European Journal of Cardiovascular Medicine

Diarrhoea is one of the most common cause for childhood mortality among children under the age of five worldwide. Nearly one in five child deaths is due to diarrhea, a loss of about 1.5 million lives each year. Africa and South Asia are home to more than 80 per cent of child deaths due to diarrhea¹. When the WHO initiated the Diarrheal Diseases Control Programme in 1980, approximately 4.6 million children used to die each year of the dehydration caused by diarrhea. Diarrhea is still a major killer of children under five, although its toll has dropped by a third over the past decade.

In India, around 1.7 million children died before reaching the age of 5 years in 2010 , and more than half of them (52%) die in the first month of life itself . The major causes of death in under-fives globally are pneumonia (17%), diarrhea (16%), malaria (7%), measles (4%), AIDS (2%), others (13%)². Acute diarrhea disease accounts for about 8% of deaths in under five years’ age group.

Displacement of populations into temporary, overcrowded shelters is often associated with polluted water sources, inadequate sanitation, poor hygiene practices, contaminated food and malnutrition – all of which affect the spread and severity of diarrhea ³. Improvements in access to safe water and adequate sanitation, along with the promotion of good hygiene practices (particularly hand washing with soap), can help prevent childhood diarrhea. An estimated 88% of diarrheal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene ⁴.

Optimal infant and young child feeding practices could prevent more than 10% of deaths from diarrhea and acute respiratory infections^5,6. The low coverage of ORT in India has been seen as a major reason for higher rates of diarrhea deaths in children⁷. Only 6% of rural residents in India have access to improved sanitation, and about 69% practice open defecation ⁸.

Promotion of behavior change in the community is necessary for the safe storage and handling of water and food. Interventions to make water safe for drinking by simple methods like boiling or chlorination, feeding only hygienic and freshly prepared or well cooked food needs to be promoted through strong behavioral change communication (BCC) and information, education and communication (IEC) efforts.  In view of the above, the present study was conducted to study the effect of information, education and communication (IEC) in prevention and control of diarrheal diseases among preschool children in the rural practice area.

1. To assess the knowledge and practices related to management of childhood diarrhoea in mothers of pre-school children .

2. To provide IEC to mothers of pre-school children on prevention and control of diarrheal diseases.
3. To assess the effect of IEC provided to the mothers of pre-school children on prevention and control of diarrhea.

An Interventional study was conducted in the rural field practice area of VIMS & RC, Bengaluru between March 2014 to March 2015. Mothers of all pre-school children

attending anganwadis regularly were included in the study and mothers of severely ill children and who were irregular to anganwadis were excluded.

Sample size calculated is 126 with prevalence rate of diarrhoea in India in under five children as 9% and expected reduction rate in prevalence of diarrhoea in under five children is 10% .

A total of 130 children enrolled in all 4 anganwadis of rural field practice area of VIMS & RC were included in the study. 4 children were lost to follow up due to migration.

Consent was taken from mothers of all pre-school children prior to the study and were interviewed through pre-tested semi structured questionnaires. Information on the knowledge, beliefs and practices will be taken as base line data and IEC was given to the mothers on the prevention and control of diarrhoeal disease in under five children through focal group discussions and interpersonal communication such as Handwashing practices, Purification of drinking water, Proper storage of drinking water, Practice of exclusive breast feeding, Initiation of complementary feeding after 6 months of age, Continuation of breastfeeding atleast up to 2 years of age, Complete immunization of the child, Proper disposal of human excreta and waste, Avoidance of open air defecation and use of sanitary latrines.

Mothers were also educated about diarrhoea as a disease, its causes, its signs and symptoms and how to identify warning signs of dehydration and when to take the child to the health facility.

Mothers were educated to give increased amounts of easily available home fluids such as lemon juice, buttermilk, rice ganji etc to their children during diarrhoea. They were taught how to prepare ORS at home with ORS sachets supplied at the health facilities.

AV aids used in the form of demonstration, posters, charts and PowerPoint presentations. Participatory communication through interactive sessions on prevention and control of diarrhoeal diseases in under five children are thought as a priority. Information education communication was given in the form of interpersonal communication and focal group discussions

Follow up was done for 1 year with every 3months IEC and an assessment was made every 3 months through post-test questionnaires.

Data was analysed using MS Excel , SPSS version 21 and Open Epi version 3.0

Data analysis is done by using Chi Square Test, Mc Nemars Chi-square test to find out associations.

Out of 126 mothers of pre-school children 77 (61.1%) belongs to the age group of 20-25 years, 44 (34.9%) belongs to 26-30year and 5 (4%) belongs to 31-35year.

Among 126 mothers, 69 (54.8%) completed high school, 34 (27%) completed higher primary, 12 (9.5%) studied up to PU, 6 (4.8%) completed primary, 3 (2.4%) were illiterate and 2 (1.5%) were graduates.

Table 1: Education status of mother and occurrence of diarrhoea in child

The present study shows that the there is a strong association (p<0.01) between the education status of the mother and occurrence of diarrhea in the child.

Only 33(26.2%) out of 126 mothers were employed and others are home-makers.

Out of 126 families, 49 (38.9%) belonged to upper lower class, 39 (31%) lower middle class, 21 (16.7%) upper middle class, 11 (8.7%) lower class and 6 (4.8%) upper class according to Kuppuswamy classification.

Among 126 children 37 (29.4%) were in age group 13-24 months, 32 (25.4%) in 25-36 months, 24 (19%) in 37-48 months, 18 (14.3%) in 1-12 months and 15 (11.9%) in 49-60 months. Out of 126 children 71 (56.3%) were females and 55 (43.7%) were males.

Out of 126, 98 (77.8%) of children were normal according to their weight for age in this study. 19(15.1%) children were found to be moderately underweight and 9(7.1%) children were severely underweight.

In this study, 122 (96.8%) mothers practiced exclusive breastfeeding and 4 (3.2%) did not. 31(24.6%) mothers continued breastfeeding the child till 1 year of age, 89(70.6%) mothers continued breastfeeding the child from 1 to 2years and 6(4.8%) continued breastfeeding the child for more than 2 years. 

120 (95.2%) children out of 126 were started on complementary feeding after 6 months and 6 (4.8%) children were started on complementary feeding before 6 months of age and 23(18.3%) children were bottle fed by their mothers out of 126 children.

Table 2: Distribution of mothers according to the source of drinking water

For drinking purpose, 83 (65.9%) houses used tap water, 32 (25.4% ) used bore well water and 11 (8.7%) used mineral water

Table 3: Distribution of  mothers according to drinking water storage practice

At the beginning of the study 30 (23.8%)  out of 126 participants kept the drinking water container open and 96 (76.2%) kept the drinking water container closed. There was 19.8% increase in the number of mothers who stored drinking water with lid closed after an IEC at the end of the study which is statistically significant.

Table 4: Distribution of mothers according to practice of boiling water before consumption

In this study out of 126, 80 (63.5%) mothers boiled water before drinking and 46 (36.5%) did not. The practice of boiling water before drinking was seen to improve in the first, second, third and fourth quarterly assessments by 4.8%, 10.3%, 22.2% and 27.8% respectively as compared to the initial assessment which is statistically significant.

Whereas, in a cross-sectional study conducted by Priti Chaudhary et al in an urban slum in New Delhi shown that 36% mothers followed any household purification method of drinking water ⁹.

Table 5: Distribution of subjects according to knowledge related to diarrhoea

The knowledge among mothers regarding diarrhoea was only 35% at the beginning of the study was seen to improve in the first, second, third and fourth quarterly assessments by 57.1%, 68.2%, 72.2% and 72.2 % respectively as compared to the initial assessment which is statistically significant with p = <0.001.

The knowledge among mothers regarding common occurrence of diarrhea in under five children was 93% in the beginning of the study, seen to improve statistically in the first, second, third and fourth quarterly by 16.7%, 26.2%, 26.2% and 26.2 % respectively as compared to the initial assessment with p= < 0.001

Similarly, the knowledge among mothers regarding diarrhea prevention was 94.4% at the beginning of the study was also seen to improve statistically by 5.6% in the first quarterly assessment as compared to the initial assessment with p=< 0.001.

Whereas in a cross-sectional study conducted by Priti Chaudhary et al in an urban slum in New Delhi shown that 96% of the mothers interviewed, defined diarrhoea appropriately ⁹

Table 6: Distribution of mothers according to knowledge regarding feeds given

during diarrhea

The knowledge among mothers regarding whether the child should be breastfed during diarrhoea was 96% in the beginning was seen to improve after an IEC i;e 100% achieved at the end of the study and the knowledge among mothers regarding whether the child should be given complementary feeds during diarrhoea was 92.9%,  seen to improve in the first quarterly assessment by 7.1% and achieved 100% at the end of the study with p valve <0.05

Table 7: Distribution of mothers according to knowledge regarding ORS

In this study 97 (77%) mothers were aware that they should give ORS to the child during an episode of diarrhea and 29 (23%) mothers were not aware and 53(42.1%) mothers knew how to make ORS at home whereas 73(57.6%) mothers were not known.

A study conducted by Ogunrinde OG et al in Northwest Nigeria found that less than 1% of the caregivers were knowledgeable about home management of diarrhoeal diseases and 8.6% about ORS use¹⁰.

Amit K. Singh et al in their study conducted in Garhwal, Uttarkhand found that 43% of the mothers interviewed gave ORS to their children during diarrhoea, 73% of the mothers believed that the frequency of feeding must be decreased at the time of diarrhoea and most of the mothers did not know the correct method of preparation of ORS¹¹ whereas Mohammed Salman Shah et al in their non-invasive interventional study in Aligarh, India found that 69% of the mothers continued breastfeeding their children during an episode of diarrhoea, 46.5% of the mothers knew about ORS and only 29.8% knew the correct method of preparation of ORS¹².

In the present study, the knowledge among mothers regarding the correct method of preparation of ORS at home was seen to improve in the first, second, third and fourth quarterly assessments by 37.3%, 46%, 48.4% and 53.9% respectively as compared to the initial assessment which is statistically significant with p value <0.001

Table 8: Distribution of mothers according to health seeking behavior during an

episode of diarrhea

The number of mothers who knew the appropriate time to take the child to the health facility during an episode of diarrhoea was 31(24.6%) at the beginning of the study, increased to 62.7% at the end of the study. This was seen to improve in the first and second quarterly assessments by 59.5% and 62.7% respectively as compared to the initial assessment following which all the mothers (100%) had knowledge regarding the same.

A study conducted by Anne-Laure Page et al found that 70.4% (95% CI: 66.6 – 74.1) reported health seeking care at a health structure and less than 10% of the children were brought to the hospital¹³.

Yasmin Mumtaz et al in their study shown that 114(90.5%) mothers took their child to a health facility during an episode of diarrhea and 4(3.2%) mothers did not take their children to any health facility, 70(55.6%) mothers took their children to a private clinic and 48(38.1%) mothers took their children to a government hospital¹⁴ whereas FC Barros et al in their study conducted in Brazil found that 66% of the children were not given any treatment for diarrhoea, 14% respondents used government health services, 1% visited a private doctor and 24% visited traditional healers¹⁵.

Bhatia V et al in a cross-sectional study conducted in Chandigarh found that only 54.8% of the children were given ORS during diarrhoea, 86.7% of the mothers were aware of ORS and 18.7% mothers knew the correct method of preparation of ORS¹⁶

In the present study 31(24.6%) mothers said that a child with diarrhea can be taken to a health facility at any time, 48(38.1%) mothers said that a child with diarrhea should be taken to a health facility immediately and 47(37.3%) mothers said that a child with diarrhea should be taken to a health facility when the danger signs appear.

According to Huda M. Haroun et al in their study it was found that knowledge of mothers about definition of diarrhea, its danger, when to seek medical help and the three rules of home management (increase in fluids, continuation of feeding and getting medical care) which was found to be 35%,28%,13% and 29% improved significantly after intervention to 91%, 94%,92% and 93% respectively with a very high significant level¹⁷.

The present study was an interventional study conducted in Kannamangala rural field practice area of Vydehi Institute of Medical Sciences and Research Centre . The study was carried out for a period of one year from March 2014 to March 2015. Objectives of the study were (1) to assess the knowledge and practices related to management of childhood diarrhoea in mothers of pre-school children, (2) to provide IEC to mothers of pre-school children on prevention and control of diarrhoeal diseases and (3) to assess the effect of IEC provided to the mothers of pre-school children on prevention and control of diarrhoea.

Study was conducted among 130 mothers of children in the under-five age group attending the anganwadis under Kannamangala rural field practice area,   Bengaluru. Consent was taken prior to the study. Over a period of one year, following the intervention, 4 mothers were lost to follow up due to migration.

In the present study, out of 126 mothers majority of the mothers (61.1%) belonged to the age group of  20-25 years, 94.4% of the mothers were hindu, 54.8% of the mothers were educated upto class 8 to 10 and 73.8% mothers were unemployed. Majority of mothers(70%) were from families belonging to lower middle and upper lower socio economic class.

The present study shows that the education status of the mother has an important role in the occurrence of diarrhea in the child. There is a strong association (p<0.01) suggesting that the education status of the mother was highly associated with the occurrence of diarrhea in the child. Thus it is important to educate mothers about diarrhea and how to prevent complications such as severe dehydration during diarrhea

By the end of the study period and following educational intervention all the mothers (100%) had knowledge regarding diarrhea, prevalence of diarrhea in under five children, importance of continuation of breastfeeding and complimentary feeding during an episode of diarrhea, importance of giving ORS to the child during an episode of diarrhea, the correct method of preparation of ORS at home and the need for taking the child to a health facility when the danger signs of dehydration appear.

This shows that through an effective IEC the knowledge, attitude and practices of the mother on diarrhea can be improved. Through interpersonal communication, as done in this study , mothers in this study were made aware of how to prevent this disease by adopting simple and healthy practices .

The study included only those children attending the anganwadis in the rural field practice area. There were no control groups taken in the study to conclude that the observed improvement in knowledge and practices regarding diarrhoea and its prevention was only because of the educational intervention.

• To create awareness not only among mothers but also among women in the reproductive age group regarding common infectious diseases prevalent in under five children.
• Knowledge regarding diarrhoea especially hand hygiene practices can be imparted to mothers as early as during ANC checkups, post-natal visits, during immunization visits for the child etc.
• The training to be given to all healthcare providers at each level regarding the common infectious diseases prevalent in under five children and on how to educate mothers on prevention of these diseases.

Conflict of Interest: Both authors were working in Vydehi Institute of Medical Sciences and Research Centre, Bengaluru during study period.

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