• No results found

Mothers’ treatment seeking behavior for children with diarrhea: a cross-sectional study in Zambia

N/A
N/A
Protected

Academic year: 2022

Share "Mothers’ treatment seeking behavior for children with diarrhea: a cross-sectional study in Zambia"

Copied!
39
0
0

Loading.... (view fulltext now)

Full text

(1)

Mothers’ treatment seeking behavior for children with diarrhea: a cross-sectional study in Zambia

Helena Dahl

Självständigt arbete – Folkhälsovetenskap GR (C) Huvudområde: Folkhälsovetenskap

Högskolepoäng: 15p Termin/år: HT-2020 Handledare: Koustuv Dalal Examinator: Katja Gillander Gådin Kurskod: FH038G

(2)

Abstract

Introduction: According to WHO, diarrhea disease is the second leading cause of death worldwide for children under five. Around 525 000 children under five are killed every year by diarrhea. Most deaths from diarrhea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa. With a

comprehensive strategy that ensures all children in need receive critical prevention and treatment measures it is possible to save the lives of millions of children at risk of death from diarrhea. The aim of this study was to identify what kind of treatment has been given to under-five children with symptoms of diarrhea and what kind of care the respondent sought in Zambia, a low-income country.

Method: A cross-sectional study with secondary data from Zambia Demographic and Health Survey (ZDHS). The first-born child under five with diarrhea the last two weeks was selected in this study, to analyze what kind of treatment was given when showing symptoms of diarrhea. Out of the first-born children (n=7048) we found that 1 289 children had diarrhea during the last two weeks before the survey.

Result: Of children having diarrhea 80% received some kind of treatment. Thirty eight percent of the children with diarrhea symptoms was given zinc and 67% was given pre-packaged Oral Rehydration Solution (ORS). The first place to seek treatment for the child’s diarrhea was at the Government Health Center (66%) followed by 18% that sought treatment at the Government Health Post.

Conclusion: This study showed that the treatment and care seeking behavior for caregivers to under-5 children with diarrhea is of public health concern. Less than half of the children receives zinc as a treatment and 67% receives prepacked ORS. There is a need for education and awareness on the efficacy of ORS and especially zinc in preventing diarrhoea mortality and contribute to the UN Sustainable Development Goals target 3.2.

Key words: care-seeking, diarrhea, child under five, diarrhea, treatment, rural/urban, Zambia.

(3)

Abstrakt

Introduktion: Enligt WHO är diarré den näst största dödsorsaken för barn under fem år. Cirka 525 000 barn under fem år dör varje år till följd av diarré. De flesta dödsfall på grund av diarré inträffar bland barn under 2 år som bor i Sydasien och Afrika söder om Sahara. Med en omfattande strategi som säkerställer att alla barn i nöd får

förebyggande åtgärder och rätt behandling är det möjligt att rädda miljontals barns liv som riskerar att dö på grund av diarré. Syftet med denna studie var att identifiera vilken typ av behandling som har givits till barn under fem år med diarré och vilken typ av vård respondenten sökte i Zambia, ett låginkomstland.

Metod: En cross-sectional study med andrahandsdata från Zambia Demographic and Health Survey (ZDHS). Det förstfödda barnet under fem, som haft diarré under de senaste två veckorna, valdes ut för att analysera vilken behandling barnet fick. Utav de förstfödda barnen (n=7048) hade 1 289 barn haft diarré de två senaste veckorna.

Resultat: Av barnen med diarré fick 80% någon form av behandling. Trettioåtta procent av barnen med diarré fick zink och 67% fick förpackad Oral Rehydration Salt.

Det första stället att söka behandling för barnets diarré var på Government Health Center (66%) följt av 18% som sökte behandling på Government Health Post.

Slutsats: Denna studie visade att behandling och sökande av behandling för barn under fem år med diarré var ett folkhälsoproblem. Mindre än hälften av barnen får zink som behandling och 67% behandlas med ORS. Det finns ett behov av utbildning och information om effekten av ORS och speciellt zink för att förhindra barndödlighet vid diarrésjukdomar och därmed bidra till Agenda 2030 mål 3.2.

Nyckelord: barn under fem, behandling, diarré, landsbygd/urban, söka behandling, Zambia

(4)

Table of Contents

Abbreviations……….4

Background………5

Definition of diarrhea………...6

Treatment of diarrhea………..…7

Zinc………...…...7

ORS………..……...8

Zambia………...….9

Heath care in Zambia………...………..10

Public health relevance ………...…………..12

Rationale………...………13

Aims and objectives……….14

Method………..15

Sample for this study……….15

Ethical consideration………...17

Result………18

Care seeking ………...…..21

Treatment ………..23

Discussion……….28

Result discussion………...28

Method discussion……….31

Conclusion………33

References………34

(5)

Abbreviations EA Enumeration area GH Government Hospital GHC Government Health Center GHP Government Health Post MOH Ministry of Health

LMIC Low- and middle-income country ORS Oral rehydration solution

ORT Oral rehydration therapy

RHF recommended home fluids SSA Sub-Saharan Africa

SDG Sustainable Development Goal U5MR Under Five Mortality Rate

UNICEF The United Nations Children's Fund

USAID United States Agency for International Development WHO World Health Organization

ZamStats Zambia Statistics Agency

ZDHS Zambia Demographic and Health Survey

(6)

1. Background

For children under five, diarrhea disease is the second leading cause of death.

Around 525 000 000 children under five are killed every year by diarrhea (WHO, 2017). Diarrhea kills more children than AIDS, malaria and measles combined (Liu et al. 2013). Most deaths from diarrhea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa. Even though the heavy toll, progress is being made. From 2000 to 2017, the total annual number of deaths from diarrhea among children under 5 decreased by 60 per cent. Through basic interventions many more children could be saved (UNICEF, 2006).

In low- and middle-income countries, diarrheal diseases are more prevalent, largely as a result of lack of safe drinking water, sanitation and hygiene, as well as poorer overall health and nutritional status (WHO/UNICEF, 2015).

Diarrhoea can last several days which can leave the body without the water and salts that are necessary for survival. Children exposed to poor environment conditions as well as poor nutritional status and overall health, are more susceptible to severe diarrhea and dehydration than healthy children. Water constitutes a greater proportion of children’s body- weight, which makes children at greater risk than adults of life-threatening dehydration, also the kidneys of young children are less able to conserve water compared to older children and adults (WHO/UNICEF, 2009).

However, it is both preventable and treatable. Many children’s lives can be saved with correct management of childhood diarrhea. With safe drinking- water and adequate sanitation and hygiene together with right treatment

significant proportion of death due to diarrhea can be prevented (WHO, 2017).

(7)

Definition of diarrhea

According to WHO (2017) diarrhea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not diarrhea, nor is the

passing of loose, "pasty" stools by breastfed babies. WHO has argued that there could be four types of diarrhea:

Acute watery diarrhea (including cholera), which lasts several hours or days:

the main danger is dehydration; weight loss also occurs if feeding is not continued;

Acute bloody diarrhea, which is also called dysentery: the main dangers are damage of the intestinal mucosa, sepsis and malnutrition; other complications, including dehydration, may also occur;

Persistent diarrhea, which lasts 14 days or longer: the main danger is

malnutrition and serious non-intestinal infection; dehydration may also occur;

Diarrhea with severe malnutrition (marasmus or kwashiorkor): the main dangers are severe systemic infection, dehydration, heart failure and vitamin and mineral deficiency.

Diarrhea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking-water, or from person-to-person as a result of poor hygiene.

Treatment of diarrhea

There is an increased loss of water and electrolytes (sodium, chloride,

(8)

potassium, and bicarbonate) during diarrhea in the liquid stool. Water and electrolytes are also lost through vomit, sweat, urine and breathing (WHO, 2005). When these losses are not replaced adequately, and a deficit of water and electrolytes develops - dehydration occurs. Tough most episodes of childhood diarrhea are mild, acute cases can lead to significant fluid loss and dehydration. This dehydration can lead to death unless fluids are quickly replaced (WHO/UNICEF, 2009). Many of the diarrheal deaths are caused by dehydration.

In 2004, WHO and UNICEF issued a joint statement on clinical treatment of acute diarrhea, recommending the use of low osmolarity oral rehydration salts (ORS), zinc supplementation, increased amounts of appropriate fluids, and continued feeding. The recommendations are

- Oral rehydration solution (ORS), a solution of clean water, sugar and salt.

- In addition, a 10-14-day supplemental treatment course of dispersible 20 mg zinc tablets shortens diarrhea duration and improves outcomes.

However, other study shows that population coverage for this basic but

effective intervention is still very low, particularly in countries that are hardest hit by diarrheal diseases. In SSA, only about one in three children experiencing diarrhea episodes receives ORS, and the proportion receiving zinc is below 5%

(UNICEF, 2015).

Zinc

According to WHO (2005) several studies have now shown that zinc

supplementation (10-20 mg per day until cessation of diarrhoea) significantly reduces the severity and duration of diarrhoea in children less than 5 years of

(9)

20 mg per day for 10 to 14 days) reduces the incidence of diarrhoea for 2 to 3 months.

Zinc is recommended (10-20 mg/day) be given for 10 to 14 days to all children with diarrhea (WHO, 2005).

Oral Rehydration Solution

OSR contains salts and sugar, which help the child to absorb water to replace what is lost during diarrheal episodes. WHO and UNICEF have for more than 25 years recommended a single formulation of glucose-based ORS to prevent or treat dehydration from diarrhea. OSR has contributed substantially to the dramatic global reduction in mortality from diarrheal disease during this period (WHO 2005, Roth et al. 2018).

Treatment of diarrhea with ORS is a simple, proven, high-impact intervention that can be provided in home settings by caretakers or by health care-providers at community and facility levels to prevent dehydration due to diarrhea and decrease related deaths. There is evidence that ORS may reduce diarrhea specific mortality by up to 93% (Munos, Fischer, Christa & Black, 2010).

Important additional components are continued feeding, including breastfeeding, during the diarrhea episode and use of appropriate fluids available in the home if ORS are not available (UNICEF/WHO, 2009). In response to low ORS coverage for children with diarrhea, in the 1980s, WHO promoted the use of so-called recommended home fluids (RHF) in addition to ORS. To refer to treatment with ORS or RHF the expression Oral rehydration therapy (ORT) was used (Victora, Bryce, Fontaine & Monasch, 2000). ORS can be prepared at home and it is a simple treatment used to prevent mortality due to dehydration and undernutrition in children with diarrhea (Das, Salam &

Bhutta, 2014). In areas where intravenous fluids are scarce or unavailable it is especially suitable and replaces indiscriminate and unnecessary use of

antibiotics to treat diarrhea (Das, Lassi, Salam, & Bhutta, 2013).

(10)

Zambia

Zambia is a former British colony situated in Sub-Saharan Africa. In 1964 Zambia gained independence and while it is today a democratic republic, the country has, for most of its independence, been under one-party rule. Zambia consists primarily of Bantu-speaking people representing nearly 70 different ethnicities. Administratively Zambia is divided into nine provinces with Copperbelt, Lusaka and Eastern being the most populous. The total population of Zambia is 17 426 623 (CIA, 2020).

Zambia was for several years one of the most successful economies in Africa, up until the economic crisis in 2015, and has for a long time been seen as a role model in the region thanks to its peaceful and democratic development.

However, Zambia faces a major challenge since being one of the most unequal countries in the world. The economic growth in the country did not benefit the majority of the people, inequalities are particularly obvious in terms of urban versus rural areas of the country and between the genders (CIA, 2020, Swedish Government, 2018).

Approximately 55% of the country’s population are living in poverty, but in rural areas the figure is over 75%. Almost 4% of the population live in extreme poverty (Swedish Government, 2018). Some of the serious problems that challenge the country is those of food insecurity, malnutrition and an unbalanced diet, leading to an unusually high proportion of children with stunted growth. However, some progress has been made in health and education, and life expectancy has risen substantially. Population growth is high. Areas such as economic empowerment, education, health, sexual and reproductive health and rights (SRHR) and political participation are lacking gender equality and are therefore serious barriers to development. The key to

(11)

achieving long-term sustainable and inclusive socioeconomic development is buy reducing inequality (Swedish Government, 2018).

The political climate has worsened and polarization in the country has

increased since the election in 2016. In a way that is unusual for Zambia since it has remained relatively stable as a country in the region from a conflict perspective. The democratic space has shrunk and the respect for human rights has worsened, particularly in terms of freedom of expression and freedom of the media. With a growing burden of debt and a large state deficit, there is a need for economic diversification, reforms and macroeconomic stability. Poor people are particularly affected badly by corruption and shortcomings in terms of accountability. Unemployment among the young part of the population is high (Swedish Government, 2018).

A functioning agricultural sector and markets are key to development, but at the same time climate change and unsustainable use of natural resources have a serious effect on the agriculture-dependent poor population and weakens their resilience. The economic development is hampered since the access to

renewable and sustainable energy for the poor rural population is very limited (Swedish Government, 2018).

Health care in Zambia

According to Government of the Republic of Zambia et al. (2015) the major causes of child mortality in Zambia are malaria, respiratory infections, diarrhea, malnutrition and anemia. Diarrhea is the third largest killer of under five children in Zambia and it is estimated that 15 000 die every year as a result of the disease (CIDRZ, 2015).

UN IGME (2020) reports that Zambia has an under-five mortality rate of 57.8%. In Zambia 13% of all deaths of children between 1–59 months are attributable to diarrhea (Chilengi, Simuyandi & Beres, 2017).

(12)

For both primary and secondary care, the health care in Zambia is facing major challenges. Absence of trained health personnel, limited access to and

knowledge of sexual and reproductive rights and services, and high

malnutrition among pregnant women and children are some of the problem areas (Zambian Government, 2011).

A report that presents the List of Health Facilities in the country (MoH, 2012) shows 1 956 health facilities recorded in Zambia. Eighty-eight percent of the health facilities in the country are Government owned, 13% are owned by private health facilities and 6% are owned by faith-based health facilities.

5 levels of health care in Zambia according to List of Health Facilities in the country (MoH 2012).

Health Centre

There are two types of health centers in the health care delivery system in Zambia. These include urban health centers or clinics (UHC), which serve a catchment population of between 30,000 to 50,000 people; and Rural Health Centre (RHCs)s, which a population of 10,000 people. In 2012, there were 409 Urban Health Centres and 1 131 Rural Health Centres in the country.

Health Posts

These are the lowest levels of health care and are built in communities far away from health centers. They cater for a catchment population of approximately 3,500 in rural areas and 1,000 to 7,000 in the urban settings and are set up within a 5 km radius for sparsely populated areas. The types of health services offered at this level are basic first aid rather than curative. There are 307 Health Posts in the country Third Level Hospitals

Third level hospitals also called Specialist or Tertially Hospitals are the highest referral hospitals in Zambia. These hospitals cater for a

catchment population of approximately 800,000 and above, and have sub- specializations in internal medicine, surgery, pediatrics, obstetrics, gynecology, intensive care, psychiatry, training and research. All complicated cases not attended to at second level hospitals are referred to third level hospitals. In 2012, there were 6 Third Level Hospitals in the country.

Second Level Hospitals

(13)

Second level hospitals, also referred to as Provincial or General

Hospitals, are found at provincial level. They are intended to cater for a catchment area of between 200,000 and 800,000 people, with services in internal medicine, general surgery, pediatrics, obstetrics and

gynecology, dental, psychiatry and intensive care services. These hospitals also act as referrals for the first level institutions, including the provision of technical back up and training functions. In 2012, there were 19 Second Level Hospitals in the country.

First Level Hospitals

First level hospitals, also referred to as District Hospitals are found at district level. In 2012, there were 84 First Level Hospitals in the country.

Public Health relevance

Since diarrhea disease is the second leading cause of death for children under five around the world with approximately 525 000 children under five are killed every year by diarrhoea, it is a public health concern.

Children living in poor or remote communities are most at risk and evidence shows children are dying from these preventable diseases because effective interventions are not provided equitably across all communities (WHO, 2013).

The Sustainable Development Goal (SDG) 3 target to “Ensure healthy lives and promote well-being for all at all ages” and also promotes that SDG aims to be significant to all countries – poor, rich and middle-income.

To achieve the SDG 3.2, which targets to end preventable deaths in newborn and under-five children by 2030 there must be a decrease in child mortality due to diarrheal diseases (SDG-report, 2015).

(14)

Rationale

Globally, around 525 000 children under five are killed every year by diarrhea.

Only 44% of children with diarrhea in low-income countries receive the recommended treatment (WHO/UNICEF, 2013). With a comprehensive strategy that ensures that all children in need will receive critical prevention and treatment measures it is possible to save the lives of millions of children at risk of death from diarrhea (UNICEF/WHO, 2009).

If children’s lives can be saved with correct management of childhood

diarrhea, it is high relevance to focus on what kind of treatment the child gets and what kind of care seeking actions the caregivers are taking. Treatment of diarrhea and care seeking behavior is important to understand to be able to prevent and implement right treatment actions, to reduce the risk for children under five of dying from diarrhea

(15)

Aims and objectives

The purpose of this study was to identify what kind of treatment has been given to under-five children with symptoms of diarrhea and what kind of care the mothers sought, in Zambia.

Study objectives:

1. What proportion of children showing symptoms of diarrhea get treatment, and what are the given treatments?

2. Where do mothers seek treatment?

3. How many children with symptoms of diarrhea were given zinc and/or ORS respectively?

4. Does the treatment for diarrhea differ regarding geographical and socioeconomic factors?

(16)

Method

Secondary data from the 2018 Zambia Demographic and Health Survey (ZDHS) was used. The survey was implemented by the Zambia Statistics Agency (ZamStats) in collaboration with the Ministry of Health (MOH). Data collection was conducted from 18 July 2018 to 24 January 2019.

The Zambian survey had a stratified two-stage sample design. The first stage involved selecting sample points (clusters) consisting of enumeration areas (EAs). EAs were selected with a probability proportional to their size within each sampling stratum. A total of 545 clusters were selected. The respondents lived in following regions; Central, Copperbelt, Eastern, Luapula, Lusaka, Muchinga, Northern, North Western, Southern and Western.

The systematic sampling of households was conducted in the second stage. In all of the selected clusters a household listing operation was undertaken. An average of 133 households were found in each cluster during the listing, from which a fixed number of 25 households were selected to obtain a total sample size of 13,625 households which is representative at the national, urban and rural and provincial levels.

Eligible to be interviewed were all women and men age 15-59 who were either permanent residents of the selected households or visitors who stayed in the households the night before the survey. Response rate for the survey was 96.4%.

Sample

The first-born child under five was selected for the purposes of the current study, to analyze what kind of treatment was given when showing symptoms of diarrhea. Out of the first-born children (n=7048) we found that 1 289 children had diarrhea during the last two weeks before the survey. The mother of the

(17)

child has provided the information concerning the child’s health.

Internal missing was 28% (n = 357) due to missing responses in the following two variables: “Place first sought treatment for diarrhea” and “How many days after the diarrhea began did you first seek treatment or advice?”

Variables of interest

Diarrhea: Showing symptoms of diarrhea, the last two weeks before the survey.

Rural/ urban: Living residence.

Economic status: The economic status of the household was measured with the Wealth Index. The Wealth Index is calculated using easy-to-collect data on a household's ownership of selected assets, for example radio, television and bicycle and also materials used for housing construction; and types of water- access and use of sanitation facilities. The individual households are placed on a continuous scale of relative wealth from which groups are created that define wealth quintiles as; poorest, poorer, middle, richer and richest.

Number of days after diarrhea for respondent to seek treatment or advice First health care facility the respondent sought treatment at (for example health post or hospital)

If receiving treatments What kind of treatments If receiving ORS and/or zinc

Data analysis

The sample, consisting of quantitative data from the ZDHS, has been analyzed in IBM SPSS Statistics version 25, looking at the different variables

concerning treatment and comparing those findings with recommended treatment by WHO/UNICEF and earlier research.

(18)

In the data analysis, cross tabulations were used to analyze the relationship of the treatment children received with the demographic factors such as

rural/urban living, economic status of the household. A chi-square test was used, and the significant level has been presented in the same table. A chi- square test is used when the study has two independent groups with data at a nominal level. It is based on the expected value compared with what was observed in a cross table (Björk, 2012).

Ethical Considerations

Secondary deidentified data was used for this study, hence obtaining ethical approval was not necessary. However, the survey has received ethical permission from the National ethical committee in Zambia. All ethical rules were strictly adhered and followed.

(19)

Results

Eighteen percent (n=1 289 children) of the first-born child had diarrhea during the last two weeks before the survey whereas 80.6% (n=5 759) did not.

Figure 1. Firstborn children from 13 595 households who had diarrhea the last two weeks before the survey.

Figure 2 shows that of the total sample (n=13 595) 60% were living in rural areas and 40% were living in urban areas.

0 1000 2000 3000 4000 5000 6000 7000

No Yes Do not know

(20)

Figure 2. Living residence (urban/rural) for the total sample (n=13 595)

Of the children that had had diarrhea the last two weeks, 30% were living in urban areas compared to 70% of the children living in rural area (Figure 3).

Figure 3. Living residence (urban/rural) for children having diarrhea.

Figure 4 shows the economic status from poorest (21%) to the riches (21%) of

40%

60%

Urban Rural

30%

70%

Urban Rural

(21)

Figure 4. Economic status of the households for the total population.

Figure 5 shows the economic status of the household for the children showing symptoms of diarrhea during the last two weeks. 32% of the children with diarrhea was living in the poorest households, 20% in middle-income household and 11% in the richest household.

(22)

Figure 5. Economic status of household for the children having diarrhea.

Care seeking

The same day that the child showed diarrhea symptoms 25% sought treatment or advice. However, most of the respondents (39.4%) answered that they sought treatment or advice the following day (figure 6).

At some point during the first three days, 88.2% had sought treatment or advice.

(23)

Figure 6. Number of days with diarrhea for respondent to seek treatment or advice.

Figure 7 shows that the first place to seek treatment for the child’s diarrhea is at the Government Health Center (GHC). 66% sought treatment at the GHC followed by 18% that sought treatment at the Government Health Post (GHP).

Nearly 90% answer that their first choice to seek treatment is at some

Government institution: Government Health Center, Government Health Post or Government Hospital (GH).

0 50 100 150 200 250 300 350 400

The same

day

1 2 3 4 5 6 7 10

(24)

Figure 7. First place the respondent sought treatment

Treatment

Eighty three percent of the respondents answered that the children with diarrhea received any type of treatment (figure 8). 71% answered that the treatment was medical treatment.

Of the ones seeking treatment or advice outside their home, almost everybody 98% responded that they had received medical treatment. 17% of children with diarrhea received no treatment at all.

62 607

168

5 26 3 6 24 9 1 9 5 4 1 2

0 100 200 300 400 500 600 700

(25)

Figure 8. Chidren that recives treatment

Figure 9 is showing what type of treatment that was given. The respondents gave the children with diarrhea symptoms different treatments. Some gave their children not only one but several types of treatments. 67% was given pre- packaged ORS liquid or/and oral rehydration, 38% was given zinc, 20% was given recommended home solution, 17% was given antibiotic pills or syrup and 6% was given antimotility.

Under 5% of the children was given antibiotic injection, intravenous, home remedy, herbal medicine, non-antibiotic injection, unknown injection and/or other (not antibiotic, antimotility, zinc).

17%

83%

No treatment Any treatment

(26)

Figure 9. Type of treatment

Zink and ORS

Of the children with diarrhea symptoms during the last two weeks 38% was given zinc while 67% were given pre-packed ORS liquid.

There was no significant geographical difference in receiving ORS (Table 1).

Also shown in Table 1, there was no difference in economic status in ORS treatment.

0 100 200 300 400 500 600 700 800 900 1000

(27)

Table 1. Comparison of children given pre-packed ORS and demographics.

Type of place of residence No Yes Don't know

Urban 30.1% (n=116) 69.9% (n=269) 0% (n=0)

Rural 34.3% (n=310) 65.6% (n=593) 0.1% (n=1)

P-value

Econimc status No Yes Don't know

Poorest 34.3% (n=140) 65.4% (n=267) 0.2% (n=1)

Poorer 32.2% (n=97) 67.8% (n=204) 0% (n=0)

Middle 35.3% (n=91) 64.7% (n=167) 0% (n=0)

Richer 29.3% (n=54) 70.7% (n=130) 0% (n=0)

Richest 31.9% (n=44) 68.1% (n=94) 0% (n=0)

P-value

0,275

0,821

Given pre-packed ORS

The chi-square test from table 2 showing relationship between zinc and residence shows that it is not significant at the 0,556 level, at the same

table showing relationship between zinc and economic status we found that it is significant at the 0,035 level.

Of the respondents that took their child to the GHC 52% received zinc as a treatment for their child and 86% had pre-packaged ORS liquid as treatment for their child.

(28)

Table 2. Comparison of children given zinc and demographics.

(29)

Discussion

Result discussion

The prevalence (18%) of diarrhea exposed in this study is comparable with that of earlier studies (Kanté, Gutierrez, Larsen, Jackson, Helleringer & Exavery, 2015, Benson, Sepiso & Hikabasa, 2020).

The results show 67% of the children that had had diarrhea during the last two weeks were given pre-packaged ORS liquid. UNICEF’s survey shows that in 2000 only 34% of children younger than 5 years in low-income and middle- income countries (LMICs) received ORS to treat diarrhea. In 2016, the proportion increased to 44%, yet the majority remained untreated (UNICEF, 2016). In many low-income countries, ORS for treatment of diarrheal diseases in children has been reported to remain below 50%, despite available evidence meaning that scaling up the use of ORS is a cost-effective way to highly reduce preventable child death (Andrus, Cohen, Carvajal-Aguirre, El Arifeen &

Weiss, 2020).

Children with diarrhea should be treated with ORS, if not available then with other fluids to help prevent dehydration (even though they are not as effective in treating children who are already dehydrated). Breastmilk is also an

excellent rehydration fluid, which should be given to children still

breastfeeding along with ORS. Children with diarrhoea should continue to be fed, in addition to fluid replacement, during the episode (UNICEF, WHO 2009).

In this study we see that more than half of the children gets treated with ORS.

However, it is still 33% of the children with diarrhea that does not get ORS. Of the children, in this study, taken to the GHC 86% received pre-packaged ORS

(30)

liquid as treatment. In high-burden SSA-countries too many children are not receiving adequate care for diarrhea, even among those seen in health facilities.

According to one study (Carvajal-Vélez, Amouzou & Perin, 2016), redoubling efforts to increase care seeking and improve quality of care for childhood diarrhea in both health facilities and at community level is an urgent priority.

This study showed that urban/rural living is not significant regarding treatment with zinc, however, did it show that the relationship between zinc and

economic status is significant. Other studies show that rural or urban areas and also household wealth has been determinants of the treatment-seeking behavior for childhood diarrhea, where children in rural areas were less likely to receive ORS treatment and zinc supplementation than those in the urban areas (Lee, Huy & Cho, 2016; Kawakatsu, Tanaka, Ogawa, Ogendo & Honda, 2017).

Also, in UNICEF’s report (2013) we can see that children in the richest 20% of households may be up to four times more likely to receive ORS when they are sick with diarrhea compared to children in the poorest 20% of households.

Furthermore, Sood and Wagners (2014) found that poor children, in SSA, were less likely to receive ORT than wealthy children – this effect was much

stronger in the private sector.

According to WHO/UNICEF (2009), Walker & Black (2010) and Buttha et al (2000) children should also simultaneously receive zinc treatment, because it reduces the duration and severity of diarrhea episodes, stool volume and the need for advanced medical care. The information about the prevalence of zinc treatment for childhood diarrhea is limited (UNICEF, 2012), only recently questions on zinc use were added to household surveys. The limited data indicate low use of zinc to treat childhood diarrhea. Also, in this study we found that only 38% of the children with diarrhea symptoms during the last two weeks was given zinc. 40.3% of the children living in urban area compared

(31)

of the children living in the poorest households was given zinc and 49.3% of the children living in the richest households was given zinc. We found that of the children taken to the GHC 52% received zinc as a treatment. Ibrahim et al.

study in Nigeria (2020) showed that difference for zinc was not statistically significant between urban and rural caregivers. Acceptability of zinc tablet was significantly associated with the utilization of zinc plus ORS, caregiver’s age, and educational attainment of respondents in both urban and rural

communities. Study shows that children are dying from these preventable diseases because effective interventions are not provided equitably across all communities (WHO, 2013).

This study shows that nearly 90% answer that their first choice to seek treatment is at some Government institution: Government Health Center, Government Health Post or Government Hospital (GH). However, according to MoH (2012) 88% of the health facilities in Zambia are Government owned.

Bradley, Rosapep and Shiras study (2020) showed that 63% for of the caregivers sought care out of home when child had diarrhea. The findings in Munos et al study (2010) shows clearly that there is an important missed opportunity to prevent child deaths due to diarrhea by making sure that health care providers are managing childhood diarrhea appropriately, including advising caregivers effectively about providing ‘good’ diarrhea management at home and the importance of seeking care outside the home.

66% sought treatment at the GHC followed by 18% that sought treatment at the GHP. Sood and Wagners study (2014) found that there was little difference in treatment between rural and urban children in SSA that received care in the public sector.

The distance to a health facility can be a contributing factor to the health seeking behavior, which is lacking in our study. A study in Ethiopia (Godana

& Mengistie, 2013) pointed out distance as a barrier to seeking treatment.

(32)

Kantés et al. study (2015) in Tanzania showed children living 1 km from health facility were more likely to receive delayed treatment, home care and/or no care at all. Another study (Bagchi, Das, Dawad, Suraya & Dalal, 2020) in India showed that the majority of women said that their family members did not use public healthcare facilities, the main reason were no nearby facilities.

Different studies have shown that there is a good proportion of childhood diarrheal cases being managed at home (Omore, O'Reilly Williamson, Moke, Were, Farag & van Eijk, 2013), home management of diarrhea is preferable by most people living in rural areas (Löfgren, Tao, Elin, Kyakulaga & Forsberg, 2012; Other, Orago, Groenewegen, Kaseje, & Otengah, 2008). Diarrhea and treatment seeking behaviors in most rural communities still remain a major challenge (Diaz, George, Rao, Bangura, Baimba, McMahon, & Kabano, 2013).

Also, UNICEF (2012) argues that it is the sickest children that lives in the poorest communities, often has caregivers that provide medicines at home or seek care outside the formal health sector, which could result in inappropriate treatment and delayed care seeking.

Method discussion

The data being used is secondary data which made it possible to study the treatment of diarrhea for children under five living in Zambia. Without secondary data, this kind of study would not been possible. However,

secondary data can lack specific information for the particular study, since the data was not collected to answer our questions.

The data showed us what kind of treatment children received and what kind of action respondent took when child had symptoms of diarrhea. The data did not show us if the action was depending on other symptoms, for example fever.

Which could be a care seeking trigger. Neither did the data tell us if the child

(33)

be interesting to see if the treatment differs. The study also lacked information about the distance to different health facilities, which can be a contributor to care seeking behavior.

Since both quantitative and secondary data is being used, we won’t get answers about why the respondent seeks help and what trigger them to seek.

(34)

Conclusion

This study showed that the treatment and care seeking behavior for caregivers to under-5 children is of public health concern. Less than half of the children receives zinc as a treatment and 67% receives prepacked ORS. Availability and accessibility of ORS and zinc to all children with diarrhea could save numerous lives of children each year.

Increased efforts are needed, particularly since diarrhea still is the third largest killer of under five children in Zambia. There is a need for education and awareness campaign on the efficacy of ORS and especially zinc in preventing diarrhea mortality.

Further independent study is recommended to identify where the gaps in treatment and care seeking behavior is, to contribute to the UN Sustainable Development Goals target 3.2.

(35)

References

Andrus, A., Cohen, R., Carvajal-Aguirre, L., El Arifeen, S., & Weiss, W.

(2020). Strong community-based health systems and national governance predict improvement in coverage of oral rehydration solution (ORS): a multilevel longitudinal model. J Glob Health, 10, 1-13.

Bagchi, T., Das, A., Dawad, S. & Dalal, K. (2020). Non-utilization of public healthcare facilities during sickness: a national study in India. J Public Health, 9.

Benson, MH., Sepiso, KM. & Hikabasa, H. (2020). Predictors of diarrhea episodes and treatment-seeking behavior in under-five children: a longitudinal study from rural communities in Zambia. Pan African Medical Journal, 36, 115.

Bhutta, Z. A., Bird, S. M., Black, R. E., Brown, K. H., Gardner, J.M., Hidayat, A., Khatun, F., Martorell, R., Ninh, N. X., Penny, M. E., Rosado, J. L., Roy, S.

K., Ruel, M., Sazawal, S., & Shankar, A. (2000). Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials. American Journal of Clinical

Nutrition, 72(6), 1516-1522.

Bhutta, ZA., Das JK., Walker, N., Rizvi, A., Campbell, H., Rudan, I. & Black, RE. (2013). Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost? The Lancet, 20, 1417-1429.

Björk, J. (2012). Praktisk statistik för medicin och hälsa. Stockholm, Liber.

Bradley, S E.K., Rosapep, L. & Shiras, T. (2020). Where Do Caregivers Take Their Sick Children for Care? An Analysis of Care Seeking and Equity in 24 USAID Priority Countries. Global Health: Science and Practice, 8, (3):518-533.

Maïga, A., Tarekegn, H., Akinyemi, A., Shiferaw, S., Young, M., Bryce, J. &

Newby, H. (2016). Diarrhea management in children under five in sub-Saharan Africa: does the source of care matter? A Countdown analysis. BMC Public Health 16, 830.

CIDRZ. (2015). Diarrhoel Disease Control. Accessed on 17th September.

CIA. ZAMBIA. (2020). The World Factbook. Central Intelligence agency.

Chilengi, R., Simuyandi, M. & Beres, L. & Bosomprah, S. (2017). Impact of targeted interventuines against diarrhea in Zambia. BMJ Global Health, 2.

(36)

Das, JK., Lassi, ZS., Salam, RA. & Bhutta, ZA. (2013). Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality. BMC Public Health, 13, 29.

Das, JK., Salam, RA. & Bhutta, ZA. (2014). Global burden of childhood diarrhea and interventions. Curr Opin Infect Dis, 27, 451-458.

Diaz, T, George, AS., Rao, SR., Bangura, PS., Baimba, JB., McMahon, SA. &

Kabano, A. (2013). Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey. BMC Public Health, 13, 157.

GBD (2018). Compare, Zambia, Institute for Health Metrics and Evaluation Population Health Building/Hans Rosling Center.

Godana, W. & Mengistie, B. (2013). Determinants of acute diarrhoea among children under five years of age in Derashe District, Southern Ethiopia. Rural Remote Health, 13, (3):2329.

Government of the Republic of Zambia, Ministry of Community

Development/Mother and Child Health, UNICEF, Zambia Centre for Applied Health Research and Development (ZCAHRD), Center for Global Health and Development, Boston University (CGHD/BU), Coalition of Centres in Global Child Health/Toronto SickKids Hospital. Health Facility and Health Worker.

(2015). Baseline Assessment for Reproductive, Maternal, Neonatal, Child Health and Nutrition Services.

Ibrahim, RJ., Jibo, A. M., Gajida, A. U., Kwaku, A. A., Awaisu, N., Yusuf, A.

M. , Kauranmata, A. I., Yusuf, S., Shuaibu, S. Y., Musa, A. & Abubakar, I. S.

(2020). Caregiver's acceptability of zinc tablet for treatment of childhood diarrhea in rural and urban communities. Sahel Medical Journal, 23(1), 51.

Kanté, AM., Gutierrez, HR., Larsen, AM., Jackson, EF., Helleringer, S., Exavery, A., Tani, K. & Phillips, J.F. (2015). Childhood illness prevalence and health seeking behavior patterns in Rural Tanzania. BMC Public Health, 15, 951.

Kawakatsu, Y., Tanaka, J., Ogawa, K., Ogendo, K. & Honda, S. (2017).

Community unit performance: factors associated with childhood diarrhea and appropriate treatment in Nyanza Province, Kenya. BMC Public Health, 17, 202.

Lee, H-Y., Huy, NV. & Cho, S. (2016). Determinants of early childhood morbidity and proper treatment responses in Vietnam: results from the Multiple

(37)

Liu, L., Johnson, H.L.,, Cousens, S., Perin, J., Scott, S., Lawn, J.E., Rudan, I., Campbell, H., Cibulskis, R., Li, M., Mathers, C. & Black, R.E. (2012). Child Health Epidemiology Reference Group of WHO and UNICEF. Global,

regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. External Lancet, 379, 2151-61.

Löfgren, J., Tao, W., Elin, L. (2012 ). Kyakulaga F & Forsberg BC. Treatment patterns of childhood diarrhoea in rural uganda: a cross-sectional survey. BMC Int Health Hum Rights, 25, 12-19.

Munos, M.K., Fischer, W., Christa, L. & Black, R.E. (2010). ‘The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality’.

Int J Epidemiol, 39, 5–87.

MoH (2012). The 2012 List of Health Facilities. University of Zambia, Medical Library, Ministry of Health.

Omore, R., O'Reilly, CE., Williamson, J., Moke, F., Were, V., Farag, TH., van Eijk, AM., Kotloff, KL., Levine, M.M., Obor, D., Odhiambo, F., Vulule, J., Laserson, K.F., Mintz, ED. & Breiman, RF. (2013). Health care-seeking behavior during childhood diarrheal illness: results of health care utilization and attitudes surveys of caretakers in western Kenya, 2007-2010. Am J Trop Med Hyg, 89, 29-40.

Othero, D.M., Orago, ASS., Groenewegen, T., Kaseje, DO. & Otengah, PA.

(2008). Home management of diarrhea among underfives in a rural community in Kenya: household perceptions and practices. East Afr J Public

Health. 5(3):142–146.

Roth, G.A., Abate, D. & Abate, KH. (2018). Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and

territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 392, 1736-1788

SDG-report. (2015). The Sustainable Development Goals of the Post-2015 Agenda: comments on the OWG and SDSN Proposals. German Development Institute / Deutsches Institut für Entwicklungspolitik (DIE), Department

“Sustainable Economic and Social Development”.

Sood, N. & Wagner Z. (2014). Private Sector Provision of Oral Rehydration Therapy for Child Diarrhea in Sub-Saharan Africa. The American Journal of Tropical Medicine and Hygiene, 7, 939–944.

Swedish Government. Ministry of Foreign Affairs. Strategy for Sweden’s development cooperation with Zambia 2018–2022.

(38)

UNICEF. (2006). Progress for children: A report card on water and sanitation. External Number 5, September.

UNICEF. (2012). Pneumonia and Diarrhoea: Tackling the deadliest diseases for the world’s poorest children. UNICEF, New York.

UNICEF. (2013). Committing to Child Survival: A Promise Renewed. Progress Report. United Nations Children’s Fund (UNICEF), September.

UNICEF. (2015). Global databases based on Multiple Indicators Cluster Surveys, Demographic and Health Surveys and other nationally representative sources. Accessed May, New York.

UNICEF. (2016). One is too many: ending child deaths from pneumonia and diarrhoea. United Nations Children's Fund, New York.

UN IGME. (2020). Levels and Trends in Child Mortality United Nations Inter- Agency Group for Child Mortality Estimation.

Victora, C.G., Bryce, J,, Fontaine, O. & Monasch, R. (2000). Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ, 78, 1246-1255

Walker, F. CL. & Black, R.E. (2010). Zinc for the treatment of diarrhoea:

effect on diarrhoea morbidity, mortality and incidence of future episodes. Int J Epidemiol, 39, 63-9.

WHO. (2005). The treatment of diarrhoea. A manual for physicians and other senior health workers.

WHO. (2013). Diarrhoeal disease: fact sheet on diarrhoeal disease provides key facts and information on scope, causes, prevention and treatment.

WHO. (2017). Diarrhoeal disease. Fact sheet.

WHO/UNICEF. (2014). Joint statement: clinical management of acute diarrhea. Geneva, WHO.

WHO/UNICEF. (2009). Diarrhoea: Why children are still dying and what can be done.

WHO/UNICEF. (2015). Diarrhoea: why children are still dying and what can be done.

(39)

Zambian government. (2011). National Health Strategic Plan 2011-2015.

References

Related documents

46 Konkreta exempel skulle kunna vara främjandeinsatser för affärsänglar/affärsängelnätverk, skapa arenor där aktörer från utbuds- och efterfrågesidan kan mötas eller

The increasing availability of data and attention to services has increased the understanding of the contribution of services to innovation and productivity in

The aim of this study was to investigate whether there was an association between maternal level of education and the treatment with antimalarial drugs in malaria positive children

This method of data collection helped in obtaining convincing and grounded knowledge and understanding as government officials, teachers, social workers, care givers

The results of this study suggest that the caliphate, as described by Hizb ut- Tahrir, bears more resemblance to an ideal type guardianship state than it does an ideal type

For children with special needs and/or disabled children to attend governmental schools with specialised education (organisations 1 and 2), they first need to receive an

Mothers living in rapidly urbanizing cities are pressured to make food choice decisions in contrary to their knowledge due to changes in the social practices, their roles at

The primary findings of the study were that more than half of the children had taken antibiotics for a respiratory tract infection within the past year and that most of the