Behavior of urban based child caretakers in the home treatment of diarrheal diseases

Behaviors of low income urban mothers and child caretakers in the treatment of childhood less than 5 year diarrhea were analysed from a surveillance study conducted between August 1988 and July 1989. Help seeking behaviors of mothers and caretakers for 412 episodes of child diarrhea were as follows: investigators 37.1%, drug stores 18.2%, wait and see or self treatment 17.0%, private clinics 12.6%, near by hospital 10.2%, and local health center 4.9%. Major treatment practices included ORT alone (54%) and ORT plus antibiotics and/or antidiarrheal drug (22%). Overall ORT usage was 76%. Twelve percent of diarrheal episodes no treatment was given to the children. Antimicrobials were believed to be essential in addition to ORT especially when diarrhea was associated with fever, vomiting and bloody stools. Thirty-six percent of invasive diarrhea cases (Shigella, Salmonella, Campylobacter) were treated with antibiotics. Only 18.2% of noninvasive diarrhea received antibiotics, most of this antibiotic use being in rotavirus diarrhea where vomiting and some fever are prominent. Availability of oral rehydration salts (ORS) and good experience with ORT were the key to the extensive use or ORT in this study. A surprisingly small number of mothers and child caretakers (4.9%) sought help from the local health center when their children had diarrhea.     

The management of diarrhoea in young children in a rural community in Zambia

Among 64 mothers in two villages in a rural Zambian population who reported childhood diarrhoea, 41 (64%) sought treatment from a health centre or clinic. Among these, 22 (54%) were given oral rehydration salts (ORS) and 19 (46%) were given medications other than ORS. Among the 23 who did not attend a health centre, 14 gave home remedies which included salt and sugar solution, of which, in five, the medicines used were from traditional healers. Overall, 43 (67.2%) of the mothers used some fluids as the first line of treatment. The fluids were infrequently given and in almost all instances, irrespective of the source of the fluid, no more than 15 ml were given over a 24 h period. Furthermore, among the mothers who used fluids, 28 (65.1%) reported stopping the fluids completely if the child vomited. None of the mothers however reported completely withdrawing food from the children. Age and educational level of the mother were not significant factors (P greater than 0.05). These findings suggest that education of mothers on home management of diarrhoea and the proper use of ORS needs to be re-emphasized and health care personnel need to be fully conversant with currently recommended methods for treatment of childhood diarrhoea.     

Community case management of childhood diarrhea in a setting with declining use of oral rehydration therapy: findings from cross-sectional studies among primary household caregivers, Kenya, 2007

We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management.     

Declining impact of oral rehydration therapy in a Papua New Guinea Highlands Province: a case study with implications for Papua New Guinea's National Diarrheal Disease Control Program.

A provincial diarrheal disease control program that was based on the delivery of oral rehydration solution (ORS) from health facilities now places greater emphasis on the management of diarrhea with fluids at home. The change in strategy has been associated with decreasing utilization of health facilities and increasing mortality from diarrheal disease. The declining impact is attributed to the promotion of home-based management with little preparation of the target population for their therapeutic role. National policy recommends home-based management for mild cases of diarrhea and ORS for more severe cases. Our observations in the Southern Highlands Province have important implications for the diarrheal disease control program in Papua New Guinea.     

Risk Factors for Diarrhea in Children under Five Years of Age Residing in Peri-urban Communities in Cochabamba,Bolivia

This study examined the relationship between childhood diarrhea prevalence and caregiver knowledge of the causes and prevention of diarrhea in a prospective cohort of 952 children < 5 years of age in Cochabamba, Bolivia. The survey of caregiver knowledge found that more than 80% of caregivers were unaware that hand washing with soap could prevent childhood diarrhea. Furthermore, when asked how to keep food safe for children to eat only 17% of caregivers reported hand washing before cooking and feeding a child. Lack of caregiver awareness of the importance of practices related to hygiene and sanitation for diarrhea prevention were significant risk factors for diarrheal disease in this cohort. The knowledge findings from this study suggest that health promotion in these communities should put further emphasis on increasing knowledge of how water treatment, hand washing with soap, proper disposal of child feces, and food preparation relate to childhood diarrhea prevention.     

Causes of childhood diarrhea as perceived by mothers in the Punjab,Pakistan

This study was carried out in the southern Punjab, Pakistan, to outline the causes of childhood diarrhea as perceived by mothers. Two hundred households in ten villages were randomly selected. Information was obtained from mothers, through a questionnaire, in-depth interviews, and direct observations. The focus was on obtaining information from mothers of children who were below five years of age. Causes of diarrhea reported by mothers were categorized in seven different domains. Causes relating to the digestive system, especially consumption of too much food, were the most important, followed by causes pertaining to contamination and those pertaining to the humoral theory of 'hot' and 'cold'. The mothers' health status was perceived as determining the health of her child through her breast milk. Through in-depth interviews, diarrhea as a symptom of envy and malice was brought up. The study draws attention to the complexity and heterogeneity of beliefs, attitudes and practices concerning diarrhea. This makes it difficult to come up with general rules for health education campaigns. Rather, in health education, the outstanding 'good' and 'bad' behavior should be selected and should be the focus. On the other hand, the heterogeneity of beliefs, attitudes and practices prevailing in the community could make mothers more receptive to new ideas than when a small set of rigid cultural norms would dominate thinking on disease transmission and hygiene. The study found that despite the mother's central role as caretaker one should not focus only on the traditional mother-child relationship, but also include the husband-wife relationship, and target other individuals involved in setting norms within the household or within the nearby community.     

Continuum of care for maternal, newborn, and child health: from slogan to service delivery

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.     

Immunisation coverage among children born to HIV-infected women in Rakai district, Uganda: Effect of voluntary testing and counselling (VCT)

To evaluate the impact of maternal HIV-infection on routine childhood Immunisation coverage, we compared the Immunisation status of children born to HIV-infected and HIV-uninfected women in rural Uganda. The study population was 214 HIV(+) and 578 HIV(-) women with children aged 6 to 35 months previously enrolled in a community study to evaluate maternal and child health in Rakai District, Uganda. Sampling of subjects for interview was stratified by the use of voluntary counselling and testing (VCT) service so that the final sample was four groups: HIV + /VCT+ (n = 98); HIV + /VCT- (n = 116); HIV - /VCT+ (n= 348); HIV - /VCT- (n = 230). The main outcome measure was the percent of complete routine childhood Immunisations recommended by the WHO as assessed from Immunisation cards or maternal recall during household interviews. We found that Immunisation coverage in the overall sample was 26.1%. For all vaccines, children born to HIV-infected mothers had lower Immunisation coverage than children born to HIV-negative mothers (21.3 vs. 27.7%). There was a statistically significant interaction between maternal HIV-infection and maternal knowledge of HIV-infection (p = 0.034). The children of mothers who were HIV-infected and knew their serostatus (HIV + /VCT + ) had a more than two-fold odds of underImmunisation (OR = 2.21, 95% CI: 1.14, 4.29) compared to children of mothers who were HIV - /VCT-. We conclude that maternal HIV-infection was associated with childhood underImmunisation and this was mediated by a mother's knowledge of her HIV status. HIV VCT programmes should encourage HIV-infected mothers to complete childhood Immunisation. Improving access to Immunisation services could benefit vulnerable populations such as children born to HIV-infected mothers.     

Ethnic disparities in clinical severity and services for alcohol problems: results from the National Alcohol Survey

BACKGROUND: This study reports lifetime estimates of the extent of unmet need for alcohol services across the 3 largest ethnic groups in America, and examines factors that may contribute to ethnic differences in service use. Prior studies report mixed findings as to the existence of ethnic disparities in alcohol services, with some suggesting that minorities are over-represented in treatment settings. METHODS: Drawing on the most recent National Alcohol Surveys, we compare rates and factors associated with the lifetime service use for alcohol problems among Whites, Blacks, and Hispanics who meet lifetime criteria for alcohol abuse or dependence. RESULTS: While bivariate analyses revealed few ethnic differences in service use, there were significant differences by ethnicity in multivariate models that included alcohol problem severity and its interactions with ethnicity. At higher levels of problem severity, both Hispanics and Blacks were less likely to have utilized services than comparable Whites. Hispanics, on the whole, reported higher-severity alcohol problems than Whites. Yet, they were less likely to have received specialty treatment and multiple types of alcohol services, and were more likely to cite economic and logistical barriers as reasons for not obtaining care. CONCLUSIONS: Future efforts to study ethnic disparities in alcohol services should utilize analytic approaches that address potential confounding between ethnicity and other factors in service use, such as alcohol problem severity. Our findings suggest that Hispanics and Blacks with higher-severity alcohol problems may utilize services at lower rates than comparable Whites, and that, particularly for Hispanics, this may in part be attributable to financial and logistical barriers to care.     

Migration and immunization: determinants of childhood immunization uptake among socioeconomically disadvantaged migrants in Delhi, India

Objective To determine the coverage of childhood immunization appropriate for age among socioeconomically disadvantaged rural–urban migrants living in Delhi and to identify the determinants of full immunization uptake among these migrant children. Methods This is a cross‐sectional survey of 746 rural–urban migrant mothers with a child aged up to 2 years, who were interviewed with a pretested questionnaire. Data pertaining to the reception of various vaccines, migration history and some other social, demographic and income details were collected. Multiple logistic regression analyses were performed to identify the determinants of full immunization status. Results Immunization coverage rates were lower among migrants than the general population of Delhi and even lower among recent migrants. The likelihood of a child receiving full immunization rose with age of the mother, her educational attainment and the frequency of her use of health care. The head of household having a secured salaried job also significantly increased the likelihood of full immunization, as did post‐natal visits by a health worker. Conclusion Migrant status favours low immunization uptake particularly in the vulnerability context of alienation and livelihood insecurity. Services must be delivered with a focus on recent migrants; investments are needed in education, socio‐economic development and secure livelihoods to improve and sustain equitable health care services.     

The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups

Ethnic minorities living in high‐income countries usually exhibit a greater risk of developing diabetes along with higher morbidity and mortality rates. We evaluated the effectiveness of interventions to improve glycaemic control in ethnic minority groups. Results of major controlled trials, systematic reviews and meta‐analyses were included in the review. Only 1/47 studies addressing diet and exercise interventions reported details on the ethnicity of the studied population. Self‐management education was successful if associated with increased self‐efficacy; delivered over a longer period; of high intensity; culturally tailored; and when using community educators. Strategies adopted in community‐gathering places, family‐based, multifaceted, and those tackling the social context were likely to be more effective. A positive relationship was found between social support and self‐management behaviour as well as quality of life, but there is little evidence about the impact of organizational changes within health‐care services on diabetes control. More research is needed to strengthen the evidence on effective strategies for response to diabetes in ethnic minorities. Also, there is a need to take into account diabetes beliefs and communication difficulties, as well as potential protective factors. Globally, many health‐care systems are inadequately equipped to improve diabetes prevention and disease outcomes in these communities. Copyright © 2010 John Wiley & Sons, Ltd.     

Drinking water quality, feeding practices, and diarrhea among children under 2 years of HIV-positive mothers in peri-urban Zambia

In low-income settings, human immunodeficiency virus (HIV)-positive mothers must choose between breastfeeding their infants and risking transmission of HIV or replacement feeding their infants and risking diarrheal disease from contaminated water. We conducted a cross-sectional study of children < 2 years of age of 254 HIV-positive mothers in peri-urban Zambia to assess their exposure to waterborne fecal contamination. Fecal indicators were found in 70% of household drinking water samples. In a multivariable analysis, factors associated with diarrhea prevalence in children < 2 years were mother having diarrhea (adjusted odds ratio [aOR] = 5.18, 95% confidence interval [CI] = 1.65-16.28), child given water in the past 2 days (aOR = 4.08, 95% CI = 1.07-15.52), child never being breastfed (aOR = 2.67, 95% CI = 1.06-6.72), and rainy (versus dry) season (aOR = 4.60, 95% CI = 1.29-16.42). Children born to HIV-positive mothers were exposed to contaminated water through direct intake of drinking water, indicating the need for interventions to ensure microbiological water quality.     

Risk factors for child mortality in rural Tanzania

We conducted a community-based nested case-control study of post-neonatal deaths in children under 5 years, with frequency-matched controls chosen from a full sampling frame provided by a demographic surveillance system. Using a questionnaire, we studied treatment-seeking behaviour in fatal illness. In cases and controls we investigated demographic and socio-economic factors, health-seeking behaviour, the household environment including accessibility of health care, and individual child care factors. Half of the deaths (215/427) occurred at home, and one-third (146/427) at a health facility. Three-quarters (330/427) of the children who died had received treatment from a health facility in their fatal illness. Four independent risk factors for death were identified which were each associated with more than 5% of child mortality: not being carried on the back while the mother cooked [odds ratio (OR) 1.6: 1.3, 2.0], poor maternal education (OR 1.4: 95% CI 1.0, 1.9 for those with no education compared with those with complete primary education), lack of exclusive breastfeeding in the first 3 months of life (OR 1.4: 1.1, 1.8), and low socio-economic status (OR 1.3: 1.0, 1.6). The majority of children who died had sought treatment at a health facility during the fatal illness, which would lend support to interventions to improve case-management. The association between mothers carrying their children and child survival was unexpected and deserves further investigation.     

Dietary management during pregnancy, lactation and common childhood illnesses in rural Bangladesh

Data were collected on nutritional aspects of women in general and during special time frames such as pregnancy, lactation and common childhood illnesses (diarrhea, acute respiratory infections and measles) from rural areas in Bangladesh. A distinctive gender bias was evident regarding decision making and food allocation within the household. Inadequate feeding practices were observed during diarrhea with 22.2% of the mothers discontinuing breast-feeding. Breast-feeding and nutritional support were comparatively better during ARI and measles. When the children were ill, 97% of the mothers administered a special diet with a variety of food preferences, which were perceived to improve the symptoms of the respective illness. Maternal education influenced both the occurrence of diarrhea and the nutritional management of diarrhea and measles significantly. Therefore, community health education should focus on the importance of breast-feeding and continued nutritional support during illnesses. In order for this health education to be effective, traditional beliefs noted in this study have to be incorporated.     

Antimicrobial use in children under five years with diarrhea in a central region province, Thailand

This cross-sectional study aimed to estimate the prevalence of appropriate antimicrobial prescribing for treating childhood diarrhea within the public hospital system in a central region province, Thailand. Reported are findings of a prospective clinical audit of 424 cases treated by 38 physicians. Appropriate use of antimicrobials was defined as prescribing antimicrobials for managing an invasive bacterial-type, bloody diarrhea or not prescribing antimicrobials for managing a watery-type or non-bloody diarrhea. Among 424 cases with diarrhea, 12.5% were invasive bacterial-type. Of the 66 diarrheal episodes in which stool samples were cultured, 7 stool specimens were positive, two with Shigella sonnei, two with Vibrio cholerae Ogawa and three with E. coli. Based on the presence of mucus and blood in stools, 27.4% of 424 cases received appropriate antimicrobial drugs. Cotrimoxazole was the most commonly prescribed drug (51%), followed by colistin sulfate (15.3%), norfloxacin (11%), and nalidixic acid (0.5%). The average number of antimicrobials per case of inpatients was higher than outpatients (1.15 vs 0.84, p < 0.001). There was a trend toward prescribing norfloxacin in childhood diarrhea. The Ministry of Public Health should continue providing effective interventions aimed at improving physicians' knowledge of diarrhea treatment. Similar efforts should be directed toward improving caretakers' knowledge about home care for childhood diarrhea and encouraging widespread correct use of oral rehydration therapy (ORT) in the community. Hopefully, such activities will help reduce the inappropriate use of antimicrobial agents in treating diarrheal disease.     

The treatment of acute diarrhea in the third millennium: a pediatrician's perspective

Diarrheal diseases continue to be a major cause of morbidity and mortality worldwide. Although new, potentially useful drugs such as acetorphan are appearing at the horizon, the cornerstone of treatment remains a proper oral rehydration (ORT). Yet, the rates at which ORT is used are still disappointingly low. Despite dramatic progresses in the understanding of the pathophysiology of diarrhea, the list of available drugs is indeed short. Recently however, several new options have appeared that may bear a great potential in the near future. The first is a potential improvement of ORS. It was recently shown that the addition of a resistant starch to oral rehydration solution reduces fecal fluid loss and shortens the duration of diarrhea in patients with cholera. Starches that are resistant to hydrolysis by amylase in fact generate in the colon short-chain fatty acids, which are known to enhance sodium absorption. The second development in treating diarrheal disease is acetorphan (racecadotril). This enkephalinase inhibitor has in fact been shown to be effective in reducing by almost half the stool output of 135 young children with acute diarrhea. Finally, probiotics. In the last few years, they have attracted a great deal of renewed interest, particularly focusing on their effects in treating and preventing diarrheal diseases. Lactobacillus GG proved effective in several clinical trials, mostly randomized and placebo-controlled, in the prevention and/or treatment of acute diarrheal disease in children. We have recently shown (6) the safety and efficacy in its administration in the ORS, especially in Rotavirus-induced diarrheas, in a large multicenter, randomized, double blind and placebo-controlled study conducted on behalf of the ESPGHAN Working Group on Acute Diarrhea.     

The use of oral rehydration solutions in children and adults

The observation that the intestinal Na⁺-glucose cotransporter remains intact in most diarrheal illnesses led to development of the life-saving, low-cost technology of oral rehydration salt (ORS) solutions. The primary therapeutic role of ORS solutions is in prevention and treatment of dehydration during management of acute gastroenteritis. Successful oral rehydration therapy involves early use of ORS with maintenance or timely resumption of regular feeding. Since the inception of the oral rehydration approach more than three decades ago, the widespread use of ORS solutions has revolutionized the management and outcomes of acute gastroenteritis in children and adults. The efficacy of the World Health Organization ORS solution and of commercial ORS formulations has been enhanced by reducing osmolarity. Newer formulations of ORS are under active investigation, with promise of added benefits, including promotion of intestinal healing. This article reviews fluid and electrolyte transport in the gastrointestinal tract, the pathophysiologic mechanisms of acute diarrhea, and the basis and formulation of current and newer ORS solutions. Guidelines for efficacious use of ORS in the management of acute gastroenteritis and short gut syndrome are also provided.     

Psychological distress and engagement in HIV-related services among individuals seeking mental health care

In the US, HIV-related mental health care has been funded for its ability to help engage and retain individuals living with HIV into other components of HIV-related care and treatment. However, little is known empirically about the types of HIV prevention and care with which they are, or need to be, connected. To explore this, data were collected from 617 individuals upon their self-enrollment in HIV-related mental health care in a large US city with high rates of HIV infection. Nearly a third of the participants (n=195) were "minimally engaged" in care services, 53% were "moderately engaged" and 15.6% were "highly engaged". There were significant differences between level of care engagement according to one's ethnicity, X(2)(4, n=617)=38.05; p<.001; Cramer's V=.18, with African-Americans and Latinos more likely to be highly engaged in care services compared to their Caucasian counterparts. Furthermore, individuals who were highly engaged in services had significantly lower levels of depression than their less engaged peers, F(2, 614)=8.18; p<.001; eta(2)=.03. Results suggest that while ethnic minorities were engaged in a higher number of care services, they were enrolling in mental health care following enrollment in other care services. Given the numerous benefits of engaging in HIV-related mental health early in the course of infection, it is important that case managers and primary care physicians educate African-Americans and Latinos on the benefits of mental health care in order to facilitate earlier engagement in HIV-related mental health services.