prac ce with sociodemographic characteris cs.A higher prac ce score was signifi cantly (p<0.001)associated with the mother's age, educa onal level, occupa on, father's educa onal level, occupa on and income.
Table 7 shows the logis c regression analysis of various variables rela ng to the level of knowledge and prac ce of home management of diarrhoea.A er adjus ng for other factors, mother's age was signifi cantly associated with level of knowledge (p=0.003) and mother's educa onal level signifi cantly infl uenced both level of knowledge (p=0.001) and prac ce (p=0.002) of the home management of diarrhoea.

Discussion
The present study has shown a generally low level of knowledge and inappropriate prac ces among mothers on diff erent aspects of the home management of childhood diarrhoea.The high awareness (100% of mothers) of the use of ORS in the home management of diarrhoea reported in this study is similar to fi ndings noted in other studies 17,18,19 .In this study, 320 (88.88%) mothers had administered ORS to their children with diarrhoea prior to presenta on.A comprehensive study conducted in India demonstrated that 63% of Indian mothers were aware of ORS whereas only 27% of them took advantage of it for their children. 17hese studies suggest a profound lack between the cogni on of ORS and its u liza on.Thus, a superfi cial understanding of ORS is not enough and it requires consistent eff orts to emphasize on importance of ORS in resolving dehydra on during diarrhoea, par cularly in children; since this group of age is more likely to be dehydrated quickly 20 .
Regarding prepara on of ORS it was observed that 321 (89.17%) mothers had adequate knowledge of the correct prepara on of ORS but it was observed that 191 (53.06%) mothers correctly prepared the ORS.The mothers do not have instruments to measure water accurately.Furthermore they are worried the ORS will go to waste if they make the whole sachet.This is lower than the fi ndings of a study by Taha, in which 64.00% of mothers and study done by Mohsin et  al. 76.00% of mothers correctly prepared ORS 6,21 .This unfortunate prac ce by home caregivers can result in either hypotonic or hypertonic dehydra on in children receiving these incorrectly prepared ORS mixtures, leading to increased morbidity and mortality 22 .
In the present study, 265 (73.61%) mothers stated their children's diarrhoea incidence was due to contaminated food and water.In a similar study in Iran 52.00% of mothers correctly iden fi ed the cause of diarrhoea 23 .However, similar study in Nigeria revealed that 35.00% of mothers were aware of contaminated food and water as an e ologic agent of diarrhoea 17 .It however contrasts with the fi ndings of a study by Uchendu et al.where 52.60% of caregivers perceived tooth erup on to be a major cause of diarrhoea 24 .The diff erence observed between the studies may be related to the general percep on of diarrhoea among caregivers in the specifi c areas.Health care workers provide basic health educa on including diarrhoeal cause and management at grass root level in Bangladesh.
In addi on to ORT, the WHO recommends Zinc supplementa on for the treatment of diarrhoea 25 .In the study 141(39.16%)mothers were aware of the use of zinc for diarrhoea management.This fi nding is diff erent from earlier studies in Uganda, and India where 17% and less than 1% of caregivers respec vely, were aware of its use 26,27 .The actual use of zinc for the treatment of diarrhoea in this study was 128 (35.56%) which is also much higher than fi ndings of the above men oned studies.This is due to educa on provided by health workers in Bangladesh.
Regarding the use of drugs, other than zinc and ORS, it was observed that drugs were given in 225 (62.50%) pa ents, either alone or in combina on with ORS and most of the drugs used were an bio cs.Mohsin et al. found that drugs were given in 79.00% of pa ents, either alone or in combina on with ORS which is much higher than study fi ndings 6 .McLennan et al. observed that 73.00% of the caregivers recommended the use of an bio cs for treatment of their children with diarrhoea 28 .The high popularity of the use of drugs such as an bio cs and an diarrhoeal agents in children with diarrhoea has been reported by other studies 29,30 .In Bangladesh, an bio cs can be procured without a doctor's prescrip on.This prac ce for the home treatment of diarrhoea by caregivers can lead to wide spread an bio c resistance.
Regarding feeding during diarrhoea only 69 (19.17%) mothers con nued feeding properly.Okoh et al. found that 93.60% caregivers con nued feeding during diarrhoea 9 .Withholding of food by a caregiver and failure to compensate for decreased food intake by increasing feeding during convalescence are major contributors to the adverse nutri onal outcomes of diarrhoea.The belief of res ng the gut during diarrhoea is based on the idea that feeding could enhance the passage of frequent watery stool, thus increasing the severity of diarrhoea.
Concerning hand washing in the preven on of diarrhoea, 100% of the mothers in this study admi ed to always washing their hands a er visi ng the toilet and a er cleaning child's faeces and 274 (76.11%) mothers used to wash their hands before feeding child.Okoh et al. found that 86.60% of caregivers washing their hands a er using the toilet, 82.20% a er cleaning child's faeces and 82.20% before feeding their child 9 .
Overall, there was a low level of knowledge and awareness of the home management of diarrhoea among respondents in this study, with 164 (45.55%) mothers having a good level of knowledge.Okoh et al. found that 29.30% of the caregivers had good knowledge of the home management of diarrhoea 9 .Ghasemi et al. found that 28.80% of the caregivers had good knowledge of the home management of diarrhoea 31 .Khalili et al. however reported a much lower level of knowledge of caregivers (3.7%) compared to the present study 23 .There was also a low level of prac ces in the home management of diarrhoea among respondents in this study, with 122(33.89%)having a good level of prac ce.Okoh et al. found that 33.80% of the caregivers had good prac ces in the home management of diarrhoea 9 .Khalili et al. found that 56% of maternal prac ce was moderate and 41.7% had a weak performance and others prac ced appropriately 23 .The methodology of the present study however diff ered from the studies by Okoh et al.Ghasemi et al. and Khalili et al 9,23,31 .Okoh et al. assessed both knowledge and prac ce using 8 ques ons for knowledge and 10 ques ons for prac ce, Ghasemi et al. assessed only knowledge of diarrhoea management using a 22 item ques onnaire and Khalili et al. assessed both knowledge and prac ce using 10 ques ons each for knowledge and prac ce while the present study assessed both knowledge and prac ce using 11 ques ons for both knowledge and prac ce 9,23,31 .The signifi cant associa on between mothers level of educa on and the level of knowledge and prac ce of the home management of diarrhoea observed in the present study were also observed in other studies 9,23,28,31 .

Conclusion
Home management of diarrhoea was grossly inadequate in terms of method of prepara on and amount of administra on of ORS, use of increased fl uid and con nued feeding.Despite the recommenda on by WHO for limited use of drugs in selected cases, they are being used randomly.Awareness and use of zinc for diarrhoea management were very low.The level of knowledge and prac ce were signifi cantly associated with the level of educa on of the mothers.We recommend more health campaigns and a wider dissemina on of informa on in hospitals, via the media and in communi es, on home management of diarrhoea so as to increase awareness among caregivers and ul mately reduce the morbidity and mortality rate from diarrhoeal diseases among children.

Fig. 1 :Fig. 2 :
Fig. 1: Pie diagram showing use of ORS by mothers at home

Table 1 :
Educa onal status of mothers 16Primary complete is defi ned as comple ng grade 516.** Secondary complete is defi ned as comple ng grade 10 16 .

Table 3 :
Prac ce based responses to home management and preven on of diarrhoea

Table 4 :
Scores of respondents for ques ons on knowledge and prac ce of diarrhoea home management

Table 5 :
Rela onship between level of knowledge and some sociodemographic characteris cs of the respondents 16Primary complete is defi ned as comple ng grade 516.**Secondary complete is defi ned as comple ng grade 1016.s Signifi cant (p<0.05), BT: Bangladeshi Taka

Table 6 :
Rela onship between level of prac ce and some sociodemographic characteris cs of the respondents

Table 7 :
Logis c regression analysis of factors rela ng to level of knowledge and prac ce of home management of diarrhoea