SCHOOL OF NURSING, COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON PRE-HOSPITAL MANAGEMENT OF DIARRHOEA AMONG CAREGIVERS WITH CHILDREN UNDER FIVE AT PRINCESS MARIE LOUISE CHILDREN HOSPITAL, ACCRA CHARITY ASANTEWAA ACHEAMPONG 10397087 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MSc NURSING STUDIES DEGREE JULY, 2013 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I declare that, with the exception of references made to other people’s work which have been acknowled ged, thi s thesis is as a result of m y ow n effort. No materi al in thi s writ e up has been subm it ted for an y other degree, neit her has it been subm it ted concurrentl y i n candidature for an y other de gr ee or certific at e. ………………………………….. Date………………… Charit y As antewa a Ach e ampong Student …………………………………… Date………………… Mrs. Com fort Kafui Af ra m Supervisor …………………………………. Date……………………. Dr (Mrs.) M aame Yaa Nya r ko Supervisor University of Ghana http://ugspace.ug.edu.gh ii DEDICATION To m y husband, Mr. M artin Ankomah and m y two dear chil dr en, Lois Adoma Ankomah and Da vid Opoku Ankomah. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT I am most grate ful to the Almi ght y God, who gav e me the kno wled ge, goo d healt h and favour to finish this script. A special note of thanks goes to all the particip an ts of thi s stud y without whose cooper ati on thi s work would not have bee n accompl ished. To my superviso rs, I wi sh to ex press m y sinc er e appre ciation for you r deep insi ght and rich ex perience in resea rch t o geth er with your anal yt ical and critic al mind have be en use ful in shaping thi s res ear ch int o its present form. I also take thi s opportuni t y to thank the Dean and all lecturers of the School of Nursing, Universit y of Ghan a, Le gon for their dedic ati on, guid ance and suppo rt. I am grateful to mana ge ment and staff of the P M L Chil dren Hospit al for their will ingness and cooperati on durin g m y data coll ecti on. Finall y, I would like t o thank Mr. Marti n Ankomah (m y husband ), Prof. David Sam of Universit y of Ber gen - Norwa y, Dr Eric Sifah (the Medical Superinten dent of PM L Chil dren Hospit al) and Dr (Mrs.) Pati ence Anete ye (R esea rch Coordinator, S chool of Nursing, Unive rsit y of Ghana ) for thei r useful suggesti on, en coura gement and directi on. To a ll who contribut ed in diverse wa ys , I sa y than k you and God bless you . University of Ghana http://ugspace.ug.edu.gh iv LIST OF ABBREVIATIONS C DD Control of Diarrho eal Dise ase C HPS Comm unit y Healt h Planning Servic es EP I Expanded Progr amm e on Imm unisati on GA V I Global All iance fo r Vac cines and Imm uniz ati on GDHS Ghana Demographic an d Healt h Surve y GHS Ghana Healt h Service HIV Human Imm unodeficie nc y Virus IMNC I Int e grated Mana gem ent of Neon atal and Chil dhood Ill nesses J HS Junior High School MDG Mill ennium Developm ent Goal M ICS Multi ple Indicator Clust e r Surve y MOH Minist r y of Healt h NH IS Nati onal Healt h Insur ance S cheme NH IA Nati onal Healt h Insur ance Authorit y OPD Out -pati ent Depa rtment ORS Oral Reh ydrati on Salt ORT Oral Reh ydrati on Th era p y P M L Princess Marie Louise R HFs Recomm ended Home Flui ds SHS Senior High School SPSS Statist ical Product and Service Solut ions SSS Suga r Salt Solut ion University of Ghana http://ugspace.ug.edu.gh v S S W Suga r-S alt - Water UN IC EF Unit ed Nati ons Int ernati onal Chil dren Educati on Fun d WHO World Healt h Organisati on University of Ghana http://ugspace.ug.edu.gh v i ABSTRACT The stud y sou ght to asse ss pre-hospi tal mana gem ent of diar rhoea and fact ors aff ecti n g it among care giv ers with chil dren under five at the PML Chil dren Hospit al in the Greater Accr a Region . Dia rrhoe a remai ns one of the leadin g cau ses of morbidi t y and mor talit y amon g chil dren under five at PM L Chil dren Hospit al despit e th e undeniable su ccess of int erventi ons su ch as ORT , appropri ate dru g therap y, opti mal br eastf eedin g pr acti ces over the yea rs. Prope r home mana gement can reduc e morbidi t y and mortali t y due to diarrhoea . Th e stud y desi gn was cross - secti onal adopti ng quant it ati ve approach. The stud y population comprised all care give rs with chil dren under five repo rting to PM L Hospit al with diarrhoea . A tot al of 120 participants wer e enroll ed int o the stud y. Permiss ion was sought fro m PML Chil dren Hospit al Management wher e the stud y was condu cte d by providi ng permiss ion letters and ethi cal cl earan ce . A structu red questi onnaire was used as a data coll ecti on tool for the stud y. Data coll ect ed was an al ys ed usin g SPSS version16.0 . The findings of the stud y show poor home man agement of dia rrhoe a including dieta r y restri cti ons durin g the diarrho e a episod e, low us e of bo th RHFs and ORS but high use of other rem ed ies such as anti biot ics and anti -diarrho ea to tr ea t diarrhoe a . The stud y also reveals that caregivers’ educational level had no relationship with knowledge about dan ge r signs of diarrhoe a, co r re ct use of ORS as well as level of awaren ess and use of RHFs and ORS . Ho weve r, a convincing evidence of relationship was established between caregivers’ educ ati on and knowledge about causes of diarrhoe a as well as healt h insurance cover and durati on of diarrhoe a illness before hospi tal visi t . The stud y recomm ended a step up in healt h educati on programm es on pre-hos pit al manag ement of diarrhoe a nati onwide. A major limi tation of the stud y is that it was limited onl y to PM L Chil dre n Hospit al and therefore the outcome cannot be gen erali z ed to the enti re countr y. University of Ghana http://ugspace.ug.edu.gh v ii TABLE OF CONTENTS Conten t Page DEC LARAT ION i DED IC AT IO N ii ACKNOW LED GEMEN TS iii LIS T OF ABBR EV IAT IONS iv ABS TRAC T v i TABLE OF CONTE NTS v ii LIS TS O F TA BLES xi i CHAPTER ONE INTRODUCTION 1.1 Back ground to the stud y 1 1.2 Statement of the prob lem 3 1.3 Purpose of stud y 5 1.4 Objecti ves of stud y 6 1.5 Significanc e of stud y 6 1.6 Statement of h ypothe sis 7 1.7 Operati onal de finiti ons 7 University of Ghana http://ugspace.ug.edu.gh v iii CHAPTER TWO LITERATURE REVIEW 2.1 Introdu cti on 9 2.2 Definiti on and t yp es of diarrhoe a 9 2.3 Knowled ge about cau ses and dan ge r signs o f diarrhoe a 10 2 .4 Feedin g practi c es dur ing diar rhoea episod e 14 2.5 Awar eness and use of RHFs and ORS 17 2.6 Other mode of treatm ent of diarrho ea at hom e 22 2.7 Factors influencing caregivers’ decision to seek healthcare 24 2.8 Summ ar y and conclu sion drawn from the liter ature 26 CHAPTER THREE METHODOLOGY 3.1 Introdu cti on 27 3.2 Research desi gn 27 3.3 Stud y s ett ing 28 3.4 Tar get popul ati on / inclusi on and ex clusi on criteria 29 3.5 Indic ators and variabl es 30 3.6 Sampl e siz e and sampl ing method 32 3.7 Data gathe ring proc e dure 34 3.8 Data gathe ring tool 36 3.9 Data proc essi n g and anal ysis 37 3.10 Vali dit y and reli abil it y of questi onnair e 38 University of Ghana http://ugspace.ug.edu.gh ix 3.11 Ethi cal approval 39 CHAPTER FOUR ANALYSIS OF DATA 4.1 Introdu cti on 40 4.2 Sampl e covera ge and chara cterist ics of respon dents 40 4.3 Respondents’ k nowle dge about caus es and the associated dan ger si gns of diarrhoe a 42 4.4 Feedin g practi c e duri ng diar rhoe a l episod e 46 4.5 Awar eness and use of RHFs and ORS 49 4.6 Other mode of treatm ent of diarrho ea at hom e 55 4. 7 Facto rs influencin g respondents ’ decision to seek care at health facility 58 CHAPTER FIVE DISCUSSION 5.1 Introdu cti on 62 5.2 Caregivers’ understanding of dia rrhoe a 63 5.3 Feedin g practi c es am ong care giv ers durin g dia rrhoeal episod e 66 5.4 Preventi on of deh ydr ati on through the us e of RHFs and ORS 69 5.5 The use of othe r mode of tre atm ent for diar rho ea at hom e 74 5.6 Caregivers’ healthcare seekin g beh aviour 76 5.7 Lim it ati ons of the stud y 78 University of Ghana http://ugspace.ug.edu.gh x CHAPTER SIX SUMMARY, IMPLICATION, RECOMMENDATION AND CONCLUSION 6.1 Summ ar y 79 6.2 Impl icati on fo r Nursi ng 81 6.2.1 Nursing man a geme nt 81 6.2.2 Nursing rese arch 81 6.2.3 Nursing educati on 81 6.2.4 Nursing practi c e 82 6.3 Recomm endati on 82 6.4 Suggesti on for futu re resea rch 83 6.5 Conclusi on 84 REFERENCES 8 5 APPENDICES 91 A: Participan t information sheet 91 B: Volunt eer agre ement 95 C: Data coll ecti on instruments 96 D: Ethi cal clear anc e: No guchi Memo rial Insti tut e for Medical Res ear ch Insti tut ional Review Board 103 E: Ethi cal clear anc e: Gha na Healt h S ervic e Ethi cal Review Comm it tee 104 F: Lett er of int rodu cti on from School of Nursin g t o PM L Chil dren Hospit al 105 G: Cross-tabulati on and chi -square t est: Res pondents’ educational level vs. knowledge of causes of diarrhoe a 106 University of Ghana http://ugspace.ug.edu.gh x i H: Cross-tabulati on and chi - square test: Respondents’ educational level vs. knowledge of dan ger signs of diar rhoe a 108 I: Cross-tabul ati on and chi - square test: Respondents’ educational level vs. awar eness of RH Fs 110 J : Cross-tabul ati on and chi - square test: Respondents’ educational level vs. awar eness of ORS 112 K: Cross-tabulati on and chi - square test: Respondents’ educational level vs. use of RHFs 114 L: Cross-tabulati on and chi - square test: Respondents’ ed ucati onal lev el vs. use of ORS 116 M: Cross-tabulati on and chi - square test: Respondents’ educational level vs. corre ct use of ORS 118 N: Mann Whit ne y test: Relations hip between he alt h insu rance and durati on of illness 120 University of Ghana http://ugspace.ug.edu.gh xii LIST OF TABLES Table Page 1 .1 . Trend in diarrho ea cases at PM L Chil dren Ho spit al: 2007 – 2011 4 3.1 . Indic ators, va riables and their definiti ons 30 4.1 . Demographic and so cio -economi c char acte risti cs of the respondents 41 4 .2 . Respondents’ knowledge about diarrhoea, its causes and danger signs 43 4.3 . Respondents’ educational level vs. knowledge of causes of diarrhoea 44 4.4 . Respondents’ educational level vs. knowledge of danger signs diarrhoea 45 4.5 . Age of chil dr en with diarrhoe a vs. t yp e of fee ding given to them 47 4.6 . Patt ern of food int ak e prior to the hospi tal visit 48 4.7 . Patt ern of wate r inta ke prior to the hospi tal visit 49 4.8 . Respondents’ awareness and use of RHFs and ORS 50 4.9 . Respondents’ perception about the use of ORS 51 4.10 . Respondents’ knowledge about correct use of ORS 53 4.11 . Responden ts’ educational level vs. awa ren e ss and use of RHFs and ORS 54 4.12 . Respondents educat ional level vs. knowled ge in the corre ct use of OR S 55 4.13 . Use of other mod e of treatm ent and sou rces of treatm ent 57 4.14 . Respondents’ awa r eness and knowled ge in the use of zinc tablet 5 7 4.15 . Durati on of illness before present ati on at hosp it al 5 8 4.16 . Reasons for sta yin g at hom e 59 4.17. Relat ionsh ip between healt h insu ran ce and durati on of illness 60 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 1 CHAPTER ONE INTRODUCTION 1.1 Backgrou n d to the stud y C hil d healt h remains a nati onal priorit y in Ghana and sev er al progr amm es an d int erventi ons are being put in place at all level s as part of the Inte gra ted Mana gement of Neonatal and Chil dhood Ill ness es (IMNC I) to ad dress chall en ges conf ron ti ng chil d survival in the countr y. Th e Ghan a Demographic and Hea lt h Surve y (GDHS , 200 8) has given stron g indi cati on that Ghana has since the turn of 21 st centur y mad e signific ant progress in improvin g the healt h of chi ldren. The surve y indi cat es that chil d mortali t y fi gur es have si gnificantl y decre ased b y about 28% after ye a rs of remainin g stagn ant. Inf ant mortali t y has decli ned from 66 deaths per 1,000 live births in 2003 to 50 deaths per 1,000 live births in 2008. Ov er the same period, under-5 mortali t y also decli ned subst anti all y from 111 deaths pe r 1,000 live births in 2003 to 80 deaths per 1,0 00 in 2008. Despit e thi s progress of significant reducti on in both infant and under -five mortali t y rates, ther e are sti ll seve ral chall en ges to be addr essed in orde r to accele r ate the att ainm ent of the 2015 ta r get of the Un it ed Nati ons Mill ennium Developm ent Go al (M D G) number 4, namel y to reduc e the mort ali t y rate among chil dren un der five b y two -thi rd. The major chall en ges in clude the need to imp rove cas e mana gement s kil l of healt h workers, s trength en the he alt h s ystem and addr ess fami ly and comm unit y pra cti c es that impact on th e hea lt h of the chil d. On e ke y st rate g y in response to the afor e -mentioned chall en ges, as outl ined i n the revised nati onal Under-5 Chil d Heal th Poli c y and Strate g y (2007 - 2015) of Minist r y of Hea lt h (MOH), Ghan a , is scali ng up and sust aini ng int e rventi ons for pr eventi on and proper home mana gem ent of diarrhoe a, which remains one of the leadin g cause s of death amon g chil dr e n in Ghana. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 2 Diarrhoe a is a comm on disorder of the gastroint esti nal s ystem ex perienc ed by most of the population someti me in their lives. According to World Healt h Organi sati on (WHO, 2009), diarrhoe a is usu all y a sym ptom of an infecti on in the int esti nal tract, which is caused b y infecti ous or ganism s, including viruses, ba cteria , protoz oa, and helm inths. The infecti on is spread throu gh contami nated food or drinki ng - water, or from person - t o -person as a result of poor hygi ene. Globall y, diarrho eal dise ases remain a leadin g ca use of death among chil dren under five. Boschi-P int o, Velebit an d Shibu ya (2008) esti m ate glob al deaths from diarrhoe a of chil dren aged less than 5 years at 1.87 million each ye ar , accounti n g for approx im atel y 19% of tot a l chil dhood deaths. Th e y further esti mate that Afri can and South -East Asia n Regions combi ned contain 78% (1.46 mill ion) of all diarrhoea death s occurrin g amon g chil dren in the developi ng world. The routine dat a from healt h facil it ies in Ghan a also indi cat e that ov er 500,000 diarrhoe al cases ar e regis tered an nu all y accounti n g fo r 5% of regist er ed Out -P ati ent Department (OPD) cas es, of which 33% are in chil dren below 5 years of age (M OH, 2010). Proper home m ana gem e nt can reduc e morbidi t y and mortali t y due to di ar rhoea. Fa ctors of particular importance include caregivers’ knowledge about causes of diarrhoea and the associated dan gers signs, preventi on of deh yd rati on during diarrho eal episod es throu gh the us e of Recomm ended Hom e Flui ds (RHFs ) and Oral Reh ydr ati on Salt s (ORS ), support of nutrit ional status through the conti nuati on of an adequate diet, avoidan ce of harmful practi ce s and earl y ref err als for tre atm ent. Avail able statis ti cs indi cate that since 1978, wh en the WHO and the Unit ed Nati ons Inte rnati onal Chil dren Educati on Fund (WHO & UN IC EF, 2001) adop ted Oral R eh ydrati on Therap y (ORT ) using ORS solution as the prim ar y tool to fight deh ydrati on, the mortali t y rate University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 3 for chil dr en under the age of five suff erin g from acute dia rrhoe a has fall e n from 4. 5 mill ion to 1.8 mill ion deaths annuall y. Preventi ve st rate gies such as br eas tfeedin g, improvin g compl ementar y feedin g, zinc suppl ementati on and increasin g cov era ge with the full set of Ex panded Progr amm e of Imm uniz ati on ( EP I) vaccin es (esp eciall y measles and rotavirus vaccines ) have also been proven to be use ful and effecti ve (GAV I, 2005). Even though th e potentials of the afo re -m enti oned int erventi ons to mana ge and fu rthe r drive down dia rrhoe a mo rtali t y hav e be en well ac knowledged, the chall en ge has been to achiev e high cove ra ge of the int erventi ons particula rl y good practi ce with ORT and corr ect diarrho ea case man a gement includi ng nutrit ion int erventi ons at home. The M DG 4 wil l be easier to att ain if proper int erventi ons in cludi ng appropri ate use of ORS and othe r RH Fs ar e adopted at hom e to prevent and man a ge dia rr hoea amon g chil dr en und er five. 1.2 State men t of the prob lem Diarrhoe a is on e of the leading causes of morbi dit y and pr eventable dea th, especiall y among chil dr en under five in Ghana (MOH, 2 010 ) . At the Princess Marie Louise (PM L) Chil dren Hospit al in th e Greate r Accr a Re gio n, diarrho ea , as demons trated in Table 1.1 , remains one of the 10 comm onl y ranked diseas es of occurr ence fo r OPD att endance, admi ssi on and death in the hospi t al . From the Table, the trend in the number and rank of dia rrhoe a diseases among the top 10 caus es of OPD att enda nce, admi ssi ons and deat hs at the hospi tal has been inc reasin g over the last five yea rs. It is beli eved that si gnificant reducti on in diarrho e a morbidi t y and mortali t y i n the hospi tal can be ach ieved if car e givers have i nsight in the causes, preventi on and pr e-hospi tal mana gement care of the disease . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 4 Table 1.1 : Trend in diarrh oea cases at PML Children Hospital: 2007 - 2011 Year Number of OPD diarrhoe a cases Number of In - pati ent diarrhoe a cases Number of deaths Rank of diarrho ea among top10 causes of Admis sion Rank of diarrhoe a amon g top 10 causes of OPD morbidi t y 2007 5112 427 2 3 rd 3 rd 2008 6189 520 7 2 n d 4 t h 2009 5330 616 12 2 n d 3rd 2010 1089 * 777 13 2 n d 4 t h 2011 8621 1132 16 2 n d 3 rd S ource: PM L Chil dren Hospi tal, Medical Records Department, Decemb er, 2012 *( T he dro p in the OP D attend ance in the yea r 20 1 0 was due to natio n wid e stri ke actio n b y the Gha na Med ical Asso ciatio n) S ome concerns, howeve r , remain that some caregivers are not well informed about the risk factors and pr event ion of diarrho ea, its ho me mana gem ent, good feedin g pr acti c es and seeking of earl y medi cal att enti on. Ex perience ha s shown that most diarrhoea cas es, which ar e presented fo r tre atm ent at the hospi tal, are poorl y mana ged at home. Th e gen eral perc epti on is that most of the car e give rs who la ck knowled ge i n the causes and the associated dan gers si gns of diarrho ea as well as diarrhoe a l mana gem ent pr acti ces su ch as corr ect use of ORS have low level of educ ati on . Another important con ce rn is that some of the car egiv ers do not tak e their chil dren earl y to the hospi tal fo r tr eat ment. Avail able records at the eme r genc y unit of the PM L Chil dren Hospit al indi cate that most of the chil dren repor ted wit h diarrhoea at the hospi tal had sever e deh yd rati on. Some of them tr y sev eral open pres criptio n drugs be fore tak ing their chil dren t o the hospi tal. The att endant effect is that the alrea d y ove r -stretch ed heal th workers spend sev era l hours and en er g y to res uscitate the chil dren wh o are usu all y in shock or sever el y deh ydr ated and in some cases, some of the affe cted chil dren l ose their lives thereb y co ntribut ing to the high University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 5 chil d mortali t y rate in Ghana. It is be li eved that some of the care giv ers ar e unable to send their chil dren to the hospi tal earl y enou gh due to fin anc ial const raint . In thi s cont ex t, a stud y of pre -hospi tal man a geme nt of diarrhoe a amon g ca re givers with chil dren under five is crit ical to ascert ain and unde rstand factors affe cti ng home management of diarrhoe a and how these factors can be addr esse d to reduce diarrhoe a morbidi t y and mortali t y among chil dren under five. Tow ards thi s end, the resea rche r se ek s t o ask the following questi ons to gener ate relevant inform ati on to help improve upon dia rrhoea mana gemen t practi ces at hom e: i. Is there a relationship between caregivers’ level of education and knowledge about causes and dan ger signs of diarrhoe a? ii. Does the quanti t y of flui d and food int ake b y chi l dren chan ge durin g diar r hoea episod e? iii. Is there a relationship between caregivers’ level o f educati on and awar ene ss and use of ORS and RHFs for home mana gement of diar rhoea? Again, is there a relations hip between caregivers’ education and correct use of ORS? iv. W hat other mode of treatm ent do care givers us e at home for mana ging chil dren with diarrhoe a befo re se eking care at a healt h facil it y? v. Is there a relationship between caregivers’ ability to pay and duration of diarrhoea il lness at hom e before s e eking tr eatm ent at a healt h care facil it y? 1. 3 Purpose of stud y The purpose of the stud y is to assess pre -hospi tal management of diarrho e a and facto rs affe cti ng it amon g car e givers with chil dren unde r five at the PM L Chil dre n Hospit al. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 6 1.4 Objectives of stud y i . To d etermine caregivers’ understanding about diarrhoea, its causes and t he associ ated danger si gns . ii. To ex ami ne the feedin g pract ice amon g ca re give r s during the dia rrhoe al ep isode. iii. To ex ami ne the level of awar eness and us e of ORS and RHFs for home mana gement of diarrhoe a. iv. To identi f y othe r mode of treatm ent , which car e givers giv e durin g diarrho ea l episod e. v. To investi gate facto rs tha t influence caregivers’ decision to seek health care. 1.5 Signif icance of study Knowled ge, att it udes an d pra cti ces of care giv ers (mothers) ar e important determi nants of the occurr enc e or outc ome of diarrhoe a amon g chil dren under five. Th e findings of the stud y are ex pected to cont ribute to the unde rstandin g of the lev els of kno wledge, att it udes and practi ces of care give rs of chil dren unde r five with diarrhoea. This wi ll help in developi ng improved process of aw areness creati on that will inform a strong basis for effe cti ve behaviou r chan ge comm unic ati on as part of the nati onal strate g y to reduc e diarrho e a chil d morbidi t y and mortali t y in Ghana. In the acad emi c realm , the stud y will provide insi ght int o diarrhoea and its home mana gement pr acti ces among ca re give rs . This will help in developi ng tailored made traini n g programm es for heal th students and service prov iders to transmi t priorit y messages on home - based mana gement of dia rrhoea. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 7 1.6 State men t of hyp oth esis The following h ypoth es e s were drawn and tested: i . 7here is no relationship between caregivers’ educatio nal level and kno wledge about th e causes and dan ger signs of diarrhoe a ; ii. 7here is no relationship between caregivers’ educational level and the use of ORS and RHFs; iii. 7here is no relationship between caregivers’ educational level and the use of ORS ; and iv. There is no rela tionship between caregivers’ ability to pay and du rati o n of dia rrhoe a illness at hom e before s e eking tr eatm ent at a healt h care facil it y 1.7 Operation al def in ition s Diarrhoea: Passi n g freq uent, loose, water y stool s three or more times in a day with or without o ther signs and s ympt o ms. In an ex clusi ve breast fed bab y, dia rrhoe a is increase in stool frequen c y or liqui dit y tha t is considered abnorm al for the mother. Caregive r: An ybod y wh o acti vel y takes pa rt in taking care of a chil d at ho me. Pre-hosp ital man age me n t: The t yp e of care care givers give to the chil dre n themselves at hom e during dia rrhoe al episod e before ac cessi n g healt h care at the hospi tal. Care seek in g beh aviou r: He alt h servic e use beh a viour, that is, the wait ing time at home befo re acc essi ng healt h ca re. Other mod e of treat m en t : Any fo rm of treat ment or drug used in home management of diarrhoe a apa rt from OR S or RHFs . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 8 Dehydration : Loss of water and diss olved salt s from the bod y, occu rri ng, for inst anc e, as a result of diarrho ea Rehydration : The cor re cti on of deh ydrati on Oral Rehydration Therap y (ORT): Th e admi n ist rati on of recomm ende d fluid by mout h to prevent or corr ect deh ydr ati on (as a result of diarr hoea) in additi on to continuous feedin g. Oral Rehydration Salt (ORS) Solution: S pecificall y, the compl ete, new WHO/UN IC E F formul a. Recommen d ed Home Fluid s (RFHs): R ecomm e nded homemade fluids for home mana gement of diarrhoe a University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 9 CHAPTER TWO LITERATURE REVIEW 2.1 Introd uction This chapter presents a review of liter ature int en ded to provide a deep er understandin g of the background to the stud y and the rese arc h questi ons and la y the foun dati on for the stud y. The li terature was sou ght from s cienc e direc t, H INAR I, J STOR, MED LINE, Pub med , C INA H L and Goo gle s cholar as well as other relevant nursin g journ al. The review was organised und er th e foll owing th emes: de finiti on and t ypes of diarrho e a, knowled ge about causes and dan ger si gn s of diar rhoea , feeding pract ic es amon g car e givers durin g episod e, awar eness and use of ORS and RHFs, other mode of treatm ent for diarrhoe a , factors influencin g caregiver’s decision to seek health care during diarrhoea episode and s su mm ar y and conclusi on drawn from the literature . 2.2 Definition and typ es of d iarrh oea Diarrhoe a is a comm on digesti ve disorder that all people will suffer at some stage durin g their lives. B y conventi o n, diarrhoe a is pr esent when three or mor e stool s are passed in 24 hou rs that are suffi cientl y liqui d t o take the shape of th e container in which the y are plac ed (Black & Lan ata, 2002). 7he 0OH’s Standard Tr eatm ent Guideli nes (2004) de fine s diarrhoe a as passi n g frequent, loose, water y st ools three or more times in a da y. How ever , in an ex clusi vel y br eastfe d bab y , diar rhoea is defined as an in cre ase in stool frequ enc y or liquidi t y that is consi der e d abnormal b y th e mot he r. This i s because an ex clusi vel y breast f ed bab y no r mall y passes s ever al soft, semi - liquid stool s each da y. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 10 Diarrhoe a is caused b y i nfecti ous or ganism s, including viruses, bacte ria, protoz oa, and helm int hs, which are tr ansmi tt ed from the stoo l of one indi vidual to t he mout h of anothe r, termed as fec al -or al tr ansmi ssi on . Other caus es of dia rrhoe a includ e food and wat er co ntamination, malnutrit ion, dietar y chan ges, med icati on and ph ysiol ogic al stress. Diarrho ea is ver y comm on in chil dre n. Severe diarrho ea le a ds to fluid loss , and m a y be life -thre atenin g particularl y in youn g ch il dren, infants who are not ex clusi vel y bre ast fed and adult s who are malnourished or have im paired immuni t y (WHO, 2009) Accordin g to Keus ch et al. (2006), ther e ar e thre e majo r t yp es of diar rho ea. Thes e ar e: acute water y, persist ent, and blood y. Acut e wat er y dia rrhoe a is the t yp e th at most likel y le ads to rapid deh yd rati on. This form is the most deadl y in youn g chil dren and is comm onl y associate d with rotavirus, enteroto x igenic E.coli , or V. cholerae (chol era ). Persis tent diarrho ea i s less comm on form and is t yp icall y conne cted with malnutrit ion and is disproportionall y associate d with an increas ed risk of death. Blood y dia rrho ea is oft en rel ated to malnutrit ion, int esti nal dama ge, or seconda r y se psis . It is often asso ciate d with d ysente r y 2.3 Know ledge abou t causes and dan ger sign s of diarrh oea Mothers or car e givers at home shoul d have adeq uate knowled ge about th e causes and the associated dan ge r si gns of diarrho ea in chil dre n. Acco rding to Othero, Ora go, G roene we gen, Kaseje, and Oten gah (2 008), knowled ge of mo thers r e gardin g causes of diarrho ea and its associated dan ge r si gns i n chil dren is a guideline t o timel y and proper man agement at home and subsequent refer ral fo r s kil led care. The y further indi cate that knowled ge of dan ger si gns of diarrhoe a is imperati ve becaus e it leads to earl y refer ral of ver y sick chil d ren and that fail ure to refe r such chil dr en result s in major compl icati on or deaths. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 11 7here is an extensive body of literature focusing on mothers’ knowledge about chil dhood diarrhoe a and its associated dan ger si gns. The eviden ce from th e literature, howev er, shows that mot hers/car egiv ers have dive rse percepti ons on caus es of diarrhoea and poor knowledge about the dange r signs of diarrhoe a. A household longit udinal stud y b y Othe ro et al. (2008) in Ken ya in 2004 -2006 shows that more than half (55.6% ) of the care giv ers att ributed the cause of dia rrhoe a to unclean wat er. Other rea sons assi gned to the caus es of diarrho ea were contaminated food (54.9 %), bad e ye (50.0% ), fals e teeth (45.6% ) and br eas t mil k (35.8%). The stud y fu rther reveal ed that m ost of the mothers (76.4%) wer e not able to mention an y of thes e dan ger si gn s associated with diarrh oea such as ex cessi ve thi rst, sunken eyes and fontanel , skin pinch retu rning slowl y and ex cessi ve drowsiness or un cons ciousn ess, which are indi cati ve of sever e illness. Onl y 3.1% of the mot hers knew all the da nge r si gns. The stud y, which invol ved a tot al of 907 mot hers/car e give rs, adopted both quanti tative and quali tative approach es. The stud y also uti li sed focus group discussi ons and semi - structured questi onnair e as data coll ecti on tool , which was deemed appr opriat e be cause it en able d them to gather ri ch and in - depth information. The prolonged stud y of the participants in the field through th e longit udinal stud y desi gn made the res ear ch findin gs factual and mor e credi ble. Simil ar studi es carried out in Nige ria in the West Afric an Sub -R e gion hav e cit ed sev era l reason s consi de red to be percei v ed caus es of diar r hoea b y m ost caregivers. 7hese include µbad water’, normal dev elop ment such as te ethi ng, consum pti on of cert ain foods or spoi lt breast milk, chan ges in weath er , worms, poll uti on or ex posure to impure thi ngs, malevolent spirit s or evil eye , immoral behavi our of par ents during pregnan c y or la ctation, infe cti on, and emot ional states such as loneliness and fear . Howev er, toot h eruption (te ethi ng), cont ami nated wat er and food are often consi dere d as the maj or cause of diarrhoe a by most car e giv ers. Diarrho ea linked University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 12 with teethi ng is often no t perceived as an illnes s by some care give rs but rather as a no rmal stage of chil dhood deve lopm ent, and treatm ent ma y not be sought unti l s ympt oms of seve re deh yd rati on or vomi ti ng develop ( Omotade, Ade ye mo, Ka yod e, & Omata de , 2000; Uch enda , Emodi , & Ik efua ,2008; Adimora, Ikef ua, & Il ech ukwu, 2011 . In relation to caregivers’ level of knowledge on the caus es of diarrhoe a , Adimora et al. (2011), maintains that it is rel ati ve to the kind of int erventi on taken by them to manage the diarrhoe a. These int e rventi ons someti mes have ne gati ve conseque nces on the healt h of chil dren espe ciall y wh e n inappropriate and unti mel y m easur es are ta ken. The outcome of thi s is increase in m ortalit y and morbidi t y rate s of diarrhoe a. . Oth er related studi es co nducted in Indi a hav e al so reve aled kno wled ge deficit amon g mot hers conc ernin g dia r rhoea, its associated da nge r si gns as well as its home mana gement practi ces. The res ear che rs recomm end the nee d for ur gent and fu rthe r inqui r y for thi s knowledge gap amon g mot hers, since major eff orts have been made ov er the past 25 yea rs in India to promot e prope r home -based man a gem ent of diarrhoe a in chil dren (Shah, Ahmad, Khali que, Anas ari, & Khan, 2011; Shah, Ahmad, Khali que, & Afaz al,2012 ) Similarly, $nsari, Ibrahim, and Shankar 2 examined mothers’ knowledge about diarrhoe a and its asso ciat ed dan ge r si gns amon g a margin ali sed comm unit y of Moran g in Nepal. The finding of the stud y indi cates th at alt hou gh mot hers wer e aw are abo ut diarrhoea and its home management, their level of knowledge pertaini ng to vit al iss ue like dange r signs of deh yd rati on due to di ar rhoea was ve r y poor. From the stud y, majorit y (about 79% ) of th e mot hers opined thi n wate r y stool , repe ated vomi ting and feb rile condit ions as indi c ati ve of more serious diar rhoea. How e ver , most of them were unawar e of other importan t signs o f deh yd ra ti on such as sunk en e ye s, thi rst (ea ge rl y drinki n g), skin pinch rec edin g slowl y, passa ge of University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 13 co ncentr ated or dark col oured urine, a drows y ch il d and the chil d not gett ing bett er aft er three da ys. The findin gs of the stud y also rev ealed a posi ti ve corr elation of maternal educati ona l level, age and occupation, husbands’ income and family si]e with mot hers ’ level of knowledg e about diarrhoe a and its pr eventi on. The stud y, which was co mm unit y-o riented, and t he first of its kind in Nepal invol ved a tot al of 130 mot hers between 16 –40 ye ars of age with a chil d below the age of 45 mont hs having diarrho ea at the time of the stud y or in the pre cedin g th ree to si x mont hs. The stud y design was cross -se cti onal adopti ng quanti tative approach with the use of structured questi onnaire as dat a col lecti on tool . Even though the use of the qu anti tative res ear ch approa c h enabled the stud y to ach ieve its objecti ves, a qua li tative approach would have provided mu ch more in-depth informatio n about chil dhood diarrh oea and its home mana ge ment among mot hers in the Musahar comm unit y of Moran g, espe ciall y as thi s stud y was the firs t of its kind in Nepal. It is important, howev er, to point out that in thi s current stud y qu anti tative appro ach is bein g used becaus e of ex tensive literature on the subj ect ex ist s . Contrar y to the findings just described in the study b y Ans ari et al (2011) that maternal educati onal level posi ti v el y corr elates with mot he rs ’ level of knowl ed ge abo ut diarrhoea and its preventi on, Uch enda et al (2008) indi cate th at the re is no relation in mater nal educ ati onal level and their level of knowl edge with respe ct to t he perceiv ed caus es of diar r hoeal diseases. Th e y however, cauti oned tha t alt hough th eir stud y did not show an y dive rgence in terms of performan ce betwe en ca re givers with diffe rent educati onal level, high er maternal educati onal level is well reco gnised as a protecti ve factor for chil dhood survival and confers the adv anta ge of being able to unde rsta nd and compl y with life - saving he alt h practi ces. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 14 2.4 Feedin g practices d urin g diarrh oea l episode The role of quali t y nut rition and good f e eding practi ce cannot be ove resti mated in chil dren, espe ciall y in chil dren under fiv e as th e y pl a y essential rol e in chil dren growth and developm ent as well as their abil it y to withs tand infecti ons. Th e MOH, WHO and UN IC E F recomm ends ex clusi ve breastfe edin g throughout the first six months of life, the int roducti on of local, nutrient rich com plementar y foods subs e quentl y with conti nued breastfe edin g to two yea rs of age and be yond (WHO, 2001; WHO, 2003; MOH, 2007 -2015 ). Accordin g to proce edin gs report b y WHO and UNIC EF on stren g then ing acti on to improve feedin g of infan ts and youn g chil dren 6 - 23 mont hs of age in nut r it ion and chil d he alt h programm es, appropriat e compl ementar y feedin g is vit al in att ainm ent of healt h y gro wth and developm ental potentials as well as the conti nue d ex ist ence of eve r y yo ung chil d. Lack of appropriate bre astfe eding and compl em entar y feedin g pr acti ces ar e m ain caus es of und er nutrit ion. This is also a direct caus e of mortali t y in chil dren, and a majo r limi tation factor in survival chil dren from reachin g their full dev elop mental potential s . It is esti mated that 32% of chil dren less than 5 year s of age in dev elopi ng co untries ar e stunt ed and 10% ar e wasted due to poor feedin g practi c es (W HO, 2008) Mortali t y in Chil dren as result of diarrho ea, as noted by WH O and UNIC E F, is often due to an underl yin g m alnut rition , which makes them more vulnerable to diarrhoea. Each incidence of the diarrho ea l episod e makes their malnutrit ion worse. It has been affirm ed that d iarrhoe a is a major caus e of malnutrit ion in chil d ren unde r five ye ars old, which ac counts for about one - thi rd of the 9.7 mill ion ch il d deaths that occur ea ch yea r (WHO, 2003; UN IC E F , 2007 & WHO, 2009 ) University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 15 Along with the admi nist r ati on of ORT, an important s trate g y for man a gin g diar rhoe a is promot ion of approp riate chil d feedin g, both dur ing and aft er a diar rhoea l episod e, to pr even t ex cessi ve and un compen sated loss of nutri ents. It is therefo re required that a chil d shoul d be given incr eas ed fluid and conti n ued feedin g dur ing and aft er diar rhoea l episod e in order to prevent deh yd rati on and malnutrit ion. Some studi es have indi cated that i n developi n g countri es, whe re mal nutrit ion and diarrhoe a are more comm on, earl y inc epti on of compl ete nutrit ion in acute diarrhoe a has sever al p otential bene fits for the chil d su ch as decre as ing stool volum e and durati on of diarrho ea (Beh rman & Kli e gman, 2004; Walke et al., 2004 ; King, Glass & Br esse, 2003). Other studi es, however, hav e shown th at in man y so cieties, the pare nt 's remedi al response to diar rhoea is t o withhol d food and fluid, including bre ast -mi lk, in the mistaken beli ef that thi s will stop th e diarrhoea and ease the strain on the intestine. 7his µtreatment’ according to :HO  , only adds to the deh ydrati on and malnutrit ion caused by the ill ness. In Ghan a, findings of the Multi ple Indic ator Clust er Surve ys (M IC S ) cond ucted in 2006 indi cated that mot hers wit hhold food and fluid during diar rhoe a l episod e. In the surv e y, it was found that about one-thi rd (34%) of und er - five chil dren with diarrhoe a drank more than usu al while 65% drank the same or less. Half of under - five chil dren with diarrhoe a ate somewhat less , same or more (conti nued feedin g), and also half ate much less or ate nothin g. Othero et al (2008), in a stud y on house househ old perc epti on and pra cti ces re gardin g home mana gement of diarrhoe a amon g chil dr en under five in N yan do Dist rict, a rur al comm unit y in Ken ya als o investigated the mothers’caregivers’ feeding practices during child diarrhoe a. In the stud y, majorit y of the mot hers (59.9%) reported that the chil dren drunk much less , 20.5% affirmed tha t the chil dren did not dr ink at all while onl y 10. 9% repo rted th at the University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 16 chil dren drank more tha n usual. The remaining 8.6% indi cated that that the y dr ank somewha t less or about the same. On respondi ng to the qu esti on on whether the chil dr en ate less, the sam e or more than usual durin g illness, again response s in dicated that about 39 .0% did not eat at all during illness, while only 6.9%) ate more than usual. Those who withheld feeds and fluids professed th at conti nued feedin g inc reas ed the rate of loose stool s. One of the mot hers in a focus group discussion stated: ³…the more fluids a child drinks when he/she has diarrhoea, the more frequent the lose stools and more so milk… ´ Other related studi es in East Afric a to ass ess fee ding pr acti ces amon g m others durin g comm on chil dhood illness have also shown a sim il ar patt ern of some mot h ers withhol ding food and fluid durin g the ons et of gastroint esti nal s ympt oms such as abdomi nal pain, vomi ti ng and severe dia rrhoe a, and febril e illnesses (Kaatano, Muro & Meda rd, 2006; Neumann, Marqu ardt & Bwibo, 2012) Both studi es empl o yed cr oss secti onal stud y desi gn. Howeve r, Neumann et al. empl o yed the cross secti onal desi gn in addit ion to longit udinal stud y desi gn. A total of 110 toddl ers wer e followed longit udinall y for a period of 12 mont h s . The starti ng period for the follow up started with the da y the y rea che d 18 mont hs of age and ended at the da y the y rea ched 30 mont hs. The main purpose of the study was to quanti f y the eff ect of comm on illnesses on ener g y int ak e an d compare thi s int ake to the int ake durin g well ness periods as well as conv a lescenc e period. Th e quanti tative fashio n of documen ti ng food int ake durin g pe riod of well ness, illness and convalesc ence in a fre e-l ivi ng population enable d the research ers to obser ve an y comp ensator y ener g y int ak e durin g con valescen ce period. Neum an et al conclud ed that consi derable reducti on in food int ake particularly durin g comm on chil dhood illness is unacceptab le but rather feedin g shoul d be acti vel y encou ra ged b y mot hers or care givers in the absenc e of vomi ti ng. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 17 In anothe r stud y conduct ed b y Shah et al (2012 ) in the urb an slum of Aliga rh, Ind i a, it was found that about t wo -thi rds (69% ) of the mot hers conti nued bre astfeedin g and thei r chil dren durin g dia rrh oea episod e while the remainin g eit her withheld or int errupt ed breas tfe edin g. Lik ewise 62.2% of mot hers with chil dren betwe en ages 7 mont hs t o 5 years conti nued with the normal feedin g patt ern of their chil dren. The prim e reas on given in the stud y by the mot he rs re gardin g withhol ding or int er rupt ing of breast milk or fed was that br east milk is responsi ble for dia rrh oea and th ere fore it ou ght t o be withheld for so long as dia rrhoe a conti nued. In the stud y, th e mot he rs also all e ged that the ener g y dense foods , wh ich the y took during l actation are s ecr eted in the breast milk, causing diar rhoea, henc e these foods ar e als o supposed to be withdra w n . In addit ion, the care gi vers in the stud y felt that it was much or l ess insi gnificant to conti nue feedin g if the y had starte d some form of dia rrhoe al treatm ent giv en t o them at the healt h -ca re facil it y. The stud y, whic h was cross -se cti onal , invol ved 300 households and a tot al of 101 mo thers with chil dr en less than 60 mont hs of age who had at least ex perienced on e episod e of di arrho ea in the t wo weeks pri or to the stud y. The us e of questi onnaire as tool fo r data coll ecti on in the stud y was good enou gh. Non etheless, sem i structured int ervie ws wo uld have provided a mu c h in -depth information since about 80% of th e target stud y popul ati on were illi terate. 2.5 Awaren ess an d use of RHFs and ORS In most cases, diar rhoe a related de aths in chil dre n are caused b y deh ydrat ion from loss of lar ge qu anti ti es of water and electrol ytes fro m the bod y in liquid stool s. Management of diarrhoe a – eithe r throu gh ORS or RHFs - can prevent man y of thes e deaths. ORS is a non- University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 18 proprietar y name for a balanced glucose - electrol yt e mix ture, first used i n 1969 and has sin ce earl y 1980s been app rov ed, recomm end ed, and dist ributed by UNIC E F an d WHO as a drug for the treatm ent of cli nic al deh yd rati on throu ghout the world (WH O, 2006). The admi nist rati on of flu ids by mout h eit her in th e form of ORS or RHFs to prevent or corre ct deh yd rati on that i s a consequen ce of dia rrh oea alongside conti nuous fee ding is known as ORT. The ORT has been widel y consi de red as ch eap and ef fe cti ve wa y of reducin g the mill ions of deaths caused eac h year b y dia rrhoe a. It can be deli ve red b y healt h workers at ver y low er level he alt h facil it ies like CHPS compounds , healt h cente rs and cli nics and can also be practi ced in the home b y mot hers with litt le guidan ce, an d thus is a technolo g y highl y suit ed to th e prim ar y healt h care app roach. Mor eover, when given along with advice on prope r feedin g practi ces, ORT has been found to contribut e to bett er wei ght gain and thus to reduce the ill effe cts of diar rhoea on nutriti onal status (Victora, Fontaine, & Monassch, 2000). It is esti mated that between 1980 and 2000, ORT decreas ed the number of chil dren under five d yin g of diar rhoea from 4.6 mill ion worldwide to 1.8 mill ion ²a 60% redu cti on (Kolpuru, 2008). Accord in g to WHO (2006), in the 1980s, about 4.6 mill ion chil dren under five ye a rs old died ea ch ye a r from diarrho eal diseas es and about two -thi rds of these de aths were att ributable to acute wa ter y diar rhoea. In respo nse to thi s mom entous burden of diarrho eal disease, the WHO int rod uced a sp ecial pro gramm e for Control of Di arrho e al Diseases (CDD) in chil dren durin g th at peri od. The pro gramm e was aim ed at redu cing diarr hoeal mortali t y in th e short -term and de cre asi ng diar rhoe al morbidi t y in the long -term. Th e prim ar y int erventi on chosen to reduc e the diarrhoe al mortali t y was promoti on of ORT with a solut ion containin g glucose, sodi um, pot assi um and a chemi c al ba se s uch as sodi um bicarbonat e. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 19 In close coll abor ati on with other int ern ati onal agen cies such as UNICEF, the WHO developed glob al guideli nes for diar rhoeal mana gement and pro gr amm e i mpl ementati on. In the diarrhoe al diseas e cont ro l effo rt, incr easin g the us e of ORT became utm ost priorit y. The fluid given could be eit her ORS ² a pre -pa cka ged powder to be diss olv ed i n a given quanti t y of water ² or an y fluid reco mm ended by nati onal C DD pro gramm es fo r prev enti on or treatm ent of dehydration. Such fluids were labeled µrecommended home fluids’ RHF . 7ogether, the two formed the basis for ORT. The CDD progr amm e recomm e nded that ideall y, reh yd rati on therap y shoul d be given to all chil dren with dia rrhoe a to prev ent or tre at deh yd r ati on. Furth ermore, it was advised that all chi ldren with diarrhoe a sh ould be given mor e to drink than usual, to compensate fo r loss es of fluid through loose st ools, and that feedin g s hould not be stopp ed during dia rrhoe a (W HO, 1989; WHO, 2006). Kolpuru (2008) has not ed that with ORT as a pref err ed opti on fo r pr eventi ng an d treati ng dia rrhoe a, a tot al of about 500 mill ion ORS sachets are produced per yea r, with UN IC EF dist ributi n g the m to chil dren in arou nd 60 developi n g countries. Despit e the relativel y high ORS acc ess rat es and its cost - eff ecti ven ess in prev enti ng and mana ging diarrho ea l diseases, va rious repo rts and studi es hav e indi cate d that t he awar eness and use of ORT has been limi ted. Forsbe r g, Petz old, Tomson and Allebe ck (2007 ) in a stud y condu cted to determi ne whether there has been an improvement in diar rhoeal man a gement fro m 1986 to 2003, th e period durin g whi ch si gnificant ef fort wer e ma de to promot e eff ecti ve case mana gement of diarrhoe a in chil dren, noted that ORT use has improved ver y litt le. In the stud y, a tot al of 107 household data of Demo gr aphic and Healt h S urve y of 40 low and middle income countries wer e anal ys ed to assess the trend in indi cators of reh ydr ati on, fluid quanti t y and food int ake in University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 20 chil dren with diarrho ea. The main findin gs of t he stud y su ggested that there has been sli ght improvement with regar ds to the use of ORT (0.39% per ye a r) and increas ed fluid int ak e (1.02% pe r ye ar). Thus, the user rates remained l ow in 2003, wh en comp ared with desired full covera ge. The resea rch er s concluded that man y chil dren in low - and middle -income countries do not receive proper tr eatm ent for diarrhoe a and thi s, point s to the ne ed in addressi ng the unfinished agenda in chi ld survival. The sampl e siz e used for the stud y was adequ ate and the findings of the stud y app eared to b e based on th e objecti ves of the stud y. Sim il ar studi es conducte d in Ni geria hav e also revealed a drop in the l evel of knowled ge of ORS among care give r s since its incepti on in the earl y 1990s. The autho rs recomm ended the need to int ensif y m atern al educa ti on on ORT . Majorit y of care give rs enr oll ed in these studi es knew about ORS while few of them new about suga r Salt Solut ion (SS S ). However their knowledge level did not reflect in their abil it y t o prepare the ORS and SSS correctl y as a significant numb er of chil dren received fluids in which the s alt and su ga r was not prope rl y mix ed with right volum e of water. Th ese studi es further rev ealed that mate rnal educati onal level did not seem to confe r an y advanta ge on being abl e to co rre ctl y mix the OR T flui ds (Adim ora et al. 2011; Uch endu et al. 2008). Adimora et.al (20 11) furthe r added that kn owledge of tre atm ent of chil dhood diarrho ea at home did not necess aril y foll ow the social class lines and hen ce educati onal level was not a ver y important factor in the knowledge of home management of chil dhood diarrhoe a. Contrar y to these findin gs, a cross -secti onal stud y by Kudlo va (2010) reve aled posi ti ve associati on betwe en mat ernal edu cati onal level and their level of knowle dge and use of ORS . Howeve r, the stud y reco rded lower rate of aw are ness (27.6%) and ORS use (1.9%) amon g the 210 car e givers invol ved i n the stud y. The stu d y was conduct ed in the Czech Republi c and was University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 21 aim ed at investi gati ng home mana gement of chil dhood acute dia rrhoe a among care giv ers with chil dren betwe en 6-59 m onths . In a related stud y in the Moran g dist rict of Nepal by Ansari et al. (2011 ), it was found that mot hers were co gni z ant with di arrhoe a and its home mana gement; however, their level of awar eness was inadequ at e. The stud y indi c ated th at mot hers ' knowled ge about the role of ORS in diarrhoe a was poo r. The most comm on answe r given b y the mot hers in their respons e to the role of ORS in diar rhoea l mana gement was that i t most l y decr eas es the fr equenc y of diar rhoea whils t in some inst ance frequenc y m a y incr eas e. Onl y 0.85% of the mot he rs indi cated that ORS prevent deh yd rati on in chil dren havin g diar rho ea. The stud y att ributed the poor knowled ge among the mot hers abo ut the role of ORS in diarrhoe a to their poor knowledge about the concept of deh ydr ati on and reh yd rati on and s trong beli efs that ORS eit her de cre ases or increas es the fr equenc y of diarrhoe a. The stud y also found tha t none of the mot he rs ou t of a total of 130 mot he rs enr oll ed in the stud y could indi c ate all the fou r co rre ct steps of ORS prep arati on and besides, man y parent s gav e the wron g volum e of ORS solut ion to the chil d during diar rhoe a. The main reason for using an in corr ect volum e of water durin g th e pr eparati on of the ORS solut ion was due to th e use of local uncali brated water -m easurin g devic es . Sim ilarl y the stud y fou nd that knowledge of mot hers about the prepar ati on of salt -sugar- wate r (SS W ) was even poorer to ORS . Most of the mot hers, ac cordin g to the stud y, were not aw are of prepa ring SSW solut ion and even those who were awar e, most of them could not mention any of the prep ar ati on steps or the y mentioned onl y a few steps. This was attributable to the SSW use bein g un comm on among the mot hers an d again most of the mot he r s not having an y prior ex posure to it. Furth ermore , its ingredi ents wer e University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 22 not avail able in read y-m ade fo rm unli ke an ORS sachet and thus the likeli hood of errors du rin g its preparati on. In Ghan a, ORT has been avail able in the healt h sys tem since the 1980s. Nevertheless, it is esti mated that less tha n 50% of chil dr en under - five yea rs with diarrho ea are tr eated with ORT (NDPC , 2005). In the MICS conducte d in Ghana in 2006, it was found that of chil dren unde r - five yea rs of age who ex perienced dia rrhoe a i n the previous two weeks, onl y about 29% receiv ed ORS and 9% received RH Fs. The surv e y further indi c ates that as man y as 63% of chil dren with dia rrhoe a received no ORS or RHFs. Even thou gh, the M IC S showed relativel y higher ORT use in the Greate r Accra Re gion wit h 39.1% of the chil dren receivi n g ORS and 19.0% rec eivi ng RH Fs, t he usa ge rate was stil l below 50%. Another stud y b y Kend ell , Mill er, Winsor, and Hale (2009) in the rural comm unit ies withi n the Ejis u -J uaben Dist rict in 2008 found that alt hough 92% of the mot hers had actuall y heard of ORS and 86.6% described the cor rect pr eparati on of the solut ion, onl y 28.4 % actuall y used ORS for their child’s most recent episode of diarrhoea. 7he gaps in the use of ORS as noted in the various studi es suggest that t her e is sti ll the need to ex plore the best wa ys t o promot e the use of ORS particularl y in the dev elopi ng countries. 2.6 Other mod e of trea t men t of d iarrh oea at home Most cases of acute diar rhoea are sel f -li mi ti ng an d do not require an y tr eat ment. WHO (2 006) on the subj ect of im plementi ng the new rec omm endati ons on the cli nical mana gement of diarrhoe a, recomm end e d ORS and fluid comm o nl y av ail able at home, br eastfe eding, conti nued feedin g, selecti ve use of anti biot ics, and providi ng zinc suppl ementati on for 10 to 14 days for diarrhoe a mana gement. Howeve r , a wo rrisom e practi ce amon g some care giver is the combi ned University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 23 ad mi nist rati on of quit e a number of different me dicines for the home management of diarrho e a aside the recomm ended ones. The use of th e se unpresc ribed medici nes which often are orthodox or tradit ional or combi nati on of both is not onl y harm ful but increas e the fin ancial burden of the fami l y. A cross -secti onal stud y by Fa yaz , Aesha, Imt i ya , Thankar, and Sami na (2006) to asses cult ural practi ces adopte d for home managem en t of diarrhea among m others in vil lages of Kashmi r Vall e y – India, reveal ed a hi gh rate of anti biot ic use (77.9%) am ong the respond ents. The stud y, which was aim ed at stud yin g the tr e atm ent practi c es vis -à-vi s cli nical signs and s ympt oms at various he alt h facil it ies, conclude d that treatm ent pra cti c es are sti ll improper because of la ck of knowle dge of pra cti ti oners in Nati onal Progra mm es . The authors recomm ended th e need t o stop the irrati onal use of anti obiot ics. Simil arl y, Hoan, Chuc, Ottos son, and Allebeck (2009) conduct ed a surv e y to ex ami ne the patt ern of dru g use among the chil dren less t h an five ye a rs with respirat or y illnesses and/or diarrhoe a, and to an al yz e the relations hip betwe en various socio -e conomi c factors an d patt ern of drug use. Th e stud y, whi ch was conducted at Ba vi dist rict, Vieti nam invol ved a tot al of 1, 836 mothers/ care give rs with under five chil dren who has suffer ed diarrho e a and/ or respirato r y illness prior to the stud y. Th e stud y point ed out that there is major problems conc ernin g irrati onal dru g use amon g chil dr en. Antibi oti cs use amon g the responden ts was 72.2 % wh il e anti - diarrho ea dru gs use was about 36.1 %. How ever , ORS use amon g ch il dren with diar rhoe a was onl y 9.7% amon g chil dren with diar rhoe a. Although anti biot ics was hi gh, the stud y surprisi ngl y found that chil dren whose mot hers had up to prim ar y l evel of e ducati on were the least likel y to use anti biot ics. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 24 In another stud y b y Ogu nrinde and Ani go (2012), the y affirmed a pressi n g need to scal e up educati onal and prom oti onal acti vit ies pertaini ng to home mana gement of diarrho eal dise ase. The sampl e for the stu dy invol v ed home car e givers with chil dren aged 1 -59 mont hs having diarrhoe a pres enti ng at randoml y sel ected comm unit y prim ar y healt h cen tres in northweste rn part of Nigeria. The st ud y hi ghli ghted that an ti biot ics and anti -diarrh oeal agents use was comm on (36%). Onl y 32% of care give rs were aware of the use of zinc in the mana gement of diarrhoe a. Howev er, adh erenc e to 10 -da y zinc sup plementation was encou r agin g (75 .5%). 2.7 Factors in f lu encing c aregivers’ decision to s eek healthcare The desire of ever y pa r ent is for their chil dren to sta y healt h y, and go through the normal developm ent al m il e stone of life. Ho weve r , in the occu rren ce of chil dhood illness such as diarrhoe al illness , care givers have consi de rable var yin g car e seekin g beh aviour dependin g on several factors. Findi n gs of a Comm unit y-based Clust er Surve ys conduct ed by Biritwum e t al. (2004) in two dist ricts in Ghana on treatm ent pr efer enc es for diar rhoea, severe dia rrhoe a, an d dysente r y in chil dren aged less than five ye a rs indi cate a low-use rat e of hospi tals for sever e diarrhoe a. The stud y, which was condu cted in Tema, an urb an dist rict an d Akwapim South, a rural dist rict, att ributed the finding to the healt hc are fin ancin g s ystem of 'cash and carr y' wher e pati ents without an y for m of healt h ins uranc e pa y fo r all servi ces out of t heir pocket. For most care giv ers, the cost of healt h care is b e yond their financial cap abil it ies. In the stud y, a tot al of 61 9 and 611 car e givers res pecti vel y in Tem a and Akwapim South with chil dren under five were in terviewed. Abo ut 48.8% of urb an mot h ers of chil dr en with severe diar rhoea visi ted publ ic/private cli nics, 9. 5% visi ted pharm acies, and 3.6 % visi ted the dist rict hospi tal whereas 22.8% of the rural mot hers visi ted publi c /private cli nics, 19.0% vis it ed University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 25 pharmacies and 13.9%, t he dist rict hospi tal. Lac k of mone y was the main reason given in the stud y b y the care give rs for not seeking medic al att enti on for their chil dren with severe diarrhoe a. In a retrospe cti ve stud y on healt h ca re s eekin g be havior, Pa ge et al (2011 ) ex ami ned the proportion of chil dren under five with diarrhoe a who consul ted at a h ea lt h facil it y. This was done to identif y th e app ropriate healt h care leve ls to set up surveil lance of severe diar rh oe al diseases. The stud y emp lo yed clust er sampl in g s urve y invol ving four he alt h dist rict region of Mardi, Ni ge r. Out of tho se repo rting diarrh oea du ring the rec all period, 70 .4% repo rted s eekin g care at a healt h facil it y, and amon g s ever e cases, 83% sou ght car e. The re was no associati on between consul tations at a healt h car e structu re an d the level of edu cati on of the car etaker. The main reasons for non - c onsul tation were spont a neous recove r y and sel f - medicati on, most l y sought from roadside vendors . Financi al pr oblems were cit ed in approx im atel y 10% of respondents as the main reason for the non - consul t ati on at the healt h ca re fa cil it y. Accordin g to Page et.al (2011), the increas e in healt h care se eking behavi our in case of diarrhoe a of chil dr en un der 5 yea rs of age in the Mar adi re gion sinc e th e 2006 DHS surv e y, suggests the effica c y of recent he alt h poli cies for chil dren in Niger. The y further noted th e aboli ti on of user fees for chil dren under 5 years old in April 2007 in Niger brou ght a posi ti ve impact on pati ent behaviour, and in particular on t he dela y befor e consul ta ti on in the case of the most vulnerable groups. In recent stud y b y Shar ke y, Chopra, J ackson, Winch, and Minkovit (2011) resea rche d int o influences on heal th car e -se eking beh aviour durin g fin al illness of infants in und er - resourc ed South - African sett ing. A quanti tative int erview was condu cted among 39 care give rs of dece ased infants in a rural comm unit y and an urban townshi p. In ad dit ion, 19 comm unit y University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 26 leaders and loc al he alt hc are providers wer e also int erviewed. The find ings of the stud y rev eale d that lim it ed autonom y of care give rs in decisi on -making, la ck of aw aren ess of inf ant dan ge r - si gn s, and identific ati on of an ex ternali z ing ca use of illness were imp ortant influences on healt hcar e - se ekin g durin g illnesses of inf ants in these sett ings. The stud y further reve aled poor fami li es faced other fin a ncial const raint s that impacted their ac cess to healt hcar e alt hough in South - African publi c - he alt h services are free. Sharke y et al. (2011) concl uded that, often there was not one factor but a combi nati on of factors occurrin g eit he r concu rr entl y or sequ enti all y that determi ned whether , when, and from wher e outsi de healt hcar e was sought during fina l illnesses of infants. 2.8 Summary and conclusion draw n from the li teratu r e The cor e objecti ve ex ami ned in the review is pre - hospi tal management of diarrhoe a and factors affe cti ng it amon g care giv ers. In relation to thi s objecti ve, the discussi on is prefaced b y the definiti on of di ar rhoe a and the various t ypes of diarrho ea. It proc eeded to review caregivers’ knowledge about causes and dan ger si gns of di arrhoe a, feedin g pra cti c es among car e givers during episod e, aw aren e ss and use of ORS and RHFs, other mode of tre atm ent for diar rhoe a and factors that influence caregiver’s decision to seek health care during diarrhoea episode. C onclusi on drawn fro m the revie w su ggest s that gener all y th er e are seve ral discrepan cies about the knowledge of causes of diarrhoea amon g mot hers / care givers. Rega rdin g dan ger si gns associated with diarrho e a and how to effe cti vel y mana ged diar rhoea at home, caregivers’ knowledge was generally poor. It also came out that a lot of factors influences care giv ers ’ decisi on to seek healt h care during dia rrhoe a episod e . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 27 CHAPTER THREE METHODOLOGY 3.1 Introd uction This chapter provides i nformation on the rese arch design used, the stud y sett in g, sampl ing methods, instruments for data coll e cti on , method for anal ysis and ethi cal issues. 3.2 Research design The resea rch design is th e over all pl an for obt aini ng answe rs to resea rch questi ons or for testin g the rese ar ch h yp otheses. The rese ar ch design guid es the rese arc her in plannin g and implementi ng the stud y in a way that is most likely to achiev e the int ended goal. Ther e ar e two broad appro ach es to res earch, qu anti tative and quali tative. Accordin g t o leed y & Ormrod, (2005), quanti tative res earch is used to ans we r questi ons about rel ati onshi ps of measu rin g variables with the purp ose of ex plaining, pr edicting and controll ing ph enomena. Usuall y, i t starts with one or more specific h ypothesis to be t ested, va riables to be studi ed ar e isol ated an d ex traneous vari ables are controll ed. A standardis ed pro cedur e is us ed to coll ect some form of numerical data, after whi ch statis ti cal procedures are used to anal yse and draw conclusi on. The quanti tative stud y ends with confirmation of the hypotheses that were te sted . On the other hand , quali tative rese ar ch, as not ed b y Poli t & Hun gl er (1996 ), invol ves the s ystemati c coll ecti on and an al ysis of more subj ecti ve narr ati ve materials usin g proc e dures in which ther e tends to be a minim um research er imposed control In thi s stud y, a quanti ta ti ve approa ch with a cr oss - secti onal desi gn was adopted. It involved taking a cross -s ecti on of eli gibl e car e givers at the time of the study and finding out the ex tent of their kno wled ge in pr e-hospi tal man a ge ment of dia rrhoe a. Cross - secti onal studies , also University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 28 known as on e-shot studi es , ar e design ed to stud y a ph enomeno n b y takin g a cross -se cti on of it at a time. The y are com parati vel y che ape r to undertake and eas y to anal ys e even thou gh the y cannot measu re ch an ge . It nec essi tates proc es sing of qu anti tative da ta and en ables the resea rche r strive for br eadth rathe r than d epth towards making vali d gen eral observ ati ons (Ba rbie, 1989). The cro ss -secti onal stud y was consi dered the most app r opriate for coll ecti n g data on the objects fo r this stud y. With regard to the qua nti tative approach, th e proponents of it or pos it ivi sm school contend that human behavior in the social sciences, just as ph ysic al phenomena in the natural sciences, is qu anti fiable in att ributes and su bject to gener ali z ati ons that ha ve unive rsal appli cabil it y (Ba cho, 20 01). This approach s eek s to test the correlation between variables and even thou gh critiqu es hold the view that it pro vides narrow lens of res earch b y focusin g on specified set of vari ables, it helps to avoid fault y con clusi ons, minim iz es misrepresent ati ons and gua rds against manipulat ion (Enu -Kusi, 2010). 3.3 Study settin g The stud y was conducte d at PM L Chil dren Hos pit al . The hospi tal was establi shed in 1926 and was named aft er Her Hi ghness Princ es s Louise M arie, th e gran d -dau ghter of Que en Victoria. It is located in the central busi ness dist rict of Accra. The comm u nit y is Korle -W okon, a highl y populat ed indi genous Acc ra s ett lement with poor environment al sanit ati on . As a result of thi s, comm unicable di seases especiall y dia rrho ea and malari a ar e re gula rl y report ed from th e area. Th e cat chment pop ulation is esti mated to be about 39,496 (PM L Hos pit al Annual Report, 2011). University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 29 The hospi tal is a specializ ed hospi tal that of fers int egr ated servic e in the mana gement of chil dhood illness . Apart from providi ng efficien t, prompt and afford able peadiatric ca r e, the hospi tal also offers other se rvices su ch as rep roducti ve and chil d hea lt h, fami l y plannin g, nutrit ion rehabil it ati on service, dental , e ye , ear nose and throat, asthm a, HIV, or al reh ydrati on point and sickle cell clinic. It has a bed compl e ment of 74. The set up includes OPD where pati ents ar e sorte d out fo r att enti on, four in -p ati en t wards, emer genc y ward and inj e cti on room. There ar e also dispens a r y, laborato r y, medic al records, cat erin g, publi c healt h and gene ral admi nist rati on unit s, as well as a mortuar y. The hospi tal also has a recr eati onal ar ea fo r chil dren. The hospi tal runs 24 -hou r emer genc y s ervic es. Pa ti ents are norm all y s een on dail y basis at the OPD and are sort ed out eit her b y appoint ment, refe rral or as an emergenc y. Th e tot al OPD att endance fo r 20 10 and 2011 was 70,911 and 75,288 respecti ve l y. On ave ra ge, 206 pati ents were seen at the OPD on dail y basis i n 2011. In-p ati ent admi ssi on was 3788 in 2010 and 4519 in 2011. 3.4 Target pop u lation / inclusion and exclusion crite ria The tar get population is the tot al group of su bject about whom the i nvesti gator is int erested and to whom the result s could reasona bl y be gene rali sed (Le ed y & Ormrod, 2005: 71 -106). The care give rs used for th e stud y were recruited from th e em er genc y ward and ORT corner of the PM L C hildren’s H ospi tal. Th e tar get population fo r the st ud y was all care give rs with chil dren und er fiv e reportin g at th e PM L Ch il dren Hospit al with diar rhoea with or without other s ympt oms . Th ese people were chosen as the tar get population because the y had the chara cterist ics that the resear cher wa s looki ng for and could provide an swers to the resear ch University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 30 quest ion. The rese arch ex cluded care givers ref er red from other healt h facil it y and those who had alread y visi ted other healt h facil it y. Care gi ver of pati ents who fell outsi de the inclusion criteria, fo r ex ampl e those dia gnosed with other ail ment aside diarrhoe a were also ex cluded. 3.5 Indicators and variab les Table 2 provides the details of indi cators and operati onal definiti ons of major variables that were us ed in the study. Table 2: Indicators, variab les and their defin ition s Objectives Indicators Variab les Defin ition of variab les Source of Data To determi ne care gi vers’ understandin g of diarrhe a, its causes and th e associated danger si gns Proporti on of care giv ers understandin g diarrhoe a Understandin g of diarrhoe a Understandin g diar rhoea means being able to define or id enti f y the disease ( i.e. frequ ent pas sing of water y stool – 3 or more times) Inte rview with care giv ers Proporti on of care giv ers understandin g causes of diarrhoe a Ex tent of knowledge about causes of diarrhoe a (adequat e, some or no knowledge) - Adequate kn owled ge m eans bein g able to mention at least 3 causes of diarrhoe a (e. g. contamina ted food, contaminated wat er, poor environmental sanit ati on, bott le feedin g etc ) - Some knowled ge means being able to ment ion less than three cau ses o f diarrhoe a - No knowled ge m eans n ot able to mention an y of th e caus e s of diarrhoe a. Inte rview with care giv ers Proporti on of care giv ers understandin g danger si gns of diarrhoe a Ex tent of knowledge about danger si gns of diarrhoe a (adequat e, some or no knowledge) - Adequate kn owled ge m eans bein g able to mention at least 3 danger signs (Becomi n g weak or lethar gic, repeat ed vomi ti ng, mark ed thi rst of water, reduc ed urine inpu t, frequent passi ng of water y stool ) - Some knowled ge is defi ned as being able to mention less than three dan ger si gns - No knowled ge m eans n ot able to Inte rview with care giv ers University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 31 Objectives Indicators Variab les Defin ition of variab les Source of Data mention an y of th e dan ge r signs To ex ami ne the ex tent of caregivers’ awar eness and use of ORS and RHF fo r home mana gement of diarrhoe a Proporti on of care giv ers aw ar e of RHFs Ex tent of awar eness of RHF (ad equate, some or no awar eness about RHFs) - Adequate awa ren ess me ans bein g able to mention at least 3 RHFs (sugar and s alt , coconut, rice wat er, porridge, mashed kenke y etc) - Some awar eness is defin e d as being able to mention less than 3 RHFs - No aw aren ess means no t able to mention an y RH Fs Inte rview with care giv ers Proporti on of care giv ers givi ng RHF prior to the hospi tal Use of RHF prior to the hospi tal Use of RHF m eans starti ng the chil d with an y of th e RH Fs befo re sending the chil d to the hospi tal Inte rview with care giv ers Proporti on of care giv ers aw ar e of ORS Awar eness of ORS Awar eness of ORS mean s having heard about ORS be fore Inte rview with care giv ers Proporti on of care giv ers givi ng ORS prior to the hospi tal Use of ORS prior to the hospi tal Use of ORS means starti ng the chil d with ORS before se nding the chil d to the hospi tal Inte rview with care giv ers Proporti on of care giv ers knowing the corre ct use of ORS Ex tent of knowledge in the corre ct use of ORS (adequate, some or no knowledge) Adequate knowl ed ge me ans bein g able to mention all the fo ll owing three pro cesses co rre ctl y (prepa rati on of ORS , fr e quenc y of admi nist ering ORS , dura ti on of mix ed ORS ) So me knowledge means being able to menti on less than the three processes corr ectl y No knowled ge me ans not able to mention an y of th e proc e sses corre ctl y. Inte rview with care giv ers To ex ami ne feedin g practi ce among care giv ers before and during the diarrhoe a episod e Feedin g patt ern among the care giv ers Types o f feedin g given to chil dr en on normal basis Types o f feedin g include s breast - mi lk onl y, breast - mi lk + infant formul a (SMA, lacto gen, cerel ac etc), infant fo rmula onl y, normal fami l y diet, modi fied fa mi l y di et Inte rview with care giv ers Proporti on of care giv ers givi ng conti nued feedin g Conti nued feedin g Conti nued feedin g is givi ng the chil d the same or incr eas ed quanti ti es of foods during the diarrhoe a episod e as befo re the diarrhoe a started Inte rview with care giv ers University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 32 Objectives Indicators Variab les Defin ition of variab les Source of Data P roporti on of care giv ers givi ng conti nued fluid Conti nued fluid This is givi ng the chil d the same or increas ed quanti ti es of fl uid during the diarrhoe a episod e as before th e diarrhoe a started Inte rview with care giv ers To identi f y other mode of treatm ent, which care giv ers give durin g diarrhoe a episod e Proporti on of care giv ers resorting to othe r mode of treatm ent prior to sending the hospi tal visit Other mode of treatm ent for diarrhoe a at home This includes the use of open descriptio ns medicine su ch as anti - diarrhoe a, par acet amol syr up, anti biot ics, herbal prep ar ati on etc Inte rview with care giv ers Sources and use of other mode of treatm ent Source of othe r mode of treatm ent Sources mean wh er e the care giv ers get the tr eatm ent from ( e. g. chemi st/ drug stor e, dru g peddlers, comm unit y healt h work e rs, left over of pr escribed dru gs etc) Inte rview with care giv ers Proporti on of care giv ers aw ar e of z inc tablet Awar eness of zinc tablet Awar eness of ORS mean s having heard about zinc tablet before Inte rview with care giv ers To ex ami ne factors that affe ct caregiver’s decisi on to seek healt h care. Durati on of illness Number of da ys of illness prior to seeking treatm ent at the hospi tal Number of da ys o f illness means the number of da ys car e givers wait till seeking tre atm ent at the hospit al when the diar rhoea occur s Inte rview with care giv ers Abili t y to p a y Care giver s with healt h insu ranc e Caregivers with he alt h insu rance is defined as car e givers hav ing vali d healt h insu ranc e durin g the diarrhoe a episod e Inte rview with care giv ers Source: $uthor’s construct, -anuary, 2 3.6 Sample size and samp li n g method A sampl e is a repres en tative sub -gro up of the populati on that meets the research’s criteria (Le ed y & Ormro d, 2005) . Minim um sample siz e was obtained using the tot al number of under five chil dren who visi ted the PML Chil dre n Hospit al in 2011 with diarrhoe a as a prox y. The tot al pati ents visi ti ng the hospi tal in 2011 were 75,288 out of whi ch 62,346 were chil dren under five. Th e statis ti cs further indi cat e that a total of 7,732 chil dren un der five reported with University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 33 diarrhoe a and vomi ti ng at the hospi tal in 2011 (PM L Chil dren Hospit al Annual Report, 2011). With this finite population (7,732), the sampl e siz e for the care givers was determi ned b y adopti ng the followin g statis ti cal formul a for minim um sampl e siz e calculati on (Yamane, 1967): N n = 1 + N (e) 2 N = the sampl in g frame (i.e. th e tot al num ber of care giv ers visi ti ng t he hospi tal with children under 5 dia gnosed with diarrhoea and other related condit ions) e = the mar gin o f error. 10% (0.10) was us e d n = the minim um sampl e siz e of car e givers visi ti ng the hospit al wit h chil dren under 5 diagnose d with diarrhoe a. From the abov e; 7,732 n = 1 + 7,732 (0.1) 2 7,732 n = 78.32 n = 99 Based on the abov e calc ulation, a minim um sample siz e of 99 was obtained from the target grou p. This was approx im ated to 100 and using a response rate of 80%, the figure was further incr eased to 120 as the sam ple siz e. The addit ional 20 was to make room for possi ble incomplete questi onnaire s or unanswer ed questi on naires. Purposi ve sampl ing tec hnique was used to select participants for the stud y. The selection was based on the researcher belief that the researcher’s knowledge about the University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 34 population can be used to hand pick the cases to be included in the sample. This was done by selecti ng care giv ers with chil dren und er five pres enti ng with diarrho ea at both the ORT corne r and the emer genc y room who met the inclusi on criteria. Those who cons e nted to be part of the stud y and could speak Engli sh, Ga and Twi wer e recruited in the stud y. Th is was due to the fact the rese arch er could spe a k an d understand thos e di alects. 3.7 Data gath erin g procedure The data gatherin g pro c edure describe s th e met hod of gatherin g the stud y inform ati on (Leed y & Ormorod, 20 05). The participants un der the stud y wer e recr uit ed from the ORT corner and the emer genc y ward at various times throughout the stud y peri od. This was done b y selecti ng car e givers with chil dren under five wh o had diarrhoea and had been ref err ed (afte r being tria ged at the nurses’ desk at the O3D ) to th e ORT corne r fo r the alr e ad y pr epar ed ORS to be given to the chil dr en while wait ing at the OPD to be seen b y doctors at t he various consul ti n g rooms. The resea rch er en sured tha t the children’s vital signs were checked at the nurses’ desk at OPD, att ended to at the ORT corn er and the y were in stabl e condit ion befor e en rollin g the care giv ers int o the study. To avoid an y fo rm of bias response from the participants , the resea rche r alert ed the nur ses at the ORT corner no t to provide healt h educati on on diarrhoea and its home management to the prospecti v e participa nts unti l after the consent process. In orde r to ensu re privac y, participants who fell withi n the inclusi on crite ria were t ake n int o the n urses’ room at the O3D one afte r the oth er after the y had been att en ded to at th e ORT corner and were waiti ng at the OPD to be se en at the various consul ti ng ro oms by doctors . Th e resea rche r then int roduce d herself to the prospecti ve participant s and then ex plained the purpose and bene fit of the stud y to the parti cipants with t he help of the p articipan ts ’ information sheet University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 35 (Appendix A). Those wh o could read wer e provid ed with the part icipant in formation sheet and for those who could not read , the she et was ex plained to them. After th e ex planati on , those who agreed to take pa rt in the stud y si gned a volunt ee r agr eement she et (Appen dix B). Those who gav e their cons ent to be part of the stud y were recruited and int ervi ewed using questi onnair e in the form of fac e to face i nterview. Prosp ecti ve pa rticipants who did not gi ve their cons ent to be part of the stud y wer e ha nded over to the ORT co rner nu rses for healt h ed ucati on on dia rrhoe a and its home manageme nt. However, for those who ga v e their consent to be part of the stud y, the y were giv en the healt h educati on aft er the int e rview. The wait in g tim e at the OPD was betwe en on e and two hours. To avoid dela yin g th e participants and also eli mi nati ng an y form of bi as, arr an gement were m ade with th e nurses at the OPD for the participants to be seen b y the do ctors at the consul ti ng ro om immediatel y afte r the int erview. Durin g t he int erview pro cess, the chil d ren wer e also obse r ved criticall y in order to alert the nurses and doctors at the OPD in case of an y sudden chan ge in condit ion so t hat prompt medical att enti on could be given. Particip ants wer e also en coura ge d to conti nue givi ng the ORS alread y pr epar e d by nurs es at ORT corn er durin g and after th e int erview sessi on. For the participants with chil dren presenti n g wit h diarrhoea with sever e deh yd rati on who were admi tt ed directl y int o the eme r genc y wa rd , the recruitm ent was done afte r the chil dren had been s een by nu rses and doctors at the ward and the y wer e in stable condit ion . Participants who fell withi n the inclusi on criteria for the stud y wer e rec ruited int o the stud y after th e y had been give n in -depth inform ati on about the stud y and what was ex pected of the m with the help of the par ti cipant information she et. Onl y thos e who gave their conse nt b y signin g the volunt ee r agreement sh eet were recr uit ed and int erview ed . Ever y effort was ma d e by the rese arch er to ensu re that the int erview proc ess did not int erfere with cli ent car e as well as University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 36 other nursin g and medi c al proc edure. The healt h educ ati on on h ome man agement of diar rhoea was done after the int e rview. Data coll e cti on was ca r ried out by th e re s ear c her hers elf. The qu esti onnaires were admi nist ered to care giv e rs indi viduall y in the for m of face- t o -fa ce int ervi ew. On the aver a ge a tot al of four questi onnaires wer e compl eted wit hin a day. In all , a tot al of 120 questi onnaires were admi nist ered but 11 6 were su ccess full y compl eted. 3.8 Data gath erin g tool In a rese arch , it is important to use alread y ex ist ing vali dated scales or questi onnaires when av ail able bec ause their vali dit y has alre ad y been establi shed. But in a sit uati on wh er e scales or questi ons are not readil y avail able i t becomes impe rati ve t o design or gene ra te appropriate questi onnair es with consi der able de gr ee of content and co nstruct vali dit y an d reli abil it y (Punch, 2005). Questi onnaire was used to collect d ata from the respondents be cause it is an approp riate tool that all ows the respond ent to give a self - repo rt at free will . The questi onnaire us ed comp rised 27 items with both open and close ended questi ons to enabl e as much information as pos sibl e to be capt ur ed (Ap pendix C). The questi on naire was divi ded int o six secti ons: socio -demogr aphic cha racte risti c s of the respondents, knowledge about diarrhoe a and the dan ger signs associated with it, aw ar eness and use of ORS and ORT for hom e mana gement of diarrho e a, feedin g practi c es befor e and during diarrho ea episod e, other mode of treatm ent which car e giv ers use during diar rhoea episod e and factors that influence ca re give rs ’ decisi on to seek he alt h ca re. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 37 3.9 Data processi n g and analysi s Data of 116 care give rs were used for the anal ysis . The dat a coll ected were edit ed to check for consi stenc y an d accu r ac y . The y wer e coded using num eric valu es to redu ce the l evel of ente ring er rors and were anal ysed using a St a ti sti cal Product and Ser vice Solut ion (SP S S version 16.0). SPSS is a powerful statis ti cal package with strong statis ti cal appli cati ons which can easil y run all the tra dit ional statis ti cal technique such as cross tabula ti on, chi -square test, Mann-W hit ne y te at, sa mpl e t -test, anova, regressi on, associati ons an d corr elation (Pol a r Engine erin g Consul ti ng Lim it ed, 2007). The anal ysis of the data was conducted ini ti all y using descriptiv e statis ti ca l procedures. Mean, median, mode and standard deviation were reported fo r conti nuous variables an d percent a ge was repo rted for cate goric al variabl e s. Statist ical tests involving Chi -squar e and Mann-W hit ne y Tests were pe rf orm ed. The chi -sq uare t ests were perfo rme d for th e cate goric al data and the tests were conducted to determi ne the following relations hips: the relations hip between caregivers’ edu cati onal level and unde rstanding about causes and dan ge r si gns of diarrhoe a; the relationship between caregivers’ educational level awareness and use of RHFs and ORS and relationship between caregivers’ educational level and correct use of ORS. 7he Mann-W hit ne y test was also performed for dat a with conti nuous varia bles and the tes t was conducted to ascertain the relation between caregivers’ ability to pay and duration of illness at home befo re s eekin g car e at healt h facil it y. All tests wer e carri ed out wit h a si gnific ance leve l of 0.05 and a two sided confidence int e rval of 95 %. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 38 3.10 Valid ity and reli abil ity of question n aire The vali dit y and reli abi li t y of questi onnaire is a criterion b y which a quanti tative inst rument is adequatel y evaluated. Accordin g to Leed y & Ormrod (20 05 ), reli abil it y is the degree of consi stenc y or dep e ndenc y with whi c h an inst rument measur es the att ribut e it is designed to me asure whil es vali dit y is the ex tent to which an inst ru ment measures wh at i t actuall y int ended to mea sure . To ensur e quali t y and confidenc e of the data , addit ional measures were tak en to control the data b y making su re the ca re g ive rs and their chil dren were comfortable. Good rapp ort was also ensured so that car e givers would provide cor rect data . Again, corr ect int erpret ati on and anal ysis of data was done b y usin g appropriate statis ti cal anal ysis . Bas ed on th ese , it can be ar gued that the questi ons and responses have reasonable and subst anti al degr ee of vali dit y. Reli abil it y was ensured by conducti n g a pil ot stud y at Ridge Re gio nal Hospit al Peadiatric Unit . Th e pil o t stud y helped in eli mi nati ng some qu esti ons whi ch were i rrelev ant. It also helped in the develo pment, translati on and as sessm ent of clarit y of the questi onnaire b y the resea rche r and b y those on whom the questi onnaire was t ested. A tot al of 10 care gi ve rs with the chara cterist ics of the st ud y sampl e were int erv iewed using qu esti onnaire . Permiss ion was sought from the Deput y Direct or of Nu rsing in -c har ge of the Peadiatric U nit of Ridge Hospit al for the pil ot . The purpose of the stud y was ex pla ined to her after whi ch, she togethe r with the nurses at the unit helped me to gain access to th e car e givers. Th e objecti ve of the stud y was ex plained to the car e givers and those who cons e nted to participate wer e int erviewed usin g the questi onnaire in the fo rm of fac e - t o -f ace int e rview afte r which the questi onnaire s wer e anal ys ed. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 39 3.11 Ethical consi d eration R esearch ethi cs describ e a broad field of en quir y that ex ami nes ap propriate and inappropriate condu ct in resea rch. The y are important standards that must be strictl y adher ed to when condu cti ng a res e arch . . In ensurin g ethi c al acc eptabili t y of the stud y, the rese arch er ensured that the resea rch was desi gned, condu cte d and r eport ed in acco rd ance with reco gnised scientific competen ce an d ethi cal approv al . Ethi cal approval was sought from the Nogu chi Memorial Insti tut e for Med ical Research and Ghana Healt h Serv ice Ethi cal Review Com mi tt ee (Appendices D & E). A letter of int roducti o n was obtain ed from the School o f Nursing, Universit y of Ghana to the PM L Chil dren Hospit al for the purpose of seekin g per mi ssi on to gain entran ce to the resear ch sett ing and the participants of the stud y (App endix F) . The letter indi cated the nature and purpose of the rese arch. Issu es rega rding info r med consent, confident ialit y, anon ymi t y, risks and benefits, freedom to particip ate and withdraw from the stud y at an yti me without givi n g reasons wer e addressed. The res ear che r ex plained the pu rpose of res ear ch to each pa rticipant with the aid of participant information sheet (Appendix A). After the ex planati on, the participants were given the volunt eer agre ement sheet to compl et e and sign to certif y tha t th e y had unde rstood and agreed to be participant s (appendix B). Indivi d ual participants wer e gi ven codes to maintain anon ymi t y and to ensu re confidenti ali t y. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 40 CHAPTER FOUR ANALYSIS OF DATA 4.1 Introd uction This chapter pres ents the data an al ysis an d findin gs. The pr esentation cov er s information on the sampl e covera ge, the demogr aphic and soc io -economi c cha ract eristi cs of the respondent s and the findin gs of the stud y in relation to the stud y obje cti ves, which include: caregivers’ understandin g of diarrho ea, its causes and the associated dan ger si gns, fe eding pra cti ce befo re and durin g diar rhoea epi sode , aw aren ess and us e of RHFs and ORS , other mode of tre atm ent of diarrhoe a at hom e and factors influencing caregivers’ decision to seek healthcare. 4 .2 Sample coverage an d characteris tics of resp on d en ts A tot al of 120 care give r s were s elected for the stud y. Of th ese potential respondents, int erviews were suc cess full y compl eted for 116 ca re givers, repres enti ng a response rat e of 96.7%. Under the demo gr a phic and socio - econo mi c chara cterist ics of th e car e givers, the dat a covered the age, sex , marit al status, relations hip of care giv ers to cli ents, occup ati on an d educati on of car e gi vers as presented in Tabl e 4.1. In terms of age dist ributi on, the result s sho w th at those withi n the age gro up of 15 an d 34 were the hi ghest (5 3.4%) amon g the respo ndents. As man y as 114 ( 98 .3%) of th e respondents were femal e s. The result s also indi c ate that 109 (94.0%) of the respondents wer e mot hers to the cli ents and 63.8% of t hem worked in the informal sector (trading, haird ressi n g, tailoring etc ) while 20.7 % of them were un empl o yed. Again, 81 (69.8 %) of the respondent s have had basic or low er l evel of educ ati on with the rem aini ng 35 (30.2% ) having had se conda r y or highe r level of educ ati on. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 41 Table 4.1 : Demograp h ic and socio-econo mic characteristics of the res p on d en ts Demographic / socio - eco nomi c chara cterist ics Frequ enc y Percent Age dist ributi on of care giv ers 15 – 24 25 21.6 25 – 34 62 53.4 35 & abov e 29 25.0 Total 116 100 Sex of care givers Female 114 98.3 Male 2 2.7 Total 116 100 Marit al status of care giv ers Married 89 76.7 Co - habit ing 18 15.5 Others 9 7.8 Total 116 100 Relation of care giv ers to cli ent Mother 109 94 Others 7 6.0 Total 116 100 Occupati on of care giv ers Traders 55 47.4 Trades - hairdr essi ng, s ea mst ress, etc 19 16.4 Unempl o ye d 24 20.7 Others 18 15.5 Total 116 100 Educati onal level of car e givers Basic or lo wer lev el of educati on 81 69.8 Secondar y or hi gh er leve l of educati on 35 30.2 Total 116 100 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 42 4.3 Know ledge abou t causes and the associated dan ger sign s of diarrh oea Data on thi s secti on was presented along th e foll owing: respondents’ knowledge about diarrhoea, its causes and danger signs, relationship between respondents’ educational level and knowledge of causes of diarrhoea as well as relationship between respondents’ educational level and knowledge of dan ger signs of diarrhoea. The dat a were an al ysed using frequenc y tables an d chi-square t ests . Respondents’ knowled ge about diarrhoe a, its caus es and dan ge r si gns Table 4.2 provides analysis on the respondents’ knowledge about diarrhoea, its causes and dan ger si gns. Of the 116 respondents, as man y as 114 (98% ) of the m were able to ri ghtl y define or identif y dia rrho ea (that is, freque nt passing of µwatery stool’, thre e or mor e times in a day) . :ith regard to the respondents’ knowl edge about causes of diarrhoe a, since th e respondents wer e abl e t o mention more than on e cause of dia rrhoe a, th e pe rcent a ges do not necessa ril y add to 100. Infecti on was top (43.10 %) amon g the att ribu table cause of diar rhoe a b y the respondents. Other reasons assi gned b y som e of the respondents (13.7 9%) to the causes of diarrhoe a wer e food all er g y, worm infecti on, change of environment, s ore in the stom ach, mosq uit o bit e, too much sweet and su gar y fo od, cold food, bre ast milk and poor environm ental hygien e. Like the causes of dia r rhoea, the respondents were able to mention more than one danger sign of diar rhoea and therefore the per ce ntages do not necessaril y add up to 100. Top among th e dan ger si gns of diar rhoea mentioned by th e respondents wer e frequent passi n g of stool (67.24%) and beco mi ng weak / letha r gic (5 0.86%). None of the res pondents knew about blood in stool and marked thi rst as danger si gns o f diarrhoe a . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 43 Table 4 .2 : Respondents’ knowledge abou t diarrh oea, its causes and dan ger sign s Freq. Percent (% ) Knowled ge about diarrhoe a Frequent passing of ’watery stool’  or more times 114 98 Others ( phle gms, gr eenis h stools etc) 2 2 Total 116 100 Causes of diarrhoe a In fecti on 50 43.10 Food pois oning/cont ami nated food 49 42.24 contaminated wat er 33 28.45 Teethi ng 22 18.97 No idea 23 19.83 Others 16 13.79 Dan ger si gns of diarrhoe a Frequ ent passin g of stool 78 67.24 Becomi n g weak or lethar gic 59 50.86 Repeated vomit ing / vom it ing ever ythi n g 32 27.59 Feve r 21 18.10 Poor feedin g (r educ ed fo od int ake) 15 12.93 Others 12 10.4 Source: Field dat a, 2013 Relationship between respondents’ educ ati onal le vel and knowled ge of causes of diarrho ea Table 4.3 provides analysis on the respondents’ educational level versus their level of knowledge about causes of diarrhoea. The result s indi cate that 19 (16.4%) of the respondent s had adequ ate knowl ed ge about caus es of di arrho ea (that is, the y were abl e to mention three or more of causes of dia rr hoea as defined in chap ter 3) while 67 (57.8 %) of them had some knowledge about the ca uses of di arrho ea (that i s, the y were able to me nti on less than thr e e causes of di arrho ea). The remainin g 30 (25.9 % ) of the care giv ers h ad no knowledge about causes of diar rhoea (that is, the y could not mention an y cause of diar rhoea or had no idea about causes of dia rrhoe a). University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 44 Table 4.3: Respondents’ educational level vs. know ledge of causes of diarrh oea Caregivers’ knowledge of causes of diarrh ea Educati onal level of car e givers Total Basic or lo wer level of educ ati on Secondar y or hi gh er level of educ ati on Freq. % Freq. % Freq. % Adequate knowl ed ge 5 6.2 14 40.0 19 16.4 Some Knowledge 48 59.3 19 54.3 67 57.8 No knowled ge 28 34.6 2 5.7 30 25.9 Total 81 100.0 35 100 116 100.0 Source: Field dat a, 2013 The result s fu rther indi c ate that 59.3% of th e res pondents with basic or l ower lev el of educati on (th at is, middle/J HS, prim ar y and no formal educ ati on) had so me knowled ge about causes of dia rrhoe a while 34.6% of th em had no knowled ge about caus e s of dia rr hoe a. Onl y 6.2% had adequ ate kn owledge about caus es of diarrhoe a. Amon g the respondents with secondar y or high er leve l of edu cati on (th at is, S HS, post SHS, terti ar y et c), 40% of them had adequate kno wled ge abo ut causes of di arrho ea while 54.3% had some kn owledge about th e causes of dia rrhoe a with onl y 5.7% having no kno wledge about causes of diarrhoe a. A chi square test conduc ted establi shed a signific ant differen ce in the knowledge about causes of diarrhoea between caregivers’ with basic  lower level of educati on and those with secondar y / hi gher level of educ ati on (A pp endix G). The test result s wer e : (X 2 = 25.046, df= 1, University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 45 P < 0.05). This suggests that the respondents’ educational level had a relationship with their level of knowled ge about causes of di a rrho ea. Relations hip between res pondents ’ education and knowledge about dan ger signs of diar rhoe a Table 4.4 provides analysis on the respondents’ educational level versus knowledge about dan ger si gns of diarrhoe a. From the result s, 62.1% of the res pondents had some knowledge about the da nge r si gns of diar rhoea (that is, the y could men ti on less than thr ee dangers si gns) while 20. 7% of them had ad equat e knowled ge of the dan ger signs (that is, the y could mention more than three dan ge r si gns). Th e r em aini ng 17.2% of th e respond ents did not know about the danger s igns (that is, could not mention or have no idea of an y of the danger signs of diar rhoe a). Table 4.4: Respondents’ educational level vs. know ledge of dan ger sign s of diarrh oea Caregivers’ k nowled ge of danger si gns of dia rrhoe a Educati onal level of car e givers Total Basic or lo wer level of educ ati on Secondar y or hi gh er level of educ ati on Freq. % Freq. % Freq. % Adequate knowl ed ge 16 19.8 8 22.9 24 20.7 Some Knowledge 55 67.9 17 48.6 72 62.1 No knowled ge 10 12.3 10 28.6 20 17.2 Total 81 100.0 35 100.0 116 100.0 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 46 The result s fu rther demons trate that 19.8% of the respondents with basi c or lower l evel of educ ati on had adequ ate knowled ge while 67.9 % had some knowled ge about dan ge r si gns of diarrhoe a. In the case of respondents with secon dar y or high er level of educati on about 22.9 % of them had adequat e knowledge while 48.6% had some knowled ge ab out dange r signs of diarrhoe a. Again, 28.6% of the respondents with higher lev el of educ ati on had no knowledge about dan ger si gns of dia rrhoea. A chi square test co nducted esta bli shed no significant dif fer ence between th e respondents’ educational level and their knowledge about dange r si gns of diarrhoe a (App endix H). The test result s were : (X 2 = 5.317, df=2, p > 0.05). Thus, the respondents’ educational level did not have an y rel ati onshi p with the level of knowledge about dan ger si gns of diarrhoe a. 4.4 Feedin g practice durin g diarrh oea l episod e 7he study investigated caregivers’ feeding practices durin g the dia rrhoe a episod e. The respondents were asked about the child’s age and the type of feed given to himher and whether the chil d was giv en less, same amount or more than usual to eat and /or drink during th e diarrhoe a prior to the hos pit al visit . The data were anal ys ed usin g fr equenc y tables. Age of chil dr en versus t ype of feeds given them Table 4.5 presents the analysis on the age of the respondents’ children with diarrhoea versus the t ype of feeds given to them. Ex clusi ve breastfe edin g was top (66.7%) amon g the fee d given to the chil dren wit hin age 0 -6 mont hs. This was followed by br east milk plus infant formul a (27.8% ) and co mpl ementar y fe edin g plus breast mil k (5.6%). University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 47 Table 4.5: Age of child ren with diarrh oea vs. type of feed in g given to the m T ype of feedin g Age cat e gor y Total 0 - 6 mont hs 7 - 24 mont hs 25 & abov e mont hs Freq % Freq % Freq % Freq % Breast mil k onl y 12 66.7 1 1.2 0 0.0 13 11.2 Breast mil k plus infant formul a 5 27.8 1 1.2 0 0.0 6 5.2 Compl ementar y feedin g onl y 0 .0 5 6.1 0 0.0 5 4.3 Compl ementar y feedin g plus breast mil k 1 5.6 29 35.4 0 0.0 30 25.9 Normal fami l y diet 0 .0 24 29.3 15 93.8 39 33.6 Normal fami l y diet plus breast milk 0 .0 22 26.8 1 6.2 23 19.8 Total 18 100 82 100 16 100 116 100 Source: Field dat a, 2013 In the case of the chil dr en withi n age 7 and 24 mont hs, compl ementar y feedin g plus breast milk was top (35. 5%) amon g the feeds gi ven to them and thi s was followed by no rmal fami l y diet (29.3%) and normal fami l y diet plus breast milk (26.8%). For those be yo nd two ye a rs (th at is, age 25 mo nths and above), as man y as 93.8 % of them were given no rmal fami l y diet while the remainin g 6.2% wer e given normal fami l y diet plus breast mil k. Patt ern of food int ake among the chil dren with dia rrhoea prior to the hospi tal visit Table 4.6 pres ents anal ys is on the patt er n of food int ake among th e chil dren with diarrhoe a prior to the ho spit al visi t. The result s show that 25% of the chi ldren wer e given th e same or more than usual to eat while 75% were given much less or somewhat less to eat . Most University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 48 of the respondents whos e chil dren were given m uch less or somewhat le ss indi cated that the chil dren had lost appeti te and refus ed to take in an y food. Oth ers also ex plained the y did not want to give much foo d to their chil dren beca use the y wanted to pre vent vomi ti ng as the chil dren vomi t an y foo d taken. Again a few of them indi cated that th e y gave l ess to their chil dren to eat be cause the y felt more food int ak e would increas e the fr equ enc y of the dia rrhoe a. Table 4.6: Pattern of food in take prior to the hosp ital visit Food int ake Frequ enc y Percent (% ) About the same 25 21.6 More than usual 4 3.4 Much less 47 40.5 Somewhat less 40 34.5 Total 116 100 Source: Field dat a, 2013 Patt ern of wate r intake among the chil dr en with diarrhoe a prior to the hosp it al visit Table 4.7 also pr esents the patt ern of wate r int a ke amon g the chil dren with diarrhoea before pres entation at th e hos pit al. From the res ult s, 35.3% of the chil dr en drank th e same or more than usual while 64.7% of them drank much less or some wh at less. Some of the respondents whose chil dren drank more than us ual or the same ex plained that the chil dre n themselves asked for m ore wate r while others also indi cated that the y gave the wate r to the chil dren to prevent deh ydrati on or repla ce fluid loss through deh ydr ati on. In the case of th e chil dren who dr ank muc h less or somewhat less some of the care give rs indi cated that the y did not want to give their chil dren more water to pr event further vomi ti ng. Others also ex plained that the chil dren themsel ves refus ed to take the water. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 49 Table 4.7: Pattern of water in take prior to the hosp ital visit W ater int ake / reasons Frequ enc y Percent (% ) About the same 33 28.4 more than usual 8 6.9 Much less 46 39.7 Somewhat less 17 14.7 No water 12 10.3 Total 116 100 Source: Field dat a, 2013 4.5 Awaren ess an d use of RHFs and ORS This secti on focused on the following: respond ents’ awareness and use of RHFs and ORS , the relationship between caregivers’ educational level and awareness and use of RHFs and ORS as well as the relation between caregivers’ educational level and knowledge of correct use of ORS . The anal ysi s was don e throu gh the use of fr equenc y t ables an d chi -square t ests . Respondents’ awareness and use of RHFs and ORS Table 4.8 presents analysis on the respondents’ awareness and use of RHFs and ORS. Almos t all the responde nts (99.1%) claimed the y wer e aw ar e of ORS . Howeve r, onl y a litt le over half (55.2% ) of th e m gav e ORS to their chi ldren prior to th e hospi ta l visi t. In the cas e of RHFs, Onl y 29.3% and 23.3% of the respondent s respecti vel y indi cat ed that the y wer e aw ar e and actuall y gav e their chil dren some RHFs be for e present ati on at the hospi tal. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 50 Table 4.8: Respondents’ awareness and use of RHFs and ORS Frequ enc y Percent (% ) Caregivers’ awareness of RHFs Yes 34 29.3 No 82 70.7 Total 116 100 Caregivers’ awareness of ORS Yes 115 99.1 No 1 0.9 Total 116 100 RHFs use b y care give rs Yes 27 23.3 No 89 76.7 Total 116 100 ORS use by care giv ers Yes 64 55.2 No 52 44.8 Total 116 100 Source: Field dat a, 2013 For the respond ents who said the y wer e aw are of RHFs, water and co con ut water wer e the most comm on RHFs mentioned by them. The rest were su ga r and salt solut ion porridge, ric e water and mashed kenke y. Ap art from these RH Fs, some re spondents m enti oned other fluids like coke, yo ghurt, cok e mix ed with paracet a mol and coke mix ed with salt , which the y perceiv ed as RHFs. Again, wate r, co conut wat er , porrid ge and su ga r and salt soluti on were th e comm on RHFs the respo ndents claimed the y gav e to their chil dren prior to the hospit al visit . Table 4.9 further presents information on the respondents’ perception about why ORS shoul d be giv en to chil dr en with diarrho ea. Hi gh e st among the reasons ass igned b y respond ents was to decr ease the stool output (53.4%). The sec ond highest amon g the reasons assi gned was to replace lost flui d or pr event deh ydr ati on (37.9 %). University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 51 Table 4.9: Respondents’ p erception abou t the use of ORS R easons for givi n g ORS to children with diarrhoea Frequ enc y Percent (% ) To decr ease the di arrho e a or stool out put 62 53.4 To replac e lost flui d / pre vent deh ydrati on 44 37.9 No idea 8 6.9 Others 2 1.7 Total 116 100.0 Source: Field dat a, 2013 Correct use of ORS Knowled ge about co rre c t use of ORS was cate goriz ed int o three: adequa te knowledge, some knowledge and no knowledge. µ$dequate knowledge’ as defined in this study is: being able to mention all the foll owing thre e co rre ctl y: - ri ght prep arati on of OR S (that is, 1 sachet of ORS - 600 mls or two coke bott les of water); rate of admi nist ering OR S (that is, frequent int erval/ after passi n g of ever y loose stool ); and ri ght dur ati on of mix ed ORS (that is, 24 hours or one da y). µSome knowledge’ is also defined as being able to mention two or one of the aforementioned variables correctly while µhaving no knowledge’ is defined as not able to mention an y of th e vari a bles corre ctl y. 7he respondents’ knowledge about the correct use of ORS (that is, correct mixture , righ t frequen c y for admi nist ering and du rati on of mix ed ORS ) is presented in Table 4.10. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 52 Table 4.10: Respondents’ knowledge about correct use of ORS C orrect use of ORS Frequ enc y Percent ORS preparati on 1 sachet of ORS - 500 ml s of water 67 57.8 1 sachet of ORS - 600 ml s of water 24 20.7 1 sachet of ORS - 750 ml s of water 13 11.2 1 sachet of ORS - 300ml s of water 3 2.6 1 sachet of ORS - 1500ml s of water 4 3.5 No idea 5 4.3 Total 116 100 Frequ enc y of admi nist ering ORS 2 - 3 times a da y 7 6.0 4 & abov e times a da y 10 8.7 After the passi ng of eve r y loose stool or at frequ ent interval 95 81.9 No idea 4 3.4 Total 116 100 Durati on of mix ed ORS 24 hours (1 da y) 100 86.2 Over 24 hours 3 2.6 No idea 13 11.2 Total 116 100 Source: Field dat a, 2013 Onl y 24 rep resenti n g 20. 7% of th e respondents kn ew about the recomm end ed volum e of water fo r mix ing a sach e t of ORS (that is, 600 mls or two coke bott les of water to I sachet of ORS ). As man y as 57 .8 % of the respondents felt that one sa chet of ORS is mix ed with 500 mls (small siz e of mineral bott le) of water while 11. 2% also beli ev ed one sa chet of ORS is mix ed with 750 mls (1 medium siz e of mineral bot tl e) of water. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 53 R ega rdin g the rate of ad mi nist ering ORS , as man y as 81.9% of the resp ondents rightl y indi cated that ORS shoul d be given aft er the passi ng of eve r y loose stool or at frequent int erval . The rest had diff er ent understandin g of how often ORS shoul d be admi nistered to chil dren with diarrhoe a. Again, for du rati on of mix ed ORS , 86.2% of the respondents rightl y indi cated that mix ed ORS shoul d last for 24 hours or a da y. The rest had eit her no ide a or beli eved mix ed ORS shoul d last for 48 or 72 hours. R elationship between respondents’ educ ati onal le vel and aw aren ess and us e of RHFs and ORS The proportions of the respondents with basic / lower level of educ ati on versus those with seconda r y/hi gh er l e vel of educ ati on who were aw are of RHFs a nd ORS as pr esented in Table 4.11 were as foll ows: RHFs (24.7% vs. 40%) and ORS (98.8% vs. 100%). Again, as indi cated in Table 4.11 , t he proportions of the res pondents with basic / lower level of educ ati on versus those with se con dar y/hi gh er lev el of edu cati on who gav e RH Fs and ORS prior to the hospi tal visit were as follows: RHFs (19.8% vs. 3 1.4%) and ORS (54.3% vs. 57.1%). Chi-square tests conducted establi shed no significant differ ence between the respondents’ educational level and their awareness and u se of RH Fs and ORS (Appendices I, J, K & L). Th e test result s were as follows: awar eness of RHFs (X 2 = 2.7 64, df= 1, p > 0.05); awar eness of ORS (X 2 = 0.000, df=1, P > 0.05); Use of RHFs (X 2 = 1.866 , df=1, p > 0.05); use of ORS (X 2 = 0.079, df= 1, p ! . . 7hus, the respondents’ educational level did not have any relat ionsh ip wit h their awaren ess and use of RHFs and ORS . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 54 Table 4.11: Respondents’ educational level vs. aw aren ess an d use of RHFs and ORS Caregivers’ educational level Total Basic or lo wer level of educati on S econdar y or higher level of educati on Freq. % Freq. % Freq. % Caregivers’ awar eness of RH Fs Yes 20 24.7 14 40.0 34 29.3 No 61 75.3 21 60.0 82 70.7 Total 81 100 35 100 116 100 Caregivers’ awar eness of ORS Yes 80 98.8 35 100 115 99.1 No 1.2 1 0.0 0.0 1 0.9 Total 81 100 35 100 116 100 RHFs use b y care giv ers Yes 16 19.8 11 31.4 27 23.3 No 65 80.2 24 68.6 89 76.7 Total 81 100 35 100 116 100 ORS use by care giv ers Yes 44 54.3 20 57.1 64 55.2 No 37 45.7 15 42.9 52 44.8 Total 81 100 35 100 116 100 Source: Field dat a, 2013 Respondents’ educational level versus their knowledge about correct use of ORS Table 4.12 further presents data on the respondents’ educational level versus knowledge in the cor rect use of ORS . In gener al, 59.5% of the car e givers had so me knowled ge in the corre ct use of ORS whil e 24.1% had no knowled ge in the corr ect us e of the ORS . Onl y 16.4 % of the care give rs had ad equate knowl ed ge in the corr ect use of ORS . Th e proportions of the respondents with basic / lower level of educ ati on versus those with seco nda r y/hi gh er lev el of educati on in te rms of knowledge in the cor re ct use of ORS were as follows: adequ ate University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 55 knowledge (14.8% vs. 20%); some knowledge (6 4.2% vs. 48.6%); and no knowledge (21 % vs. 31.4%). A chi-square test condu cted establi shed no significant d ifference between caregivers’ with basic or lower l evel of educ ati on and those with secondar y or high er level of edu cati on in terms of knowledge in th e corre ct use of ORS (Appendix M ). The test result s were (X 2 = 2.508, df=2, P > 0.05). Thus the responden ts’ educational level had no relationship with their level of knowledge in the cor re ct use of ORS . Table 4.12: Respon d en ts education al level vs. know ledge in the correct use of ORS Caregivers’ knowledge of corr ect use of ORS Educati onal level of car e givers Total Basic or lo wer lev el of educati on Secondar y or hi gh er level of educ ati on Freq. % Freq. % Freq. % Adequate knowl ed ge 12 14.8 7 20.0 19 16.4 Some Knowledge 52 64.2 17 48.6 69 59.5 No knowled ge 17 21.0 11 31.4 28 24.1 Total 81 100.0 35 100.0 116 100.0 Source: Field dat a, 2013 4.6 Other mod e of trea t men t of diarrh oea at home Data on the other mod e of treatm ent wer e pr esen ted alon g the following: proportion of respondents resortin g to other mode of treatm ent prior to the hospi tal visit, source of medicine / University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 56 treatm ent, respondents ’ awareness about ]inc tablets and respondents’ p er cepti on about the use of zinc tablets. The data were anal ysed throu gh th e use of frequen c y tables . Proporti on of respondent s resorting to othe r mode of treatm ent prior to the hospi tal visit Table 4.13 demons trates the proportion of the respondents who resorted to other mode of treatm ent for their ch il dren with diarrho ea prior to the pr esentation at the hospi tal and th e sources of tre atm ent. As man y as 83 repres enti ng 71.6 % of the responde nts had given o n e or more medicines to their chil dren prior to present ati on at the hospi tal. Among the 83 responden ts who reported as having given their chil dren me dicines befor e the hospi tal visi t, 50.6% of them gav e anti diarr hoea dru gs, 36.1% gav e parac etamol, 31.3% gav e anti biot ics while 24% gave other dru gs su c h as anti malaria , haem a ti nics, metronidaz ole, flag yl , dewormer, zinc t ablets, ome ga oil , seven sea oil and gripe wate r. Onl y 9.6 % gav e thei r chil dren zinc tablet . It is important to point out the respondent s mentioned more than on e medicine and ther efor e t he perc enta ges do not necessaril y add to 100. C hemi sts / drugs stores wer e top (71.08% ) among the sou rce of me dicine for th e chil dren with diarrhoea prior to the hospi tal visit. This was followed by left o ver prescribe d drugs (24.1% ) and medi cine from fri ends / fami ly m embers (4.8%). The respondents provid ed various reasons fo r givi ng the medicines to thei r chil dren prior to the hospi tal visi t. Most of them ex plained that the y gave th e medicine partic ularl y th e anti biot ics and anti diarrho ea dru gs to stop or reduc e the diar rhoea and vomi ti n g. Wit h regard to the para cetam ol s yr up, anti m alari a drugs, fla g yl, dewomer and metronidaz ole the rea son given was that the y wanted to reli eve the chil dren of the feve r a nd abdomi nal pain. Others also s aid the y gav e the haematini cs t o stimulate the children’s appetite for food. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 57 Table 4.13: Use of other mod e of treat men t and sou rces of treat men t Frequ enc y Percent (% ) Use of other mod e of treatm ent Yes 83 71.6 No 33 28.4 Total 116 100 Sources of tre atm ent Nearb y chemi st / drug st ore 59 71.1 Left over of pres cribed drugs 20 24.1 From frie nds or fami l y m embers 4 4.8 Total 83 100 Source: Field dat a, 2013 Awar eness about zinc ta blet and its use Table 4.14 demons trates the level of awaren ess about zinc tablet and its use among the respondents. A lar ge nu mber (80) rep resenti n g 69% of the respondents said the y had hea rd about zinc tablets. Most of them said the y he ard about it through pu bli cit y on radio and televisi on. Table 4.14: Respon d en ts ’ awareness and knowledge in the use of zinc tablet Frequ enc y Percent (% ) Awar eness about zinc ta blet Yes 80 69 No 36 31 Total 116 100 Use of zinc tablet To reduc e stool output 38 32.8 To prevent diar rhoe a 6 5.2 No idea 72 62.0 Total 116 100 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 58 R ega rdin g the use of zinc tablet, even thou gh 69 % of the respond ents clai med the y wer e awar e about the tablet, as man y as 62 % of the m could not tell the use of the tablet. Of the remaining 38 % who said the y knew about the use of the zinc tablet, 32.8% of them ex plained that it helps to reduce the stool output while 5.2% indi cated that it helps to prevent diar rhoea. 4.7 Factors influencing respondents’ decision to seek care at health facility This secti on focused on the following: durati on of illness pri or to the hospi tal visi t, relations hip betwe en respondents’ abil it y to pa y and durati on of illness before pres entation at the hospi tal and reasons for the durati on of illness prior to the hospi tal visi t. The data wer e anal ys ed usin g desc riptiv e statis ti cs and Mann-W hit ne y test. Durati on of illness prior t o the hospit al visit Table 4.15 pr esents des c riptiv e statis ti cs on durati on of illness befo re pr ese ntation at the hospi tal for tr eatm ent. From the an al ysis , the du r ati on of the illness befo r e pres entation at th e hospi tal ranged from on e to seven da ys with an avera ge durati on of 2. 5 day s ± 0.98. The comm onest durati on of the ill ness prior to the hospit al visit was 2 da ys. Table 4. 15 : Duration of illn ess bef ore presen tation at hosp ital Freq. Mean durati on (da ys) median durati on (da ys) Mode (da ys) SD Min no. of days Max . no. of days Care givers 116 2.5 2 2 0.98 1 7 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 59 R easons for the dur ati on of illness prior to the hospi tal visit Table 4.17 provides dat a on reasons assi gn ed by the respondents fo r wait ing at home before presentation at th e hospi tal. The reasons varied in proportion bet ween respondents with and without vali d healt h insurance. In the case of those with vali d healt h insurance 55.2 % of them claimed the y wait e d at home because the condit ion of the chil dren was not serious while 31% indi cated the y start ed mana gement of the di arrhoe a at home as a firs t aid. Onl y 1.7 % of the respondents with val id healt h insuranc e clai med the y wait ed at home bec ause the y did no t have mone y. Table 4.16: Reason s for stayin g at home Caregivers Reasons for sta yin g at ho me Frequ enc y Percent Care givers with vali d healt h insu ranc e Started mana gement of the diarrhoe a at hom e 18 31.0 Not having mone y 1 1.7 Wait ing for life pa rtner 2 3.4 Condit ion was not serious 32 55.2 Others 5 8.6 Total 58 100.0 Care givers without vali d healt h insu ranc e Started mana gement of the diarrhoe a at hom e 15 25.8 Not having mone y 14 24.1 Wait ing for life pa rtner 6 10.3 Condit ion was not serious 20 34.5 Others 3 5.1 Total 58 100.0 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 60 On the contrar y, 34.5 % of the respondents witho ut vali d healt h insurance indi cated the y wait ed at home bec ause the condit ion of the chi ldren was not s erious whil e 25.8% indi c ated the y started the mana ge ment of the diarrhoea at home as first aid. Agai n, compared to those wit h vali d healt h insura nce, as man y as 24.1% of the non -healt h insur a nce holde rs indi cate d that the y wait ed at hom e because the y did not hav e mone y while 10.3% cla im ed the y wait ed fo r their partners. Relations hip between he alt h insu rance and durati on of illness prior to the hospi tal Data on relationship between respondents’ ability to pay and duration of illness before presentation at the hospi tal for tre atm ent are prese nted in Table 4.16. The assum pti on here was that respondents with va li d healt h insuran ce had more abil it y to pa y than those without healt h insurance. Th e an al ysis indi cates that 58 repr esen ti ng half (50%) of the respondents had vali d healt h insu ranc e. Table 4.17: Relation sh ip betw een health insu rance and duration of illness C are givers Freq. Mean durati on (da ys) median durati on (da ys) Mode (da ys) SD Min no. of days Max . no. of days Care givers with vali d healt h insurance 58 2.3 2 2 0.84 1 7 Care givers without vali d healt h insu ranc e 58 2.8 3 3 1.1 1 7 Source: Field dat a, 2013 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 61 Among the respond ents with vali d healt h insurance, the ave ra ge dur ati on of the illness before pr esentation to the hospi tal was 2.3 da ys ± 0.84 rangin g from 1 – 7 days, while the comm onest durati on of illness prior to pres en tation at the hospi tal was 2 da ys. For th e respondents without vali d healt h insurance, the aver a ge durati on of the illness before presentation to the hospi tal was 3 days ± 0.84 rangin g from 1 – 7 da ys, while the comm onest durati on of illness prior to presentation at the hosp it al was 3 da ys. A Mann-W hit ne y t est conducted establi shed a significant dif fer enc e in the durati on of illness before pr esentati on between those with vali d healt h insurance card holders and those without vali d healt h insu rance (App endix N). The test result s were: (U = 1250. 000, N 1 = 58, N 2 = 58, P < 0. 05). Thus those without vali d healt h insurance sp ent more nu mber of da ys at hom e before takin g their chil dren for tr eatm ent at the hospi tal as compar ed to th ose with vali d healt h insurance. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 62 CHAPTER FIVE DISCUSSION 5 .1 Introd uction The purpose of thi s stud y was to ass ess pre -h ospi tal management of diarrhoe a and factors af fecti n g it among ca re give rs with chil dren under five. The objecti ves included d etermining caregivers’ knowledge about the causes and danger signs of diarrhoe a; ex ami ning the feeding pr acti ce amo ng ca re givers prior to ho spit al visi t; ex ami ning the ex tent of awa reness and use of ORS and RHFs for home man a ge ment of diarrhoea; iden ti f yin g other mode of treatm ent which care giv ers give to their chil dren prior to hospi ta l visi t; and ex ami ning factor s that affect caregivers’ decision to seek health care . Data was obtained from 116 care givers who met the inclusi on criteria . The ca re givers wer e ma inl y femal es and mot hers . Most of them were aged 15 and 34 and work ed in the informal secto r (tradin g, hairdr essi ng, t ail oring etc ). The findings of the stud y indi cated poor home management of diarrh oea includin g dietar y restri cti ons during the dia rrhoe al episod e, low use of both RHFs and ORS but high use of other remedies such as anti biot ics and anti -diarrhoea to treat diar rhoea. The discussi on of the findings was done unde r the following th ematic headin gs in relation to t he objecti ves and the stated hypothesis : i. C are g ivers’ understanding of diarrhoea ii. Feedin g practi c es amon g care giv ers durin g diar rh oeal episod e iii. P reventi on of deh ydr a ti on through the us e of RHFs and ORS iv. The use of othe r modes o f treatm ent fo r diarrho ea at hom e v. Caregivers’ health care seeking behaviour University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 63 5 .2 Care givers’ understanding of diarrhoe a High mo rbidit y and m ortalit y especi all y amon g chil dren under five as a result of diarrhoe a can easil y be prevented if care giv ers have adequate underst anding of diarrho e a . Caregivers’ understanding about diarrho ea parti cularl y the causes and t he associated dan ge r sign s of diarrho ea, as noted by Othero et al (20 08), is important to ens ure timel y and prope r home mana gement and even subsequent ref e rr al of chil dren to a hea lt h care facil it y fo r treatm ent. In the cu rrent stud y, it was rev ealed th at alm o st all the care give rs rightl y unde rstood diarrhoe a as frequ ent passing of µwatery stool’ three or more ti mes in a da y). This notwit hstanding, their knowledge about the cau ses and dan ge r signs of diarrhoe a was not sati sfactor y. Over a qu arter of the car egiv ers had no knowled ge about the caus es of dia rrhoea while onl y 16.4% of them ha d adequate knowled ge about diarrho ea. Th e rest (57.8%) had som e knowledge about cause s of diarrhoea. The co mm onest perceived cau se of diarrhoea was infecti on (43.1%) followed b y food poiso nin g / contaminated food (4 2.24%), contaminate d water (28.45 %) and t eeth ing (18.9% ). Wit h rega rd to dan ger s igns of diarrho ea, onl y about a qu art er of the care give rs ha d adequate knowled ge, 62. 1% had some knowled ge and 17.2 % had no kn owledge at all about them . Top among the danger si gns of dia rrhoe a identified by the respo ndents were frequ ent passi ng of stool followe d by be comi ng weak / le thargi c . The car e givers were un awa re of othe r important dange r signs such as blood in stool, marked thi rst and reduced urin e output . Understandin g of such danger si gns is critical as it helps ca re give rs to respond prompt l y b y givi n g oral fluids or to seek treatm ent at healt h facil it ies. This implies that there is the need for more healt h edu cati on fo r car e givers on the cause s and dan ger si gns of di a rrhoea. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 64 The findings relatin g to the knowledge about the causes of dia rrhoe a support the findings of sim il ar studi es conducted by Omotade et al. (2000), Uchenda et al. (2008), Adimora et al. 2 in 1igeria in :est $frica to assess mothers’ caregivers’ knowledge about the causes of diarrho ea. The findings of those studies indi cated that mothers/car e givers hav e inadequate kno wled ge about the causes of dia r rhoea. Thos e studi es al so point ed out that contaminated wate r an d food as well as te ethi ng are most often consi dered b y th e mot hers/care giv ers as causes of diarrhoea. Agai n, the observati on relating to the knowledge about the dan ger si gns of diarrhoe a is sim il ar to that of Ansari et al (200 1), Shah et al (2011) and Shah et al (2012) whose studi es also reve aled some knowled ge deficit amo n g mot her s concernin g caus es of di arrhoe a, its associat ed danger si gns as well as it s home mana gem ent practi ces. In the pr esent stud y, the large number of the car egiv ers who could descr ibe diarrhoe a might probable be due t o prior ex posure and experienc e w it h diarrhoeal diseases. Whil e it is easy to remember µwatery stools’ as a symptom of diarrhoea through prior expose and ex perience with the dise ase, rememb erin g a mul ti ple of causes and dan ger signs ma y not be eas y and ma y requir e co gnit ive reasoni n g. Ano ther factor that could have possi bl y contribut e d to the knowled ge gap in the causes and dan ger signs of diar rhoea is the fact that he alt h care professi onals do not give enough he alt h educati on on diarrhoea. As a result of the rampant nature of the dia rrho e a in chil dren, healt h care professi onals ma y hav e ta ken for gr anted that care giv ers ar e well info rmed particularl y about the causes and dan ger s igns of the diseas e. Care givers ar e there fore denied of the needed information that could help them protect the ir chil dren from this deadl y but preventable condit ion. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 65 Concernin g the relationship between caregiversµ educational level and knowledge of causes of di arrho ea, the findings of the curr ent stud y indi cat e that a gr eate r proportion (40% ) of care giv ers with secondar y or high er level of educ ati on had adequate know ledge about causes of diarrhoe a compa red to those with basic or low er level of educ ati on (6.2 %). The opposi te was, however, the cas e with regard to proportion of care givers with some know ledge about caus es of diarrhoe a. A relativel y gr eater proportion (59.3%) of the care give rs with basic or lower level of educati on had some kno wledge about causes of diarrhoe a than those wit h seconda r y or hi ghe r level of educati on (54.3%). Sim il arl y, the propor ti on of the caregive rs with basic or lower level of educ ati on that had no knowled ge about causes of dia rrhoe a was disproporti onatel y mo r e (34.6%) than thos e with secondar y or hi gher lev el of educati on (5.7 %). :ith regard to the relationship between caregiversµ educati on and kno wledge about danger signs of diarrho ea, the findings again indi cate that a relativel y greater propo rtion (22.9%) of care givers wit h higher level of educ ati on had adequate kno wledge about dan ger signs of dia rrhoe a than t hose with lower lev el of educati on (19.8 %). Ho wever, a much hi ghe r proportion (67.9% ) of th ose with lowe r lev el of educati on had some kno wledge about dan ger sings comp ared to those with high er lev el of ed ucati on (48.6% ). Again, a gr eate r proportion (28.6%) of the care give rs wit h higher educ ati on had no knowledge ab out dange r signs of diarrhoe a compar ed to those with lower level of educati on (12.3%). Even thou gh the stud y further establi shed a si gn ifi cant diff eren ce betwe e n ca re gi vers’ educati onal lev el and kn owledge about caus e s of diarrho ea (X 2 = 25.046, df= 1, P < 0.05 ), no significant diff eren ce w as establi shed between care gi ver’s educational level and knowledge about dange r signs assoc iated with diarrhoea (X 2 = 5.317, df=2, P > 0.05). This suggests that University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 66 caregivers’ education ha d a posi ti ve relations hip with knowledge about the causes of dia rrhoe a but no relations hip wit h knowledge about the dan ge r signs o f diarrho ea. The findin gs as related to the causes of dia rrho ea in thi s present stud y are consi stent with the findings from a cross secti onal stud y b y Ansari, Ib rahim & Shank ar (2011) on mot hers ’ knowledge about diar rho ea and its mana gem ent. It was found in their study that ther e is posi ti ve correlation of maternal educational level, age and occupation, husbandsµ income and famil y siz e with motherµs level of knowledge about causes of diarrhoe a and its prev enti on. On the other hand, the findi ngs ar e in contrast with the findings of a si mi lar stud y b y Uchenda et al. (2008) to assess how ca re give rs mana ge dia rrhoe a at home before s eekin g he alt h care. Th e y indi c ate that there is no relation in maternal educ ati onal level and their level of knowledge with respe ct to the perceiv ed caus es of dia rrhoe al dise ases. The rese ar chers , nonetheless, cauti oned t hat alt hough their stud y did not s how an y div er genc e in terms of performan ce betwe en ca re givers with diffe rent educati onal level, high er maternal educati onal level is well reco gnised as a protecti ve factor for chil dhood survival and confers the adv anta ge of being able to unde rsta nd and com pl y with life- saving he alt h practi ces. 5.3 Feedin g practices amon g caregive rs durin g diarrh oeal epi sod e Accordin g to the MOH under -five Chil d Healt h Poli c y (2007 -201 5), ex clusi ve breastfe edin g shoul d be promot ed from birth to 6 mont hs. Ex clusi ve breastfeedin g me ans tha t infant is breastfed and given no othe r soli ds or liquids , including wate r (drops of vit am ins, minerals or m edicines are all ow ed wh en medic a ll y indi cated ). In the cas e of compl ementar y feedin g, the poli c y reco mm ends that it shoul d begin at 6 mont hs of age. It is also recomm ended that compl ementar y foo ds shoul d be of appropriate quali t y (ener g y de nsit y, mic ronutrient University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 67 compos it ion, or food handli ng), quanti t y and freq uenc y. Besid es, breastf ee ding shoul d conti nue unti l 2 years of age an d be yond in addit ion to compl ementar y feedin g. The poli c y furthe r requires that a childµs feeds are continued and increas ed du ring and aft e r diar rhoea l episod e. This is to help the bod y fight the offendin g or ga nism s. Due to the likel y loss of appeti te, the feeds ne ed to be appeti z ing and nutrit ious and be given in small frequent amount s accordin g to the childµs ability to toler ate. The findings of the pres ent stud y su ggest a relativel y hi gh rate of br eastf eedin g amon g mot hers especiall y fo r chil dren withi n the first six months of birth. This is in support of recomm endati on b y the MOH, WHO and UN IC EF that chil dren shoul d be breastf ed throu ghout the first six mont hs of life, the int roducti on of local, nutrient rich compl ementar y food s subsequentl y with conti nued breast feedin g to t wo years of age and beyond (WHO,2001; WHO,2003; MOH, 2009a). Argu abl y we can say th at mot hers ar e gra duall y embr acin g the healt h educ ati on on ex clusi ve breast f eedin g as well as conti nuous br eastfe eding of their chil dre n to two years and be yon d. Nonetheless, the re is the need to int ensif y t he educ ati on on the importance of br eastfe ed ing amon g mot he rs espe ciall y ex clusi ve bre astfe eding, in spit e of the seeml y improv ed breastf eedin g practi ce amon g m others thi s stud y has reve aled. With rega rd to compl ementar y feedin g, th e relativel y high number of chil dren withi n age 7 and 24 mont hs wh o were giv en nor mal fa mi l y di et inst ead of com plementar y feeds ma y be due to the fact that in recent time chil dren ar e enroll ed int o school befo re the y tu rn age two. Since most of these schools have the same menu for all chil dren irr e specti ve of their age differen ces, ther e is a high probabil it y th at these chil dren were int roduc ed to normal fami l y diet at school inst ead of compl ementar y feeds or modi fied fami l y diet that is mashed or cooked ver y soft. There is there fore t he need for MO H/GHS to coll aborate with Ghan a Educ at ion Servic e to University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 68 include pre -schools in school healt h pro gramm e and also ensu re th at food offer ed are nutrit ious and hygi enicall y prep ar e d and contain the app ropr iate micro -nutrients. Concernin g conti nued feeding durin g diarrho ea episod e, in the current stu d y, the vast ma jorit y (75% ) of the chil dren wer e given muc h less or somewhat less amount of food while about a quarte r (25 %) was given th e sam e or mo re than the usu al amount of food prior to the hospi tal visi t. Wit h regar ds to patt ern of fluid int ake durin g th e diar rhoe a l episod e, the result s indi cate that 35.3 % of the chil dren drank the s a me or mor e than usual while 64.7% of them drank much less or so mewhat less. The findings su ggest a high rate of diet restriction of chil dren prior to the hos pit al. This i s a con cern because dietar y restri cti on of chil dr en durin g diarrhoe a ma y compromi se their healt h. From the findin gs, it could be stated that care gi vers might not be well i nformed about some of the basi c techni ques of feedin g sick chil dren in ord er to me et their nutrit ional needs . The techniqu es include mot ivating the sick chil d ren to eat in bit but regul arl y rather th an fo rcin g food on them and also feedin g them att ra cti vely with light nou rishing diet inst ead of their normal food regim en. This observati on seems to match up with findings of the Ghana M ICS conducted in 2006, which also revealed that half the chil dr en invol ve d in the surve y ate somewhat less or nothi ng du ring diar rhoea episo de while onl y about one thi rd (34%) of unde r - five chil dren with diar rh oea drank mo re than usu al and 65% dr ank the same or less. On respondi ng to reaso ns for chan ge in feeding patt ern of the chil dr en prior to the ho spit al visi t, over half of the car e givers ex plained that their chil dren wer e eati ng mu ch less or somewhat less bec ause t he y had lost appeti te and had refus ed to take in an y food given them or could not suck well . J ust a small proportion of the car e givers (3.4 %) ex plained that off e rin g the chil dren conti nued feeding would incre ase the frequenc y of the diar rhoe a . This rather seems to University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 69 contradict the observ ati on made b y Othero et al (2008) whe re most of the mot hers who withhel d feeds pro fessed that conti nued feedin g inc re ased t he rate of loose stool s. 5.4 Preven tion of deh ydra tion through the use of RHFs and ORS Diarrhoe al diseases are major tar get in the globa l efforts to increas e survi val and reduc e the disease burden in chil dren (UN IC E F/W HO, 2009). Prev enti on , as noted by Bhutt a et al (2010), is of prim ar y im portance in these ef forts but adequat e mana geme nt of cases is essential to reduc e mortali t y, in particular the admi nist rati on of ORS and RHFs to tre at deh yd rati on. Accordin g to the MOH under -five Chil d Healt h P oli c y (2007 -2015), OR T including ORS and RHFs shoul d be used for mana gem ent of acute and pe rsist ent diarrho ea. ORS shoul d be packa ged in sach ets for prepar ati on of 600 ml solut ion. The poli c y fu rthe r recomm ends hom e - based fluids su ch as porr idge, coconut jui ce, pl ain rice wate r, and mashed kenke y for the home - based mana gem ent of diarrhoe a. Meanwhile a chil d is closel y obse rv ed for an y signs of deh yd rati on foll owin g which urgent refer ral is ma de. The stud y reve aled a wide gap betw een aw a reness and use of ORS among the care giv ers. From the res ult s, alm ost all the ca re givers (99.1% ) said the y were aw are of ORS . Ironicall y, onl y a litt le over half of the car e givers actuall y gav e ORS to their chil dren with diarrhoe a prior to the hospit al visi t. Thus , in spite of the high level of awaren ess of ORS , the actual number of car e gi vers using ORS for the benefit o f the chil dren with diarrhoea was relativel y ve r y low. Wit h rega rd to RH Fs, both the level of awa reness and use amon g th e care giv ers wer e ve r y l ow compar ed to ORS . Onl y 29.3% and 23. 3% of the care give rs respecti vel y indi c ated th at the y were awar e and actuall y us ed some RH Fs before pres entation at the hospit al . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 70 These findin gs support those of Kendell et al (2009), which indi cated high level of awar eness of ORS but relativel y lower use r rate of ORS among mot hers. The lower user rate of FHFs and ORS among mot hers is further supported by MICS conduct ed in Ghana in the year 2006. The surve y found that of chil dren under -fi ve ye ars of age who ex perienc ed diarrho ea in the previous two weeks, onl y about 29% receiv ed ORS and 9% rec eive d RHFs. The surve y further indi c ated th at as man y as 63 % of chil dre n with diarrho ea re ceive d no ORS or RH Fs . Even thou gh, the M ICS showed relativel y hi ghe r ORT use in the Greater Acc ra Re gion with percent a ges of chil dren who rec e ived ORS and RHFs, 39.1% and 19.0 % respecti vel y the us a ge rate was stil l below 50% . The high lev el of awa re ness of ORS compared to the RHFs among car egiv ers in thi s present stud y could be att ributed to the hi gh media publi cit y given to ORS and particul arl y during the re centl y launc hed of new Osmol arit y ORS and zinc tablet. On the other hand, the lo w user rate of ORS could be att ributed to factors suc h as non -avail abil it y of ORS sachets; mot her s not being conv ersant wit h the corr ect prep ar ati on of ORS , misinformation about diarrhoe a etc. Some care giv ers erroneo usl y beli ev e that diar rhoe a is caused b y teethi n g and wor ms an d thi s wrong perc epti on possi bl y in fluenc e their decisi on to resort to othe r mode of tre atm ent inst ead of usin g approp riate rem edies like ORS and RHFs. Othe r possi ble reason which mi ght account for th e low user rates is that some chil dre n do not like the taste of ORS and ma y refuse to drink it. Caregive rs who might have ex perienc ed thi s ma y not be encou ra ged to give ORS the nex t time the chil d suffers another dia rrhoe a l epi sode. Thus, it is notewor th y to promot e RH Fs for home mana gement of diarrhoe a as it presents the care givers with alt ernati ve opti ons for mana ging di arrho ea. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 71 S everal reasons were gi ven by care givers as to wh y ORS shoul d be giv en to chil dren with diarrhoea. Ove r hal f of the care giv ers beli ev ed that ORS shoul d be given to chil dren with diarrhoe a to dec reas e the stool output and 37.9% indi cated that ORS helps to replac e lost fluid or prevent deh ydrati on. This finding cor roborates wi th the findings of Ans ar i et al (2011) wher e majorit y of th e respond e nts indi cated that the rol e of ORS in diarrho ea l mana gement is most l y to decre ase the frequ enc y of diarrhoe a. It also em er ged from the stud y th at amon g the avail able RHFs, most of the car e givers who gave some to the ch il dren, gave water follow ed by coconut wat er, por ridge and su gar and salt solut ion. Some car e givers, howev er, had erro neous beli ef that fluids such as coke, yo ghurt , coke mix ed with paracet amol and coke mix ed with salt were also forms of RHFs and th ere for e gav e some of these fluids to their suffe rin g chi ldren. This observ ati on suggests si gnifican t knowledge deficit amon g the care giv ers in RH Fs and highli ghts the need fo r healt h educ ati on to be int ensified on RHFs for the ca re givers. The findings of the stud y, again, indi cate th at the proportion of care give rs with secondar y / hi gher leve l of educ ati on who we re awar e of RHFs and ORS were more in comparison with the care give rs with basic / lower level of educ ati on. Furthermo re, the proportion of care giv ers with secondar y / highe r level of educati on who used RHFs and ORS prior to the hospi tal visi t was more in compa rison with the ca re givers with basic / lowe r level of educati on. How ever, the differ ences wer e not sta ti sti call y signific ant . The test result s wer e as follows: awareness of RHFs (X 2 = 2.764, df= 1, p > 0.05); awareness of ORS (X 2 = 0.000, df=1, P > 0.05); Use of RHFs (X 2 = 1.866, df=1, p > 0. 05); use of ORS (X 2 = 0.079, df= 1, p > 0.05) . These su ggest that the caregiversµ educational level had no relations hip with awa reness and us e of RHFs and ORS . Thes e findings va r y from tha t of Kudlova (2010), wh ich reve aled posi ti ve University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 72 associati on betwe en mat ernal edu cati onal level and their level of knowle dge and use of ORS . Howeve r, the y s eem to confirm the earli er as sertion made b y Adim ora et al (2011 ) that knowledge of treatm ent of chil dhood diarrhoea at home does not necessa ril y follow the social class lines. In their stud y, educ ati onal level was not a ver y ess enti al factor in the knowled ge of home mana gement of chi ldhood diarrhoea. Rega rdin g the co rre ct us e of ORS (that is, cor re c t mix ture of ORS , right frequen c y fo r admi nist ering ORS and durati on of mix ed ORS ), the findings of the stud y were mix ed. Onl y about one-fifth of the care givers knew about the recomm ended volum e of water for mix ing a sachet of ORS (that is, 600 mls or two coke bott l es of water to I sach et of ORS ). Most of the care giv ers (57.8%) erron eousl y beli eved that one sachet of ORS is mix ed with 500 mls (small siz e of mineral bott le). Howev er, for the freq uenc y of admi n ist erin g ORS , a subst anti al proportion (81.9%) of the car e givers ri ghtl y in dicated that ORS should be given aft er the passi ng of eve r y loose st ool or at frequent int erva l. Sim il arl y, in the case of durati on of mix ed ORS , a siz eable proporti on (86.2%) of th e car e gi vers ri ghtl y indi cated th a t mix ed ORS should last for 24 hours or a da y. T he se findi ngs conc ur with simi la r obse rva ti on by Ansa ri et al (2011). From the i r study the y found tha t none of the mothe rs out of a total of 130 mothers enroll e d in the stud y coul d indic at e all the four correc t ste ps of ORS pre pa ra ti on and besi des, many pare nt s gave the wrong volum e of ORS solut i on to thei r chil d re n duri ng dia rrhoe a . This is furt he r support e d b y the findi ngs of Adim ora et al (2011) and Uchendu et al (2008). Thei r studi e s also reve a l that a signi fi c ant numbe r of chil dre n rec ei ve d ORS and SSS in whic h the salt and suga r were not prope rl y mixe d with right volum e of wate r. Furthermo re, from the re sult s of the current stud y, no significant diffe ren ce was found in the knowledge about cor rect use of ORS between care give rs with higher l evel of educ ati on and University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 73 those with lower level of educati on (X 2 = 2.508, df=2, p ! . . 7his suggests that caregiversµ educational level had no relationship with caregiversµ level of knowled ge in the correct use of ORS . This finding conc urs with some earlier stu dies including of Adimora et al (2011) an d Uchendu et al (2008), which have ar gu ed that m aternal educ ati onal level does not con fer an y advanta ge on bein g able to corre ctl y mix the ORT flui ds. The findin gs of the cu rrent stud y su ggest that ca re givers hav e ch all e nge with the recomm ended volum e of wate r to mix ORS as compare to how to adm ini ster the ORS . The chall en ge with the cor re ct mixture of the ORS could be att ributed to proli fe rati on and use of bott led and sachet wate r in the countr y. In the past, beer bott le and coke bott le wer e the comm onl y mode of meas uring the volum e of water for the mix ture of ORS . The MOH therefor e recomm ended that mot he rs shoul d use one beer bott le or two coke bott les of water in mixing of ORS . However, in rec en t times, most Ghanaians prefe r the use of the bott led and sachet wate r to the normal pipe bone water. Th e bott led wate r comes in various volum e s but it seems the 500 mls volum es are the most comm onl y used. This ma y account for the reas on wh y majorit y of the care giv ers in thi s curr ent stud y end ed up using 500 mls of water in mix ing the ORS . Another reason might be due to the convenient nature of using bott led water as compar e to using the beer bott le. In using the beer bott le the car e giver has to sea rch for one which might not be readil y avail able at the incidence of the dia rrhoea. The bott le also has to be wash ed well before usin g it. The wh ole proc ess app ear cum bersome to most mod er n Ghanai an care giv ers and thi s poses a chall en ge to usin g the cor re ct volum e of water to mix the ORS . Perhaps it is time for the car e givers to be educat ed on other mo des of measurin g the vol ume of water for the ORS that will be convenient, acceptabl e, and eas y to com pl y with b y all care give rs irrespe cti ve University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 74 of their educ ati onal ba c kground since ORS mix ed with wron g qu anti ty of water could be ineffective and even unsafe for the child’s health. 5.5 The use of oth er mo d es of treat men t for diarrh oea at ho me The WHO (2006) on the subj ect of implementing the new recomm end ati ons on the cli nical management of diarrhoe a, recomm end ed ORS and fluid comm onl y avail able at home, breastfe edin g, conti nue d feedin g, sele cti ve use of anti biot ics, and providi ng zinc suppl ementati on for 10 to 14 da ys for di arr hoea l mana gement. Us e of anti biot ics is recomm ended onl y when appropriate, that is, in the presenc e of blood y di arrhoe a or shigell osis and for anti -dia rrhoe al dr ugs, he alt hcar e providers are to abstain from admi nist ering them. Th is notwit hstanding, the use of anti biot ics and anti -diarrhoe al dru gs for tr e atm ent of diarrho ea appears to be much popu lar amon g ca re give rs. In the curr ent stud y, as man y as (71.6 %) of t he car e givers had given one or more medicines to their chil dr en prior to present ati on at the hospi tal and about half of th em gave anti diarrhoe al dru gs while alm ost one -thi rd of the m gav e anti biot ics. Some of them gav e othe r drugs includin g pa rac et amol , anti malaria, ha e matini cs, metronidaz ole, dewormer etc. It is noteworth y to state onl y 9.6% of the car e givers gav e their chil dren zinc tablet. The sou rce of most of the medicines was chemi sts /drug sto res. Various reasons were assi gned b y the care giv ers for givi n g the medicines to their chil dr en befo re seekin g ca re at ho spit al. Most of the care giv ers said the y gav e the medicine particula rl y the anti biot ics and anti diarrhoea dru gs to stop or reduce the diarr hoea and vomi ti ng. Others ex plained that the y gav e the parac etamol, anti - malaria, metronid a z ole and dewormer to rel ieve the chil dren of the fever and abdomi nal pain. Some, again, said they gave the haematinics to stimulate the childrenµs appetite for food. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 75 A possi ble ex planati on for the findin gs in the present stud y could be t he inadequ ate knowledge on the part of the care givers about the causes of diarrho ea and its management. The y therefor e resort to other forms of tre atm ent whic h in their opini on might be able to mana ge the diarrhoe a effe cti vel y. It ma y also be due to th e percepti on of the care give rs that those medi cines would be able to stop the diarrhoe a fast er than ORS . Another possi ble reason for the hi gh use of the medicines particularl y th e anti biot ics and anti -diarrhoe al drugs might be as a result of the eas y ac cess of th e medici nes over the counter. Again, as some of the chemi sts or drugs stor es do not have the se rvices of a quali fied pharmacist or a train ed dispensar y techni cian thro ughout the da y, ther e is a high possi bil it y that some of the care give rs might have fall en int o the hands of untrained che mi cal shop att endants who might have limi ted knowledge about the effects of irrati onal use of drugs espe ciall y in chil dren. These att enda nts might have influen ced the ca re give rs in sett li ng for the anti - diarrhoe al and other dru gs inst ead of ORS and zinc. These e mer gin g iss ues require a definite effort b y MOH/GHS to int ensif y educ ati on agains t irrati onal use of dru gs i n the mana gem ent of diarrhoe a. Rega rdin g zinc tablet, t he stud y rev ealed th at even thou gh 69% of t he care give rs claimed the y wer e awa re about the t ablet, as many as 62 % of them could not tell the use of the tablet. The findin g of the stud y is consi stent with the findings of Ogun rinde and Ani go (2012 ) who reported inadequ ate knowledge of the use of Zinc tablet in the management of diarrho e a among care giv ers. The high level of aw aren ess of the zinc tablet among the car e givers might possi bl y be due to the fact that it was recentl y lau nched in the countr y and has received a lot of media publi cit y in recen t times. Thus, the memories of the dru g mi ght be s ti ll fresh with the care giv ers. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 76 On the other hand, th e inabili t y of most of the care give rs to ex plain the use of the zinc tablet might be due to fact that the information propell ed in the media might not be in -depth enough for the care giv er s to properl y u nd erstand the use of the tablet. It is therefo re impe rati v e for the info rmati on on zinc tablet to be repack aged to enable th e care givers have ad equat e understandin g and bett er appreci ate the us e of th e tablet for man a gement of diarrhoe a. This ma y gr ati f y the ps yc hologi cal needs of the car e givers who stron gl y beli eve that it is a must to giv e a drug for effe cti ve mana gement of diarrho ea in chi ldren. 5.6 Caregive rs healthcare seek in g beh aviou r The stud y establi shed a significant diff eren ce in the durati on of illness before se ekin g care at a healt h facil it y between care give rs with vali d healt h insurance and those without vali d healt h insuranc e (U= 12 50 .000, N 1 = 58, N 2 = 58, P < 0.05). This su gges ts that car e givers with vali d healt h insuranc e were mor e likel y to spend less number of da ys at home in the event of illness of their chil dren as compared to those without vali d or no insurance. This find in g conforms to that of Page et al (2011 ) who fo und that the incre ase in healt h ca re se ekin g behaviour in the case of diarrhoe a of chil dren un der 5 yea rs of age in the Maradi region is as a result of the effic ac y of recent he alt h poli cies for chil dren in Ni ger. The y added the aboli ti on of user fees for chil dren un der 5 yea rs old in April 2007 had brought a posi t i ve impact on pati ent behaviour, and in pa rticu lar on the dela y befor e co nsul tation and in the most vulnerable groups. Furthermo re, the findin gs of the curr ent stud y reveal that enrolm ent in t he NHIS was low among the car e givers. Despit e its obvious benefi ts and regardless of it being free fo r chil dren under 18 years, as man y as half of the care givers were without vali d healt h insurance. This observati on could be ex plained by the fac t some of the caregive r s cannot afford the University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 77 premi um char ged b y insurance sch eme bec ause of financial const raint . Other reason could be that some of the care giv ers might not be well informed about the whole insurance packa ge an d the benefits asso ciated with it. Therefor e the y are not att ra cted to get enroll ed in the scheme. This im pli es that the NHIA will need to ensu re co nti nuous educati on on healt h insurance and its associated benefit to the enti re pubic to enh ance its enroll ment esp eciall y among car e givers with chil dren under five. Concernin g reasons for the durati on of illness prior to the hospi tal visi t, it varied in proportion betwe en care givers with and without vali d healt h insuranc e. In the cas e of those with vali d healt h insuran ce ov er half of th em claimed t he y wait ed at home bec a use the condit ion of the chil dren was not se rious. Onl y 1.7% of the vali d he alt h insuranc e holder claimed the y wait ed at home bec ause t he y did not have mone y while 3.4% said the y wai ted for their partn ers. On the contra r y, onl y 34.5% of those without vali d healt h insuranc e ind icated the y wait ed at h ome bec ause th e condit ion of the chil dren was not serious while 25.8 % i ndicated the y started as a first aid to mana ge the diarrhoea at home. Almos t a quarter of the non -healt h insuranc e holders indi cated th at the y wait ed at home be cause the y did not hav e m one y while 10.3% claimed the y wait ed for t heir partne rs. The findings of the curr ent stud y support those from Sharke y et.al (201 1) which cit e d that limi ted autonom y of care giv ers in decisi on -m aking, fin ancial const r ain ts, lack of aw aren ess of infant danger- sings, and identificati on of an ex ternali z ing cause of illness were important influences on healt hcar e-seekin g durin g illnesses of infants. This is furt her supported b y Biritwum et al (2004) who also indi cated lack of mone y as the main reason given b y t h e care giv ers fo r not se ekin g medi cal att enti on for t heir chil dren with seve re diarrhoe a. Again, the findings su ggest that fact ors including the serious ness of illness and abil it y to pay durin g illness University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 78 play a key role in caregiversµ decision to seek health care. Caregiversµ inability to detect danger signs asso ciated with dia rrhoea coupled with their inabili t y to pa y ma y lea d to dela y in se ekin g medical att enti on. This ma y l ead to prev entabl e de ath ther eb y contrib uti ng to hi gh inf ant mortali t y rate. It is the re fore important for car e givers to ha v e ad equate knowledge on dan ge r signs of diarrhoe a in addit ion to enroll ing in the NHIS to enable them see k earl y care at healt h facil it y to av ert pr eventa ble deat hs amon g chil dr e n. 5.7 Limitation s The findings of thi s stud y alt hou gh informative are also subj ect to some limi tations. Quanti tative rese ar ch en hances gener ali z ati on of the result s when data are dr awn from fairl y large random sampl es. In the current stud y, how ever, the stud y inst it uti on was limi ted to on l y 30/ childrenµs hospital. Representation and generali]ation of the study could have been max im iz ed if caregiv ers from other hospi tals wer e incorporat ed int o the stud y. The resea rche r had to restrict the stud y population because of limit ed time and financ ial co nstraint s. It is also possi ble that the reco gnit ion of the rese arche r as a nu rse b y car egiv ers coul d have alt ered their respon ses to sati sf y th e rese arch er. This was, howev er, m ana ged b y info rmin g care giv ers that truthful responses were ne eded to ensure the data coll e cted wer e vali d and useful. Apa rt from thes e limi tations , the stud y provides fas cinating preli mi nar y findings that dese rve furt he r expl orat i on. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 79 CHAPTER SIX SUMMARY, IMPLICATION, RECOMMENDATION AND CONCLUSION 6.1 Summary The stud y sou ght to ass e ss pre -hospi tal mana gement of diarrho ea and fact ors aff ecti n g it among car e givers with chil dren under five at the PM L Chil dren Hospit al in Accra. Th e stud y empl o yed a qu anti tative cross -se cti onal desi gn using a tot al of 120 purposiv el y s ampl ed care giv ers with chil dr en under five pres en ti ng with diarrhoe a at the PM L Chil dren Hospit al. A questi onnaire with 26 items with both open and close ended items was designed. This cover ed socio-demo graphic ch ara cterist ics of the respond e nts, know ledge about dia rrhoea, its caus es and danger si gns associated with it, awareness and use of ORS and RHFs, feeding pr acti ces durin g diarrhoe al episod e, other mode of treatm ent whic h care give rs use durin g diarrhoe a l episod e and factors that affect caregiverµs decisi on to seek heal th care. Data obtained was anal ysed using the SPSS version 16.0 statis tical packed. Chi -square and Mann-W hit ne y t ests were used to test the various components of th e questi onnaire to investi gat e the speci fic objecti v es and h ypothesis . The major findi n gs of the stud y ar e summed up as follows:  Almos t all the care giver s who participated in the stud y ri ghtl y unde rstood di arrhoea as frequent passing of µwatery stoolµ three or more times in a day but their knowledge pertaini ng to the caus es and dangers si gns of diar r hoea was not satisf actor y.  C onvincing evid ence of relations hip was established between caregiversµ educ ati onal level and knowled ge ab out causes of diarrho ea. Howeve r, no convin cing evidence of relationship was established between caregiversµ educational level and knowledge about danger si gns of dia rrhoe a . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 80  The findings rev ealed a high rate of br eastf eedin g among mot hers espe ciall y for chil dr e n withi n the first six months of birth. Howev er fee ding pr acti ces amon g car egiv ers durin g diarrhoe a episod e was not encoura gin g as a hi gh rate of diet restriction of chil dren prior to the hospi tal was reported. This is a concern because diet ar y restricti on of chil dren during dia rrhoe a ma y co mpromi se their healt h.  The findings reve aled a wide gap betw een aw areness and use of ORS among th e care giv ers. Even though the awa reness lev el of ORS among the ca re givers wer e subst anti all y hi gh, the ac tual number of ca re give r s who gav e ORS to their chil dren prio r to the hospi tal was relativel y ve r y low. In the case of RHFs, the stud y fo und that both the level of aw ar eness an d use amon g the ca re give rs wer e ver y low compar ed to ORS .  The level of awa reness and use of RHFs and ORS among car e givers with higher level of educati on was compa rab le with those with low er level of educati on. Thus, the eviden c e available did not support any relationship between the caregiversµ educational level and awar eness and use of R HFs and ORS . Sim il arl y, the level of knowled ge in the co rre ct use of ORS among care givers with higher level of educati on was comparab le with those with lower level of educa ti on.  It emer ged from the stud y that most of the care giv ers empl o ye d other remedies including the use of ant ibi oti cs and anti -diarrho ea dru gs to treat diar rho ea inst ead of ORS , RHFs and zinc. Chemi sts / drugs stores were top among the source s of medicines resorted to b y care giv ers for treatm ent o f diarrho e a.  C onvincing evidenc e of a relations hip wa s establi shed between healt h insurance and durati on of diar rhoea illness at home be fore hos pit al visi t. The evidence avail able was supportive of the view that caregiversµ with valid health insurance are more likely to University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 81 spend less number of da ys at home in t he eve nt of illne ss among the i r chil dre n as compa re to those without vali d or no insura nce . 6.2 Implication for Nursin g The outcome of the study has impli cati on s for nu rsing and thes e can be viewed in t erms of four areas o f nursin g: mana gement, resea rch, educati on and pra cti ce. 6.2.1 Nursin g man age men t Nurse Mana gers in the various hospi tals shoul d ensure that there ar e plan ned, relevant and appropriat e teachin g protocols for nurses for edu cati n g mot hers on diarrhoe a and its home mana gement as well as other comm on chil dhood ill ness. The y shoul d also ensure conti nuous in - service tr aini ng of nu rse s on mana gem ent of co mm on chil dhood illness such as dia rrhoe a so that the y will alw a ys b e abreast with cur rent trend of mana gement of these diseases. 6.2.2 Nursin g research Further rese ar ch on pre - hospi tal management of diarrhoe a amon g care giv ers n eed to be carri ed out at mul ti -sit es with larger sampl e siz e to confirm the findings of current stud y. The need for an addit ional co mprehensive comm unit y based surve y cannot be over -emph asis ed but thi s was not possi ble in the curr ent stud y becaus e of limi ted tim e and financial const raint s. 6.2.3 Nursing education The findin g will info rm nurse edu cators on the knowledge gap on hom e mana gement of diarrhoe a amon g ca re gi vers. This will enable t hem to make the nec es sar y amendments and restructurin g in the educ ati onal curriculum fo r nurses so that the y can m eet the infor m ati onal University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 82 needs of car e givers. This will also help equip nurses with relevant knowledge and improve thei r healt h informational diss emi nati on skil ls to help bridged the knowledge gap on hom e mana gement of dia rrhoe a and chil d welfa re iss ues . 6.2.4 Nursin g practice 1urses by virtue of their role as health care professionals’ and clients advocate , pla y a pivot al role in influencing beh aviour modi ficati on among the people th e y come int o contact with in course of th eir work. Nurses must strive t o empower th emselv es th rough conti nuous and periodic upgradin g in courses on current trend of management of disease condit ions including diarrhoe al diseases and quali t y cli ent ca re in gene ral. Comm unit y healt h nurses shoul d coll aborate with the opini on leaders in the variou s comm unit ies and intensif y healt h educ ati on on diarrhoe al diseases to reduce di arrho ea chil d m ortalit y. 6.3 Recommen d ation  The MOH / GHS shoul d step up edu cati onal pr ogr amm es on pr e-hospi t al mana gem ent of diarrhoe a. This should involve: o The use of mass media, comm unit y durb ars, drama groups and othe r co mm unit y-b ase d educati on to sensit ise the publi c and the comm unit y on diar rhoe a particular l y causes an d danger si gns of diarr hoea , the use of RHFs, ORS and zinc tablets, the need for conti nued feedi n g durin g diar rhoe a and reco gnis in g wh en to seek addit ional medical care. o C onti nuous sensitisatio n of indi vidual caregiv er s by healt h providers o n home-based mana gement of diarrho e a , espe ciall y durin g chil d welfa re cli nics and ho me visi ts . The sensit is ati on shoul d focus on vit al inf ormation on diarrhoe a contained in the wei ghin g University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 83 book, which includes the causes and dan ger signs associated with diarrho e a an d ho w to mana ge it at home. Again the s ensit isatio n shoul d invol ve pra cti cal de mons trati on of how to prepar e ORS corr ectl y. o Developi n g app ropriate educati onal and tr aini ng materials includin g post e rs to transmi t priorit y messa ges on t he caus es and dan ger signs of dia rrhoe a, prepar ati on and admi nist rati on of ORT solut ions, the importance of RHFs and conti nued feedin g and the need for ref err al if the ch il d's condit ion worsens. o C oll aborati ng with Minist r y of Edu cati on / Gha na Educ ati on Servic e to incorpor ate lessons on the causes and dange r signs of diar rhoea and its home management in prim ar y schools.  The Pharmac y Coun cil shoul d streaml ine and m onit or the acti vit ies of chemi sts /drug stores particularl y with regard to the sale of drugs such as anti bio ti cs and anti - diarrhoe al -dru gs without prescriptio n. The Council shoul d also champi on rati onal use of drug in chil dren espe cial l y in dia rrhoe a man a gem ent. Separ ate guidelines for tre atm ent of diarrhoe a in chil dren shoul d be prepar ed for t he chemi sts /drug stor e att endants and ORS packets shoul d be made avail able in ad e quate suppl y at the dru gs stores and throughout the enti r e he a lt h s yst em.  The MOH/GHS shoul d come out with an appropriate, µuniversally’ avail a ble measurin g container to help care giv ers to mix the ORS with the right vol ume of wate r.  The NH IA shoul d step up their educati on pro gr amm es on the benefits of the healt h insurance pa cka ge amon g the cit iz enr y espe ciall y the lower social class an d those in the informal sector in ord er to increas e their en rollm ent. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 84 6.4 Suggestion for future res ea rch In view of the fact that t his resea rch was limi ted to onl y one hospi tal in Accr a, futur e resea rch shoul d ex ami ne sim il ar d ata in more he alt h facil it ies in the Gre ater Accr a and othe r regions to ex pand the evidence base to enhan ce pr e-hospi tal mana gem ent of diarrhoe a. 6.5 Conclusion P roper home m ana gem e nt can reduc e morbidi t y and mortali t y due to di ar rhoea. Fa ctors of particular importance include caregiversµ knowledge about causes of diarrhoea and the associated dan gers signs, preventi on of deh yd rati on during diarrho eal episod es throu gh the us e of RHFs and ORS , support of nutrit ional status through the conti nuati on of an adequate diet , avoidance of harmful practi ces and earl y ref err als for tr eat ment. Th e current stud y reveal s inadequate kno wl ed ge about the causes and da nge rs si gns associat ed with diarrhoe a amon g care giv ers even thou gh the y appea r to rightl y describe diarrho ea as freque nt passi ng of µwate r y stoolµ three or more times in a day . 7he findings of the study also showed dietary restri cti ons during th e dia rrhoe a epi sode, low use of both RHFs and ORS but hi gh use of oth er remedie s such as antibi oti cs and an ti -diarrhoea. The stud y fu rther reve a led that knowled ge abo ut danger si gns of diar r hoea and the corre ct use of ORS as well as the lev el of aw areness and use of RH Fs and ORS amon g care giv ers with higher l evel of educati on wer e comparable with those with lower level of education. $ positive relationship was however established between caregiversµ educational level and knowled ge ab out causes of diarrho ea as well as healt h insurance and du rati on of diarrhoe a illness at home befor e hospi tal visi t. 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Poster session pr esented at: 18th Annual GHEC Conferen ce . King, C.K., R. Glass . , Br esee, J .S . , & Duggan, C . (2003 ).Mana gin g acute gastroenterit is amon g chil dren:oral reh ydrati on, maintenance, and nutrit ional therap y. MMW R ., 21: 52: 1-16. Kolpuru, S. (2008).Oral reh ydrati on therap y. Pedi atric oncall . Retrieved J anuar y 12, 2013 from htt p:/ /www.pediatriconca ll .com/ fordoctor/di sease e andcondit ion/ Gastroint esti nal_di sorder Keusch, G., Font aine, O. , Bh ar gav a, A. , Bos chi -P int o, C., Bhutt a, Z.A., Gotuz z o, E., Rivera, J ., Chow, J ., Shahid -S all es, S., Lax im inara yan, R., In Jami son, D.T., Brem an, J .G., Claeson, M., Evans,D.B., J Ha,P ., Mill s,A., &Mus grove, P.(2006). Dise ase Contr ol Pri or it ie s in Devel opi ng Count ri es. 2nd edit i on. Was hingt on (DC) : Wor l d Bank; 2006. Developing Countries. N ew York:Ox ford Univers it y Press; 2006: 371 -388. Leed y, P.D., & Ormrod, J .E (2005).P racti cal Rese arch: Planning and Desi gn. (8 t h ed) Pearson Mer rill Pren ti ce Hall . MOH (2002). Inte grated Mana gement of Chil dho od Ill ness ( IMC I). Review of introductory and early implementation phases. MOH, Accra, Ghan a. MOH (2007-2015 ). Under-5 Child Health Policy. MOH, Acc ra, Gh ana. MOH Standard treatm en t guidelines, Gh a n a Nat ional Drug Progr amme (2004) . ³Disorders of the gastr o intestinal tract system´ pp 3 -14 ) MOH (2010). The Health Sector Medium-Term Development Plan (HSMTDP) 2010-2013 : Accel erati n g pro gr amm e implementation towards att aini ng equit able univ ersal cove ra ge. MOH, Acc ra, Gh ana NDP C (2005). Scali ng -up healt h investm ents for bett er he alt h, ec onomi c growth an d acc elerat ed povert y redu cti on. Ghana ma croe con omi cs and healt h ini ti ati ve (GMH I) University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 88 Neumann, CG . , Ma rquar dt , M. , & Bwibo , N. O. ( 2012). Impact of morbid it y on food int ak e in rural Ken ya n chil dren. S Afr J Cli n Nutr 2012;25(3):142 -148 Poli t, D.F. & Hungle r B.P . (1996). Nursing Research: Principles and Methods. P hil adelphi a: Lippi ncott Compan y Othero, D.M., Ora go, A. S .S ., Groenewe gen, T., Kaseje, D.O., & Oten ga h, P.A. (2008). Home mana gement of dia rrhoe a amon g under fiv es in rural comm unit y in Ken yah: Household Percepti ons and Practi ces . East Afric an J ournal of Publi c Healt h, Volume 5. Ogun rinde, O.G ., Raji . T ., & Ani go, K.M .(2012 ). Knowled ge, att it ude and practi ce of home mana gement of chil dh ood diarrhoea amon g care giv ers of under -5 chil dren with diarrhoe al disease in Northwestern Ni geri a. J Trop Pediatr . Apr; 58(2):143 -6. doi: 10. 1093/t ropej/ fmr048. Page, A. L., Hast ache, S. , Luqu ero, J .F., Djibo, A., Manz o, M. L. & Grais, R.F. (2011). Healt h care s eekin g behaviou r for diarrhoe a under fiv e in rural Ni ger: result of a cross secti onal surve y. BMC Public Health,11:389 doi:10.1186/1471-11-389 Polar Engine erin g Consul ti ng Lim it ed. (2007) Sta ti sti cal Package for Socia l Sciences. Retrieved from http: // www.winwra p.com/ . Shah, M.S ., Ahmad, A., Khali que, N., Khan, I. M., Ansari, M.A.and Khan, Z. (2011). Do th e mot hers in rural Ali ga r h know abo ut home based mana gement of acute diarrhoe a? Biology and Medicine, 3 (2) Special Issue: 76-80. Shah, M.S ., Ahmad, A., Khali que, N., Afz al, S., Ansari, M. A. and Khan , Z. (2012). Home- based mana gement of acute diarrhoe al disease in an urban slum of Aligarh , India. J In fect Dev Ctries ; 6(2):137 -14 2. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 89 S harke y, A., Chopra, M ., J ackson, D., Winch, P.J .,& Minkovitz , C.S . (2011). Influen ces on healt hcar es -se ekin g duri ng final illness of inf a nts in under resour ced sout h African sett ing. J Healt h Popul Nutr 378 -87 Uchendu, U.O., Emodi , I.J . , & Ik efuna, A.N. (2 008). P re-hospi tal m ana gem ent of di arrho ea among ca re give rs pr esen ti ng at a tertiar y healt h i nsti tut ion: impli cati ons for pra cti ce and healt h educ ati on. UN IC EF( 2007 ). The state of the world’s children 2008 . New York, NY Victora, C.G., Br yc e, J . Fontaine, O., & Monassc h, R. (2000). Reducing deaths from diarrhoea through or al reh yd rati on therap y. WHO Bull eti n, 78(10):1246 -55 WHO (1 989). Walker, W.A., Goulet,O., Kleinm an, R.E. , Sherman,P .M. , Shneider a, B. L., & Sande rson , I.R.(2004 ). Pediatric Gas troint esti nal Disease: Pathoph ysiol o g y, Dia gnosi s, Mana gement, 4th ed (Pa ge 174) Hami lt on, Ontario:B.C . Decker, WHO (2009). Diarrho ea l Disease. Fact sheet N°330. R etrieved Februa r y 13, 2012 from: www.who.int /m ediacentr e/factsh eets/ fs 330/en/index .htm l WHO (1989). Program me for Control of Diar rhoea Dise ases. Seventh Progr amm e Report. 1988 –89. Geneva: WHO document WHO/C DD/90.34 WHO and UN IC EF (20 01). Reduced Osmolarity Oral Rehydration Salts (ORS) Formulation . WHO/FC H/CAH/01.22. Report from a meeti n g o f ex perts joi ntl y or ganiz ed b y the 8nited 1ations Children’s Fund and the :orld Health Organi]ation, *eneva . WHO/UN IC E F (2003). Global strate g y on infant and youn g chil d feedin g. Geneva, World ( htt p:/ /www.who.int/ child_adolescent_he alt h/doc uments/ 9241562218/ en/index .htm l WHO (2006). Oral reh yd rati on salt s: Producti on of the new ORS . WHO/F C H/CAH/06.1 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 90 W HO (2008) Stren gthe ning acti on to improve feedin g of inf ants and youn g chil dren 6- 2 3 mont hs of age in nutrit io n and chil d healt h pro gra mm es: report of proc eedi ngs, ISBN 978 92 4 159789 0 (N LM cla ssi ficati on: WS 120) Yamane, T. (1967 ). Stat ist ics: An introductory analysis. 2nd Ed., New York: H arpe r and Row. Retrieved Novemb er, 13, 2010 from http: edis.i fas.ufl.edu/pd006 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 91 APPENDICES APPENDIX A PARTICIPANT INFORMATION SHEET Title : Pre Hospit al managem ent of diarrhoe a among ca re give rs with chil dren under five at the Princess Marie Louise C hil dren Hospit al, Accr a Principal Investigator : Charit y As antew aa Ache ampong , School o f Nu rsing, Col le ge of Healt h Science, Unive rsit y of Ghana, Le gon P.O Box LG 43 Lego n. General Information abou t Research This stud y seeks to assess home management of diarrhoea amon g car egiv ers with ch il dren under five prio r to seeki ng medical att enti on at the hospi tal. Th e stud y will gen er ate relevan t information on the chall enges care give r fac e in home management of diarrhoea. This is envisaged to contribut e t o improving home mana gem ent of diarrho ea. You have be en select ed for thi s stud y bec ause yo u are a car e giver wit h a chil d under five presenti n g with diarrhoe a. Please, you have the right to decide whether yo u want to take part in the stud y or not. You wil l be recruited int o the stu d y after your chil d has been att end ed to at the ORT corne r and is wait in g at the OPD to be seen at the consul ti ng room b y a doctor. Your chil d will be in a stable condit i on or out of dan ger be for e the int erview comm enc e. We will also liaise with the nurses to ensur e tha t your chil d is att end ed to prompt l y b y a doct or afte r the int ervie w. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 92 If you agr ee to be part of the stud y, you will be given a consent form and yo u will have to give yo ur consent b y signin g t he form, aft er which you will answer questi ons fro m the questi onnaire. 7he questions will centre on your knowledge on diarrhoea and how you managed your child’s ward’s diarrhoea at home before coming to the hospital. 7he questions will be in the form of face to face int e rview. The questi ons will be rea d out to you and you ar e at libert y to answ er what you can and le ave an y questi on you are not able to answe r. Th e answers you give will be record ed on the questi on naire. The inte rview wi ll last between 30 - 40 mi nutes Possib le Risks and Discomf orts There is no ris k asso ciate d in taking part in the stu d y Possib le Benef its It is hoped that thi s study will come out with fin dings, which will contri bute to the process of finding best wa ys of strengthenin g home -bas ed mana gement of diarrho ea as part of the nati onal strate g y to reduc e diar rh oea morbidi t y and mortal it y amon g chil dren in Gh ana. Confid en tiali ty The venue for the int erv iew will be such that no bod y will hea r what you sa y .Your name will not be recorded on th e questi onnaire form but onl y on the agre ement f orm which onl y m y supervisors will have ac cess to it. How ever you will be given an ID nu mber which will be record ed on the questi onnaire for the purpose of coding of information. You will not be named in an y reports and all information about you will be pr otected in the best o f my abil it y. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 93 Compensation There would be no mon etar y gain fo r participati ng in the stud y: how eve r you r ef fort will be much appre ciated. Voluntary Participation and Right to Leave th e Resea rch You have the free will to decide whether you wan t to take part in the stud y or not. If you agree , yo u will be given a cons ent form and you will have to give your cons ent by signin g the consent form. In case you canno t read the consent fo rm yo urs elf, somebod y can read and ex plain it to yo u and si gn the consent form as a witness. This will be done afte r the pr ocedures invol ved in the stud y have been ex plained to you in his presence. You are free to opt out of the stud y at an y time if you wish. Your refusal to participate in th e stud y will not aff ect yo ur chil d 's ca re in thi s hospi tal. Contacts for Addition al Information 1. Mrs. Com fort Kafui Af ram, Mp hil , BA, Dip, School of Nursing, Col le ge of Healt h Science Unive rsit y of Gh ana Le gon P. O Box LG 43 Legon. E mail : aoakk@ yahoo . com Tel: 0278153024 2. Dr (Mrs.) M aame Ya a N yarko, FW ACP , MBc hB, Head of cli nic al Serv ices, PM L Chil dren Hospit al, P.O Box GP 122 Accra Email mee ya a@ ya h oo.com Tel: 0244018888 University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 94 Your righ ts as a Participan t This resear ch has been reviewed and app roved by th e Insti tut ional Review Board of No gu chi Memorial Insti tut e for M edical Rese ar ch (NM IM R - IR B). If you hav e an y questi ons about your rights as a res ear ch parti cipant you can contact t he IR B Offic e betwe en t he hours of 8am -5pm through the landline 0302916438 or email addresses: nirb@no guchi.m im com.org or HBaidoo@no gu chi.m im com.org . University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 95 APPENDIX B VOLUNTEER AGREEMENT The above document de scribing the ben efits, risks and procedur es for the rese arch titl e (Pre hospital management of diarrhoea among caregivers with children under five at the PML Children Hospital) has been read and ex plained to me. I have been giv en an oppo rtunit y to have an y qu esti ons about the research answ ered to m y sati sfa cti on. I agr ee to participate as a volunt eer. ______________________ ___________ ____________________________ Date Name and si gnatur e or mark of volunt eer If volun teers cannot rea d the form the ms elves, a witness must sign here: I was pr esent whil e the benefits, risks and pro cedu res were read to the volu nteer. All questi ons were answe red and the volu nteer has agreed to take part in the resea rch. _______________________ ___________________________________ Date Name and si gnatur e of witness I certif y that the nature and purpose, the potenti al benefits, and possibl e ris ks associated with participati ng in this res ea rch have been ex plained to the above indi vidual. _______________________ __________________________________ Date Name Signatur e of person wh o obtained consent University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 96 APPENDIX C DATA COLLECTION INSTRUMENTS TOP IC : PRE -HOS P ITA L MAN AGEMENT OF DIARR HOEA AMO NG CAREG IV ERS W ITH CH ILDRE N UN DER FIVE AT PM L HO S P ITA L A. SOCIO DEMOGRAPHIC INFORMATION 1. ID No. --- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- - 2. Age of caregi ver 15-24 25-34 35-44 45-54 55 above 3. Gender of caregi ver Male Femal e 4. What is the highes t level of educat i on you have compl et ed? No for mal educat i on Vocat ional /T echni cal / Commer ci al Primar y Post Sec JHS/ Mi ddl e School Terti ar y Secondar y / SHS Other s, plea se specify --- -- - -- -- -- -- -- - 5. Mar it al Stat us Marr ied Separated/ Di vor ce d Singl e Co -habi t i ng Widowed University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 97 6. What is your Occupat i on/ Prof essi on? Civi l Ser vant / Publi c ser vant Trader Trades - hai r dres si ng, seamst res s, car pent r y etc Unempl oyed Others , p lease Specify…………… 7. Rel ati onshi p of car egi ver to cli ent Mother Grandmot her Fat her Grandfat her Sibli ng Other, Specify…………………….. 8 . What is the age of your chil d? 0-6 mont hs 7- 12 mont hs 13 -18 mont hs 19- 24 mont hs 25 -30 mont hs 31-36 mont hs 37 -42 mont hs 43- 48 mont hs B. KNOWLEDGE ABOUT CAUSES OF DIARRHOEA AND THE ASSOCIATED DANGER SIGNS 9 . What do you underst and by diar rhoea? Frequent pass ing of wat er y stool (3 or mor e times ) Frequent passi ng of non -wat er y stool Blood in stool s Greeni sh stools No idea 3hlegm’s mucus in stool Others, please specify …………………………………… University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 98 10. What do you thi nk are the cause s of diar r hoea ? (T ick as many as poss i bl e) Infec t ion Worm inf ection Food poi soni ng/ Cont ami nat ed Food Contami nat ed wat er Teet hi ng No idea Others 3lease Specify………………………………………………. 11. What are some of the danger si gns ass oci at ed wit h diarr hoea ? (T ick as many a s pos si bl e) Becomi ng weak or let har gic Frequent pas si ng of diar r hoea Repeated vomi t i ng  vomiting everything Others, please specify …………… Fever and blood in sto ol Marked thir st of wat er Poor feedi ng Reduc ed uri ne out put C. FEEDING PRACTICE 12. What do you feed your chil d on? Breast mil k onl y Breas t mil k + Inf ant for mul a Compl e ment ar y feedi ng onl y Compl e ment ar y feedi ng plus brea st mil k Normal fami l y diet Others, 3lease specify……………………………………………………………… University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 99 13 (a) Duri ng the diar r hoea ill ness, did the chil d eat ---- - About the same? More than usual ? Much les s? Somewhat less? (b) Any reason for the answer given ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- - ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- 14 (a) Duri ng the diar r hoea ill ness, did the chil d dri nk --- -- About the same? More than usual ? Much les s Somewhat less (b) Any reason for the ans wer given ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- - ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- ---- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - - - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- D. AWARENESS AND USE OF ORAL REHYDRATION SALT (ORS) AND RECOMMENDED HOME FLUIDS (RHFs) 15. What avail abl e recommende d home -made flui d / home base oral rehydr at i on flui d can be given to a chil d wit h diarr hoea ? (T i ck as many as man y as poss ible) Coconut wat er Mashe d kenkey Sugar and salt sol ut i on Rice water Water Other , please spe ci f y--- -- -- -- -- -- -- -- - -- - University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 100 Porri dge 16 (a) Was your chil d given any home -made flui d befor e comi ng to the hospit al ? Yes No (b) If yes , what home -made flui d did you give to your chil d bef ore comi ng to the hospi t al ? (T ick as man y as possi ble) Coconut wat er Mashe d kenkey Sugar and salt sol ut i on Rice water Water Other , pleas e spe ci f y--- -- -- -- -- -- -- -- - -- - Porri dge 17 ( a ) Have you heard about a flui d made from a sp ecial pa cket call ed ( ORS) ? Yes No (b) If yes , was your child given some bef or e comi ng to the hospit al ? Yes No 18. Preparati on, stor age and how long mixed ORS lasts (a) How is ORS pre par ed? 1 sachet of ORS - 300 mls (1 coke bott le) of water 1 1 sachet of ORS - 500 mls (1 smal l size of miner al bot tl e) of wat er 1 sachet of ORS - 600 mls (1 beer bott le) of wat er 1 sachet of ORS - 750 mls (1 medi um si ze of miner al bot tl e) of wat er 1 sachet of ORS - 1000 mls (1 litr e) of wat er 1 sachet of ORS - 1500ml s (1.5 litr es or lar ge size of miner al bot tl e) of wat er (b) How often shoul d ORS be given? Once a day 2-3 times a day 4-5 times a day 6 & above times a day University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 101 After the passi ng of ver y loose st ool No idea (c ) How long shoul d the mixed ORS last? 24 hrs (I day) 48 hrs (2days) 72 hrs (3days) 96 hrs (4days) Others please specify ……………………………………………… 19. Menti on the reason (s) why ORS or RHF is given to chil dren havi ng diar rhoea To increa se the diarr hoea No idea To decrea se the diar rhoea Others, please specify…………….. To prevent dehydr at i on E. OTHER MODE OF TREATMENT GIVEN 20. Was your chi l d given medi ci ne / other treat ment bef or e comi ng to the hospi tal? Yes No 21 (a) If yes , plea se indi cate the type of treat ment given? Anti bioti cs Syrup parac et amol Anti diarr hoea Others, pleas e speci f y. Her bal prepar ati on (b)Why did you give that par ti cul ar treat ment ? ---- -- -- - -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- - - -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- - -- -- -- -- - - 22. Wher e did you get the treat ment from? Near by chemi st /dr ug stor e Communi t y heal t h wor ker Left over of pres cri bed drugs Drug peddl er s From fri end or fami l y me mber Other s, please spe ci f y University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 102 23. (a) Have you heard about Zinc Tabl et ? Yes No b :hat is the use s of it……………………………………………………… F. HEALTH CARE SEEKING BEHAVIOR 24. Do you have a val i d heal th insuranc e (Not expi r ed) ? Yes No 25. How long did you stay at home bef or e comi ng to the hos pi tal? 1 -2days 3-4 days 5-6 days 7days and above. 26. Why did you stay home for that long? Start ed home mana ge ment Not havi ng money Wait ing for life par tner Condi ti on was not ser i ous Others, 3lease specify…………………………………………………………… Thank you University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 103 APPENDIX D University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 104 APPENDIX E University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 105 APPENDIX F University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 106 APP END IX G Cross-tabu lation and chi- square test: Respondents’ educational level vs. knowledge of d an ger sign s of diarrh oea K now ledge of cause s of diarr hoea * Educational level of caregivers: Cross -tabul ati on Educati onal level of car egiver s T ot al Basi c or lower level of educ at i on Secondar y or higher level of educ at i on Knowledge of causes of diarr hoea adequat e knowl edge Count 5 14 19 Expected Count 13.3 5.7 19.0 % wit hi n Knowl edge of causes of diar rhea 26.3% 73.7% 100.0% % wit hi n Educati onal level of car egi ver s 6.2% 40.0% 16.4% % of Total 4.3% 12.1% 16.4% Some knowl edge Count 48 19 67 Expected Count 46.8 20.2 67.0 % wit hi n Knowl edge of causes of diar rhea 71.6% 28.4% 100.0% % wit hi n Educati onal level of car egi ver s 59.3% 54.3% 57.8% % of Total 41.4% 16.4% 57.8% No knowl edge Count 28 2 30 Expected Count 20.9 9.1 30.0 % wit hi n Knowl edge of causes of diar rhea 93.3% 6.7% 100.0% % wit hi n Educati onal level of car egi ver s 34.6% 5.7% 25.9% % of Total 24.1% 1.7% 25.9% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Knowl edge of causes of diar rhea 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 107 K now ledge of cause s of diarr hoea * Educational level of caregi vers : Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Pear son Chi - Squar e 25.046 a 2 .000 Likel i hood Rati o 25.556 2 .000 Line ar - by - Line ar Ass ociati on 23.026 1 .000 N of Vali d Cases 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 5.73. Note: From the result of the Chi -S quar e Tests , the Pea rson Chi -S quar e which is 25.046 is associated with a signifi cant level of 0.000 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the valu e of 0.000 is smaller than the apha value of 0.05, so it can be concluded that the result is significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 108 APPENDIX H Cross-tabu lation and chi- square test: Respondents’ educational level vs. knowledge of d an ger sign s of diarrh oea K now ledge about danger si gns of diarrhoea * Educational level of caregi vers Cross -tabul ati on Educati onal level of car egi ver s Tot al Basi c or lower level of educ at i on Secondar y or higher level of educ at i on Knowledge about danger si gns of diarr hoea adequat e knowl edge Count 16 8 24 Expected Count 16.8 7.2 24.0 % wit hi n Knowl edge about danger signs of diarr hea 66.7% 33.3% 100.0% % wit hi n Educati onal level of car egi ver s 19.8% 22.9% 20.7% % of Total 13.8% 6.9% 20.7% Some knowl edge Count 55 17 72 Expected Count 50.3 21.7 72.0 % wit hi n Knowl edge about danger signs of diarr hea 76.4% 23.6% 100.0% % wit hi n Educati onal level of car egi ver s 67.9% 48.6% 62.1% % of Total 47.4% 14.7% 62.1% No knowl edge Count 10 10 20 Expected Count 14.0 6.0 20.0 % wit hi n Knowl edge about danger signs of diarr hea 50.0% 50.0% 100.0% % wit hi n Educati onal level of car egi ver s 12.3% 28.6% 17.2% % of Total 8.6% 8.6% 17.2% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Knowl edge about danger signs of diarr hea 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 109 Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Pear son Chi - Squar e 5.317 a 2 .070 Likel i hood Rati o 5.075 2 .079 Line ar - by - Line ar Ass ociati on 1.103 1 .294 N of Vali d Cases 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 6.03. Note: From the result of the Chi -S quare Tests , the Pearson Chi -S quar e which is 5.317 is associated with a signifi cant level of 0.070 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the valu e of 0.070 is greater than th e apha value of 0.05, so it can be concluded that the result is not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 110 APPENDIX I Cross-tabu lation and chi-square test: Res pondents’ education vs. aw aren ess of RHFs Awarenes s of RHFs * Educational level of caregi vers : Cross -tabul ati on Educati onal level of car egiver s Tot al Basi c or lower level of educat i on Secondar y or higher level of educ at i on Awar ene ss of RHFs Yes Count 20 14 34 Expected Count 23.7 10.3 34.0 % wit hi n Awar enes s of RHFs 58.8% 41.2% 100.0% % wit hi n Educati onal level of car egi ver s 24.7% 40.0% 29.3% % of Total 17.2% 12.1% 29.3% No Count 61 21 82 Expected Count 57.3 24.7 82.0 % wit hi n Awar enes s of RHFs 74.4% 25.6% 100.0% % wit hi n Educati onal level of car egi ver s 75.3% 60.0% 70.7% % of Total 52.6% 18.1% 70.7% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Awar enes s of RHFs 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 111 Awarenes s of RHFs * Educational level of caregi vers Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Exact Sig. (2 - si ded) Exact Sig. (1 - si ded) Pear son Chi - Squar e 2.764 a 1 .096 Cont i nuit y Cor r ecti on b 2.075 1 .150 Likel i hood Rati o 2.683 1 .101 Fisher 's Exac t Test .121 .076 Line ar - by - Line ar Ass ociati on 2.741 1 .098 N of Vali d Cases b 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 10.26. b. Comput ed onl y for a 2x2 tabl e Note: From the result of the Chi -S quare Tests , the Pearson Chi -S quar e which is 2.764 is associated with a signifi cant level of 0.096 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the valu e of 0.096 is greater than th e apha value of 0.05, so it can be concluded that the result is not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 112 APPENDIX J Cross-tabu lation and chi-square test : Respon d en ts ’ education vs. aw aren ess of ORS Awarenes s of ORS * Educational level of caregi vers: Cross -tabulati on Educati onal level of car egiver s Total Basi c or lower level of educ at i on Secondar y or higher level of educ at i on Whether hear d about ORS Yes Count 80 35 115 Expected Count 80.3 34.7 115.0 % wit hi n Whet her hear d about ORS 69.6% 30.4% 100.0% % wit hi n Educati onal level of car egi ver s 98.8% 100.0% 99.1% % of Total 69.0% 30.2% 99.1% No Count 1 0 1 Expected Count .7 .3 1.0 % wit hi n Whet her hear d about ORS 100.0% .0% 100.0% % wit hi n Educati onal level of car egi ver s 1.2% .0% .9% % of Total .9% .0% .9% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Whet her hear d about ORS 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 113 Awarenes s of ORS * Educational level of caregi vers Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Exact Sig. (2 - si ded) Exact Sig. (1 - si ded) Pear son Chi - Squar e .436 a 1 .509 Cont i nuit y Cor r ecti on b .000 1 1.000 Likel i hood Rati o .722 1 .395 Fisher 's Exac t Test 1.000 .698 Line ar - by - Line ar Ass ociati on .432 1 .511 N of Vali d Cases b 116 a. 2 cel ls (50.0%) have expec t ed count less than 5. The mini mu m expe ct ed count is .30. b. Comput ed onl y for a 2x2 tabl e From the result of the Ch i -S quare Tests , the corr ec ted value, which is 0.000 is associate d with a significant lev el of 1.000 (as pr esented in t he colum n labeled As ym p. Sig [2 -sided] ). To be significant the Sig. value needs to be 0.05 or small er. In thi s ca se, t he value of 1.000 is gr eate r than the aph a val ue of 0.05, so it can be concluded that the result i s not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 114 APPENDIX K Cross-tabu lation and chi- square test: Respondents’ educational level vs. use of RHFs Use of RHFs by caregi vers * Educational level of caregi ver s: Cross -tabul ati on Educati onal level of car egiver s Tot al Basi c or lower level of educ at i on Secondar y or higher level of educ at i on Whether home - made flui d was given prior to the hospi tal visit Yes Count 16 11 27 Expected Count 18.9 8.1 27.0 % wit hi n Whet her home - made flui d was given bef or e hospit al 59.3% 40.7% 100.0% % wit hi n Educati onal level of car egi ver s 19.8% 31.4% 23.3% % of Total 13.8% 9.5% 23.3% No Count 65 24 89 Expected Count 62.1 26.9 89.0 % wit hi n Whet her home - made flui d was given bef or e hospit al 73.0% 27.0% 100.0% % wit hi n Educati onal level of car egi ver s 80.2% 68.6% 76.7% % of Total 56.0% 20.7% 76.7% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Whet her home - made flui d was given bef or e hospit al 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 115 Use of RHFs by caregi vers * Educational level of caregi ver s Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Exact Sig. (2 - si ded) Exact Sig. (1 - si ded) Pear son Chi - Squar e 1.866 a 1 .172 Cont i nuit y Cor r ecti on b 1.269 1 .260 Likel i hood Rati o 1.799 1 .180 Fisher 's Exac t Test .231 .131 Line ar - by - Line ar Ass ociati on 1.849 1 .174 N of Vali d Cases b 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 8.15. b. Comput ed onl y for a 2x2 tabl e Note: From the result of the Chi -S quare Tests , the Pearson Chi -S quar e which is 1.866 is associated with a signifi cant level of 0.172 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the valu e of 0.172 is greater than th e apha value of 0.05, so it can be concluded that the result is not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 116 APPENDIX L Cross-tabu lation and chi- square test: Respondents’ educational level vs. use of ORS Use of ORS by caregi vers * Educational level of caregi vers: Cross -tabul at ion Educati onal level of care giv ers Total Basic or lower level of educati on Secondar y or higher level of educati on Whether ORS was given prio r to the hospi tal visit Yes Count 44 20 64 Ex pected Count 44.7 19.3 64.0 % withi n Whether ORS was given befo re hospi tal 68.8% 31.2% 100.0% % withi n Educati onal level of care give rs 54.3% 57.1% 55.2% % of Total 37.9% 17.2% 55.2% No Count 37 15 52 Ex pected Count 36.3 15.7 52.0 % withi n Whether ORS was given befo re hospi tal 71.2% 28.8% 100.0% % withi n Educati onal level of care give rs 45.7% 42.9% 44.8% % of Total 31.9% 12.9% 44.8% Total Count 81 35 116 Ex pected Count 81.0 35.0 116.0 % withi n Whether ORS was given befo re hospi tal 69.8% 30.2% 100.0% % withi n Educati onal level of care give rs 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 117 Use of ORS by caregi vers * Educational level of caregi vers Chi -Square Test Value df Asymp. Sig. (2 - si ded) Exact Sig. (2 - si ded) Exact Sig. (1 - si ded) Pear son Chi - Squar e .079 a 1 .779 Cont i nuit y Cor r ecti on b .006 1 .939 Likel i hood Rati o .079 1 .779 Fisher 's Exac t Test .840 .470 Line ar - by - Line ar Ass ociati on .078 1 .780 N of Vali d Cases b 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 15.69. b. Comput ed onl y for a 2x2 tabl e Note: From the result of the Chi -S quare Tests , the Pearson Chi -S quar e which is 0.079 is associated with a signifi cant level of 0.779 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the v alu e of 0.779 is greater than th e apha value of 0.05, so it can be concluded that the result is not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 118 APPENDIX M Cross-tabu lation and chi-square test : Respondents’ education vs. correct use of ORS K now ledge in the correct use of ORS * Educational level of caregi vers Cross -tabul at ion Educati onal level of car egi ver s Tot al Basi c or lower level of educ at i on Secondar y or higher level of educ at i on Knowledge in the corr ect use of ORS adequat e knowl edge Count 12 7 19 Expected Count 13.3 5.7 19.0 % wit hi n Knowl edge in the cor rect use of ORS 63.2% 36.8% 100.0% % wit hi n Educati onal level of car egi ver s 14.8% 20.0% 16.4% % of Total 10.3% 6.0% 16.4% Some knowl edge Count 52 17 69 Expected Count 48.2 20.8 69.0 % wit hi n Knowl edge in the cor rect use of ORS 75.4% 24.6% 100.0% % wit hi n Educati onal level of car egi ver s 64.2% 48.6% 59.5% % of Total 44.8% 14.7% 59.5% No knowl edge Count 17 11 28 Expected Count 19.6 8.4 28.0 % wit hi n Knowl edge in the cor rect use of ORS 60.7% 39.3% 100.0% % wit hi n Educati onal level of car egi ver s 21.0% 31.4% 24.1% % of Total 14.7% 9.5% 24.1% Tot al Count 81 35 116 Expected Count 81.0 35.0 116.0 % wit hi n Knowl edge in the cor rect use of ORS 69.8% 30.2% 100.0% % wit hi n Educati onal level of car egi ver s 100.0% 100.0% 100.0% % of Total 69.8% 30.2% 100.0% University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 119 K now ledge in the correct use of ORS * Educational level of caregi vers Chi -Square Tests Value df Asymp. Sig. (2 - si ded) Pear son Chi - Squar e 2.508 a 2 .285 Likel i hood Rati o 2.481 2 .289 Line ar - by - Line ar Ass ociati on .168 1 .682 N of Vali d Cases 116 a. 0 cel ls (.0%) have expected count les s than 5. The mini mum expe ct ed count is 5.73. Note: From the result of the Chi -S quare Tests , the Pearson Chi -S quar e which is 2.508 is associated with a signifi cant level of 0.285 (as pr esented in the colum n la beled As ymp. Sig [2 - sided] ). To be si gnificant the P-value needs to be 0.05 or small er. In thi s ca se, the valu e of 0.285 is greater than th e apha value of 0.05, so it can b e concluded that the result is not significant. University of Ghana http://ugspace.ug.edu.gh Diarrhoea Management 120 APPENDIX N Mann Whitney test: Relation sh ip betw een health insu rance and duration of illn ess Mann-Whitney Test Ranks Whe ther have val i d healt h insur ance N Mean Rank Sum of Ranks Dur ati on at home befor e presenti ng at hospit al Yes 58 51.05 2961.00 No 58 65.95 3825.00 Tot al 116 Test Stati stics a Durati on at home befor e pres ent i ng at hospit al Mann - Whi t ney U 1250.000 Wil coxon W 2961.000 Z - 2.521 Asymp. Sig. (2 - t ai l ed) .012 a. Groupi ng Var iable: Whether have val i d healt h insur ance Note: From the test result , the Mann -W hit ne y U, which is 1250.000 is associated with a significant l evel of 0.01 2 (as pr esented in the colum n labeled As ymp. Sig [2 -sided] ). To be significant the P-v alue needs to be 0. 05 or small er. In thi s case, the valu e of 0.012 is small e r than the apha value of 0. 05, so it can be conclud e d that the result is signifi cant. 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