DIARRHEA ACCOUNTS FOR HIGH LEVELS OF MORALITY IN YOUNG CHILDREN IN DEVELOPING COUNTRIES IN NIGERIA

CHAPTER ONE

Introduction

Background to the Study

Diarrhoea accounts for high levels of mortality in young children in developing countries like Nigeria, despite worldwide efforts to improve overall child health levels. Each year, in the developing countries of Asia, Africa and Latin America, approximately five million children under five years of age die from acute diarrhoea. About 80 per cent of these deaths are in the first two years of life (Lucas & Gilles, 2009) In the developing world as a whole, about one-third of infant and child deaths are due to diarrhoea and approximately 70 per cent of diarrhoeal deaths are caused by dehydration – the loss of large quantity of water and salts from the body, which needs water to maintain blood volume and other fluids to function properly (Gupta & Mahajan, 2005). UNICEF (2002) submitted that in Nigeria, infant mortality rates are twice as high in rural settings as they are in urban ones due to poor hygiene and poor sanitation. Of the annual 3 million infant births in Nigeria, approximately 170,000 result in deaths that are mainly due to poor knowledge and management practices of childhood diarrhoea. Several factors are likely to contribute to the very high diarrhoea morbidity and mortality rates, in children under-five years including poverty, female illiteracy, poor water supply and sanitation, poor hygiene practices and inadequate health services (Park, 2009). Malnutrition is another established risk factor for mortality among children with diarrhoea disease. This may be due to inadequate case management. The first line of management of diarrhoea, is therefore, the prevention of dehydration. This can be achieved at home using Oral Rehydration Therapy (ORT).

Diarrhoea is the disturbance of the gastrointestinal tract comprising of changes in intestinal motility and absorption, leading to increase in the volume of stools and in their consistency (Ballabriga, Hilpert & Isliker, 2000). In diarrhoea, stool contains more water than normal stool and is often called loose or watery stool. In certain cases, they may contain blood in which case the diarrhoea is called dysentery (Obionu, 2001). Any passage of three or more watery stools within a day (24 hours) is referred to as diarrhoea (Tauxe, 1997). The consistency and the volume of stool constitute how to classify diarrhoea.

World Health Organization – WHO (1993) classified diarrhoea as acute or persistent based on its duration. An episode of diarrhoea that lasts less than two weeks is acute diarrhoea, while diarrhoea that lasts more than two weeks is persistent. Morley (2000) further classified diarrhoea according to its typology: Secretary diarrhoea, osmotic diarrhoea and exudative diarrhoea. Secretary diarrhoea results from active process in the intestinal epithelium stimulated by the presence of toxin, chemical or nutritional product in the intestinal linning. Osmotic diarrhoea is caused by the presence of the intestinal linning of osmotically active solutes that are poorly absorbed by the injection of laxatives such as magnesium sulphate or magnesium hydroxide. Exudative diarrhoea is associated with damage to the mucosa lining leading to outpouring of mucus, blood and plasma protein among other substances. However, it is important to note that the classification of diarrhoea does not influence the cause.

Diarrhoea is a symptom of infection caused by a host of bacterial, viral and parasitic organisms most of which can be spread by contaminated water. Diarrhoea in most cases is caused by three major groups of micro-organisms namely; Viruses, bacteria and protozoa or parasites (Lucas & Gilles, 2009). The main agents of diarrhoea according to them are enteroviruses (e.g. rotavirus, escherichia coli, campylobacter spp, shigella, vibrio cholera, salmonella (non typhoid), entamoeba histolytica, giardia lamblia, cryptosporidium). These are further grouped in the following ways: Viruses (e.g. Rota virus); Bacteria (e.g. shigella, escherichia coli, vibrio cholerae, salmonella non typhoid, campylobacter spp). Parasites (e.g. entamoeba histolytica, crytosporidium and giardia lamblia). All over the world, viruses especially rotavirus has been identified as the major cause of acute diarrhoea in children. Studies in Nigeria also found viruses as the major causes of diarrhoea in 60 per cent of cases with bacteria responsible for about only 3-20 per cent. Most of these pathogens are transmitted by faeco-oral route. Childhood diarrhoea within the context of this study refers to any type of loose, watery stool that occurs more frequently than usual in a child. The various causative agents vary according to the signs and symptoms manifesting from the disease.

The main consequence of diarrhoea are frequent loose or watery stools, the risk of dehydration, damage to intestine (especially when there is bloody diarrhoea) and loss of appetite with or without vomiting. However, Victoria, Bryce, Fountaine and Monasch (2000) asserted that signs of dehydration are not evident until there is acute fluid loss of approximately 4-5 per cent of body weight. The signs and symptoms of dehydration include sunken fontanelle, dry mouth and throat, fast and weak pulse, loss of skin elasticity and reduced amount of urine. This loss leads to shock and untimely death of under-five. Werner (2001) noted that dehydration takes its heaviest toll on infants and children under-five. The signs and symptoms according to Longmach, Wilkinson and Rajagopalan (2004) are passage of frequent loose watery stools, abdominal cramps or pain, fever particularly if there is an infectious cause and bleeding. Bacteria and parasites often can produce bloody diarrhoea (dysentary). In addition, inflammatory bowel disease, polyps and colorectal cancer can cause blood and mucus in the stools, nausea and vomiting may also be present in the case of infection.

The main dangers of diarrhoea are dehydration and malnutrition (WHO, 1993). Dehydration according to WHO is most often caused by loss of a large amount of water and salt from the body, while malnutrition can be caused by an inadequate diet due to poverty, a lack of appropriate foods or incorrect beliefs about feeding, frequent infections of which diarrhoea is one of them.

Spradley and Allender (1996) stated that the most common modes of transmission of diarrhoea are contaminated food and water, dirty feeding utensils (especially feeding bottles and teats) and the faecally contaminated fingers of the infants or the mother. Infection occurs through ingesting food contaminated with adequate doses of Salmonella, and Shigella or E. Coli. The cycle begins when the infectious agent multiplies and grows in the food medium. The agent subsequently invades the host upon ingestion of the food.

There are other physical modes of transmission of diarrhoea as identified by the United Nations Children’s Fund – UNICEF (1998). These include: poor source of water supply, especially in rural areas; poor environmental sanitation leading to attitudinal problems of defecating in open spaces, pit latrine, bushes and in the streams (used for drinking and bathing). Feeding bottle is also a feature of infection (Federal Rebublic of Nigeria – FRN 2002). Lucas and Gilles (2009) also maintained that transmission of diarrhoea occurs by the faecal-oral route due to poor standards of personal and environmental hygiene. These conditions will determine the seriousness of infection of diarrhoea. The most important aspect of managing a child with diarrhoea are preventing or treating dehydration and maintaining good nutrition.

These preventive practices according to WHO (1993) include breast feeding, improved weaning, use of plenty of water for hygiene and clean water for drinking, hand washing, use of latrines, proper disposal of the stools of young children, use of Oral Rehydration Therapy (ORT) and Oral Rehydration Solution (ORS) and immunization against measles. Cutting (1994) stressed that drinking extra fluid in the early stages of diarrhoea is crucial in preventing dehydration and subsequent death. He also noted that the combination of giving more fluid than usual as soon as diarrhoea starts and continuing feeding is an effective home therapy for acute diarrhoea. The knowledge and practice of these becomes necessary for the mothers in the issues of childhood diarrhoea.

Traditionally, mothers are expected to spend most of their time in the house, looking after their children and carrying out other domestic functions. It may be right and natural, therefore, that the first person to manage a diarrhoea episode at home is possibly the mother. Mothers on this basis have been identified as the most important people involved in the management of childhood diarrhoea, hence mothers are used for this study. Landy (1992) referred to them as the key persons and managers of the home. She asserted that people, especially mothers possess adequate knowledge about their baby’s health and disease prevention. Thus, they are recognized as very important persons for the smooth running of the family, including supervision of health of their children. Macleans (1998), on his own part, accorded mothers the traditional responsibility of looking after their children with regard to weaning and nursing care. This, according to him, is because of their being close to their children. This situation is similar to the relationship between mothers and their children in Ezeagu LGA. As asserted by Davely and Wilson (1981) and Bethann, Gopel, Douglas and Lynn (1992), literate mothers are better able to look after their children than non-literate ones. Thus, those who possess the appropriate knowledge are more likely to be able to take the appropriate action to protect their children especially the under five (childhood).

According to Hodges (2001) childhood is a period of rapid physical growth, including the development of the brain almost to its full adult size, and is also a critical period for the development of the cognitive functions. He further added that the key factors for child growth and development are adequate care, good health, nutrition and stimulation. Inadequate nutrition and care in the first few years of life can seriously interfere with brain development and lead to such neurological and behavioural disorders as learning disabilities (Bargley, 1996). Childhood in the context of this study means the condition or period of being a child or a young human being below the age of five. The knowledge of adequate and quality childhood care could lead to healthiness of the child in terms of prevention of early childhood diseases like diarrhoea.

Knowledge according to Winifred (1989) is accumulated facts, truth, principles and information to which human mind has access. Knowledge can be defined as the sum of conceptions, views and propositions which has been established and tested (Conforth, 1996). The Nigerian Education Research Council – NERC (1982) asserted that an educated and knowledgeable person is one who understands, among other things the basic facts concerning health and disease and protects his or her own health and that of the community. WHO (1995) also maintained that if a person is well informed in the area of health, he or she would be able to reject practices that imperil his or her health. The individual will also be well equipped to make the right decision concerning the children and family, and will play active role in improving the society in which the person lives. In the context of this study, knowledge refers to the act of having adequate information and understanding of the concept, signs and symptoms, modes of transmission and management practices of diarrhoea by the child bearing mothers. Adequate or high level knowledge of the concepts, signs and symptoms, mode of transmission of diarrhoea is capable of guaranteeing proper management practices of diarrhoea among children.

Management according to Osinem (2008) is the co-ordination of all the resources of an organization through the process of planning, organizing, directing and controlling in order to attain organizational objectives. Koontz and Weighrich (2005) described management as the process of designing and maintaining an environment in which individuals working together in groups efficiently accomplish selected aims. Management as defined by wikipedia, the free Encyclopaedia (2007) is the art and science of getting things done through others. It can also refer to the person who performs the act of management. Management in this context involves childbearing mothers doing or producing something like proper breastfeeding, washing feeding bottles, washing plates and hands, keeping the environment clean and producing oral rehydration solution to cope with childhood diarrhoea. Ekenedo (1994) noted that there was a relationship between knowledge and management practice adopted by mothers. She concluded that better life will not come from mere acquisition of knowledge but from its practice.

Practice, according to Hornby (2001) is a way of doing something that is common or habitual; it is a way of doing something or expected way in a particular situation. Funks and Wagnalls (2003) defined practice as any customary action or proceeding regarded as individuals habit. Sally (2004) further defined practice as an established way of doing things especially one that developed through experience and knowledge. When management relates to practice, it becomes management practice.

Bucher (1994) perceived management practice as the application of good health actions to ones daily living such as proper personal hygiene and nutrition. In this study, management practices refer to all the actions that are undertaken by mothers to avert childhood diarrhoea. There are many such management practices.

WHO (1993) identified a number of management practices and these are: breast feeding, Oral Rehydration Therapy(ORT), weaning practices, use of plenty of water for hygiene and use of clean water for drinking, hand washing, use of latrines, safe disposal of stools of young children and measles immunization. Early knowledge and practice of these in the home may increase the chances of its efficacy and likely reduce complications following diarrhoea. It is most likely that mothers who are the home-makers will make use of them in order to save their children when they are informed. Okafor (1993) opined that women are better able to understand information and follow instructions if their level of education and information should be raised. The way of determining if women possess adequate knowledge regarding childhood diarrhoea is to assess the level of knowledge they possess about the aspects of the disease.

Level of knowledge and practice can be ascertained in numerous ways. Ashur (1977) opined that a proportion of less than 40 per cent correct response should be taken as indicator of low level of knowledge, 40 – 59 per cent is considered average and 60 – 80 per cent is considered high, while over 80 per cent is regarded as very high level of knowledge. Okafor

modified Ashur’s four scales of measurement into five scales by carving two levels that is, 10-20 per cent as “very low” and 21-39 per cent as “low” out of Ashur’s proportion of less than 40 per cent described as “low” level of knowledge. The Ashur’s (1977) principle was adopted in the present study to determine the knowledge and management practices of childhood diarrhea by mothers in Ezeagu L.G.A.

This study was carried out in Ezeagu L.G.A of Enugu State, with its headquarter at Aguobu Owa. The inhabitants of the area are mainly farmers, civil servants and traders. The possible sources of water supply range from the use of stream, tanker water to the occasional use of tap water. They also use rain water during rainy seasons. General environmental sanitation is poor as there are no facilities for refuse disposal. They make use of open refuse dumps to dispose of refuse – dumping them into nearby bushes, burn them or dumped by the roadside. They use pit latrines and nearby bushes for sewage disposal. However, some well- to-do families make use of water closet system. Some are literate while others are not. The sociodemographic factors that may influence this study include; education, age and parity of the women. This is because an educated mother might use health information more than the uneducated counterparts (Okafor, 1993). Their age and parity also differed and might have conferred different levels of experience which may also affect the management of childhood diarrhoea. Studies such as those of Rao, Vinod, Mishra and Rutherford (1998), which revealed that more educated women were more likely than less educated women to manage diarrhoea in children. Ekenedo (1994) found that age and parity level might affect the rate at which childhood diarrhoea is managed. This revelation which was made by Ekenedo (1994) Sixteen years ago and confirmed by Rao et al (1998) – might have influence on mothers in Ezeagu LGA where the present study will be carried out.

The desire to effect change in behaviour for reducing the risk of future illness according to Philips (1991) should be based upon theoretical models that identify predictors of behavioural change. Several models or theories concentrate on the significance of socio- cognitive variables in preventive health. Theoretical models relevant to childhood diarrhoea knowledge and management practices among mothers in the context of the present study will include the following: health action process approach, systems management theory and self efficacy theory.

The extents to which mothers in Enugu state portray their knowledge and management practice of childhood diarrhoea do not appear to have received adequate research attention. This cannot be less true about mothers in Ezeagu LGA. Finding out these, certainly, will represent a positive step forward in the effort to promote the childhood diarrhoea knowledge and management practices. Following from these therefore, one is then inclined to ask, what is the level of knowledge possessed by mothers in Ezeagu LGA of Enugu state towards the childhood diarrhoea and what management practices do they adopt? The above in essence, represent the reason of this study.

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