Factors related to mothers home practicer on management of accute diarrhea in children under five years old, in nam dinh city, viet nam

Thesis entitledFACTORS RELATED TO MOTHERS’ HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE YEARS OLD, IN NAM DINH CITY, VIET NAM was submitted to the Faculty o f G

FIVE YEARS OLD, IN NAM DINH CITY, VIET NAM

_I

NGUYEN MANH DUNG

A

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF PRIMARY HEALTH CARE MANAGEMENT

FACULTY OF GRADUATE STUDIES

MAHIDOL UNIVERSITY

2002

ISBN: 974-04-1355-2 COPYRIGHT OF MAHIDOL UNIVERSITY

Thesis entitled

FACTORS RELATED TO MOTHERS’ HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE

YEARS OLD, IN NAM DINH CITY, VIET NAM

was submitted to the Faculty o f Graduate Studies, Mahidol University for the degree of Master o f Primary Health Care Management

M ahidol University

FACTORS RELATED TO MOTHERS’ HOME PRACTICES ON

MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE

YEARS OLD, IN NAM DINH CITY, VIET NAM

ACKNOWLEDGEMENT

This thesis would not have been possible without the help and support of many people

First and foremost, it is my honour and pleasure to express my sincere gratitude

to Asst Prof Nonglak Pancharuniti, my major-advisor, for her valuable guidance, support and inspiration throughout the thesis period Her effort, assistance and commitment made the entire thesis process an enjoyable time that I will always live to remember

I am also grateful to Dr Kitti Shiyalap and Asst Prof Somsak Wongsawass, my co-advisors, for their kindly advice, guidance and encouragement during the thesis process M ore specifically, I appreciate their support and guidance with regard to thesis analysis and general review o f my thesis that led to its successful completion Furthermore, I express my sincere thanks to Asst Prof Junya Pattaraarchachai, for her valuable suggestions and comments, especially during the last moments o f my thesis

I will always be grateful to you all

Also, I express sincere thanks to the Vietnamese Ministry o f Health, and the Namdinh Medical College for selecting me to participate in the Master o f Primary Health Care Management course at ASEAN Institute for Health Development My special thanks go to the Canadian International Development Agency (CEDA), and operated by the Association of Universities and Colleges o f Canada (AUCC), a partnership between the School o f Nursing, Memorial University o f Newfoundland, Canada, and the Secondary Technical Medical School 1 (STMS1), Ministry o f Health, Vietnam The author would like to thank the project Director, Dr Lan Tran Gien, Professor, Nursing, Memorial University, Dr Hoang Dien Phan and Dr Vu Dinh Chinh (project Co-Directors) for their encouragement and support that enabled me to attend this course

I am also grateful to the leaders o f Namdinh health center, all the health personnel and respondents for their cooperation and assistance during the time o f data collection Their support and enthusiasm made the entire data collection process a memorable experience for me

I am also grateful to all the professors and staff o f the AIHD, the MPHM office, the computer department, the library center as well as my classmates for supporting me

to complete my thesis successfully I also thank the ASEAN house staff for their facilities during my stay in ASEAN house

Last but not least, I express my gratitude to my family members, relative and friends for according me the moral support and motivation throughout my study at the ASEAN Institute for Health Development, Thailand

Nguyen Manh Dung

SỐ 4437629: CHỦ ĐỀ: QUẢN LÝ CHĂM SÓC s ú c KHOẺ BAN ĐẦU

TỪKHỌÁ : BỆNH TIÊU CHẢY/ THIJC HÀNH TẠI NHÀ/ TRẺ EM/ VIỆT NAM

TRONG VIỆC X Ử TRÍ BỆNH TIÊU CHẢY CẤP Ở TRẺ EM DƯỚI 5 T U ổI, TẠI THÀNH PHÓ NAM ĐỊNH, VIỆT NAM.

NHỮNG NGƯỜI HƯỚNG DAN:

270 bà mẹ có con bị bệnh tiêu chảy trong vòng 6 tháng gần đây, đã được phỏng vấn trực tiếp (thông qua bộ câu hoi) để thu thập các thông tin, sử dụng trong nghiên cứu này Nó bao gồm: Các đặc điểm về nhân khẩu-xã hội học, nhân thức về sự nhạy cảm, sự nguy hiểm của bệnh tiêu chảy ở trẻ em cùng với lợi ích, những điều trở ngại cũng như các điều gợi ý giúp đỡ bà mẹ trong thực hành và việc thực hành tại nhà của các bà mẹ trong xử trí bệnh tiêu chảy cấp ờ trẻ em

Sự phân tích kết quả nghiên cứu đã chỉ ra rằng: Phần lớn các bà mẹ ở độ tuổi từ 26-34, có trình độ VH hết phổ thông trung học và có thu nhập ở mức thấp Các bà mẹ trong nghiên cứu này chủ yêú là: nội trợ, làm nghề tự do và có tổng số người trong gia đình không quá 4 người Số đông trong họ đã nhận được các thông tin về liệu pháp bù nước và điện giải từ nhân viên y tế Toàn bô nhận thức của họ

đã được phân loại trung bình: 52^6%, mức cao: 33% Có 38% bà mẹ (Ịạt mức cao

về điểm thực hành, mặc dù 50% bà mẹ đã thực hiện tăng lượng nước uống cho trẻ, 65.6% tiếp tục cho trẻ ãn, 54.8% đã không sử dụng bất kỳ loại thuốc nào, 55.2%

đã có được nhận thức về các dấu hiệu nặng của bệnh khi con họ bị tiêu chảy và 67.4% bà mẹ đã có được hành vi thực hành rửa tay đúng trong khi chăm sóc trẻ

Spearman correlation test đã đưa ra kết quả: mối liên quan có ý nghĩa thống kê giữa điểm thực hành tại nhà của các bà mẹ với tổng số năm học (VH- GD), tổng số thành viên trong gia đình, tổng số ưẻ dưới 5 tuổi trong gia đình, nhận thức của bà mẹ về bệnh tiêu chảy, cũng như các điều gợi ý giúp đỡ bà mẹ trong thực hành với giá trị r, mong đợi tương ứng, 0.334, 0.305, 0.444, 0.277 và 0.380 Kết quả nghiên cứu cũng chỉ ra rằng: Thực hành tại nhà của các bà mẹ trong xử trí bệnh tiêu chảy cấp ở trẻ em dưới 5 tuổi là cao hơn có ý nghĩa trong; nhóm các bà

mẹ đang làm việc tại các cơ quan, xí nghiệp nhà nước (p=0.005)

Fac of Grad Studies, Mahidol Univ Thesis /iv

4437629 ADPM/M: MAJOR: PRIMARY HEALTH CARE MANAGEMENT

M.P.H.M (PRIMARY HEALTH CARE MANAGEMENT)

NGUYEN MANH DUNG: FACTORS RELATED TO MOTHERS' HOME PRACTICES ON MANAGEMENT OF ACUTE DIARRHEA IN CHILDREN UNDER FIVE YEARS OLD, IN NAM DINH CITY, VIETNAM

THESIS ADVISORS: NONGLAK PANCHARUNITI D D S.,M P.H , D r.P.H , KITTI SHIYALAP B.Sc IN PHARM , M.P.H., Ph.D.,

SOMSAK WONGSAWASS B.Sc, M.Sc., M.P.H., 103p ISBN: 974-04-1355-2

This thesis is a cross- sectional study, conducted to identify factors related

to mothers' home practices on management o f acute diarrhea in children under five years old, in Namdinh City, Vietnam

The subjects were 270 mothers who had children with diarrhea in the lasf six months A structured interview questionnaire was used to collect the information in this study This included their socio-demographic characteristics, perception to susceptibility, severity o f childhood diarrhea in accordance with benefit, barrier, cues to action to support mothers on home practices and mothers' home practices on management o f acute diarrhea in children

The analysis indicated that, the majority o f mothers were with the age between 26-34 years, graduated at secondary school, and having low income Most o f them were self-employed or housewives, and with small family size (< 4 people in the family) M ost o f them had received information o f Oral Rehydration Therapy from health personnel Over all o f their perception about childhood diarrhea and home practices on management o f acute diarrhea was classified to be moderate (52.6%) and up to high level (33%) About 38% o f mothers had high level o f practice score, although 50% of them would feed the children with more fluid, 65.6% continue feeding, 54.8% didn't use any drugs, 55.2% recognized* dangerous signs, and 67.4% had hygiene behavior o f washing hands

Spearman correlation gave the statistical significant results o f the relationship between mothers' home practices and total years o f education of mothers, total family members, family's income, total number children under five years old in the family, mothers' perception o f diarrhea and d ies to action of mother with rs equal to, 0.334, 0.305, 0.444, 0.441, 0.277, and 0.380 respectively

It was also found that the score o f mothers' home practices on management of acute diarrhea in children was significantly higher in the group o f mothers working for the government (p= 005)

ACKNOW LEDGEMENT iii

ABSTRACT iv

LIST OF T A B L E S ,vii

LIST OF FIGURES ix

LIST OF ABBREVIATIONS x

CHAPTER I INTRODUCTION 1.1 Rationale and justification of study 1

1.1.1 Magnitude o f diarrhea among children Worldwide and Vietnam 1

1.1.2 Case management of acute diarrhea 2

1.1.3 Practice o f mothers on management o f acute diarrhea in children 3

1.1.4 Problem statem ent 4

1.2 Research obj ective 6

1.2.1 General objective 6

1.2.2 Specific objectives 6

1.3 Conceptual frame w o rk 7

1.4 Operational definition '8

1.5 Usefulness o f the study 11

1.6 Scope and limitations o f the stu d y 12

1.7 H ypothesis 12

H LITERATURE REVIE 2.1 Epidemiology o f diarrhea 13

2.1.1 Present global situation of diarrheal disease 15

2.1.2 Present situation o f diarrheal disease in Vietnam 17

2.2 Management o f diarrhea in children at hom e 18

2.2.1 Give the children more fluid than as u su a l 19

2.2.2 Continue feeding the children 22

2.2.3 Take the child to a health worker i f 2

2.2.4 Using antibiotic and antidiarrheal drugs 27

2.2.5 Behavior o f hygiene practice o f mothers 29

2.3 Health beliefs m odel »31

2.3.1 Perceived susceptibility 31

2.3.2 Perceived severity 31

2.3.3 Perceived benefit of taking action and barriers 31

Page

CONTENTS (Cont.)

2.4 Factors related to mothers' home practice 36

2.4.1 Socio-demographic factors o f m others 36

2.4.2 Perception o f mother toward diarrhea in children 37

2.4.3 Cues to action support mother on managing acute diarrhea 40

III RESEARCH METHODOLOGY 3.1 Study design 42

3.2 Study population 42

3.3 Sample size estimation 42

3.4 Study a rea 43

3.5 Instrum ent 45

3.6 Data collection 47

3.7 Data analysis 48

IV RESULTS Results 49

V DISCUSSION Discussion 67

VI CONCLUSION AND RECOMMENDATIONS Conclusion 75

Recom m endation 77

REFERENCES 80

APENDIX ‘ A Questionnaires 87

B The result o f test normal distribution 98

C Summary o f the results 99

B IO G RA PH Y 103

Page

1 The main types o f diarrhea 13

2 Estimates o f diarrhea associated death, 1995 16

3 Selected communicable disease in SEAR countries, 1995 16

4 Summary o f findings about using O R S 21

5 Summarized guideline o f WHO/CDD about amount fluid supplied for children with acute diarrhea 22

6 Summary o f findings about mothers' home practice on feeding children with diarrhea 25

7 Summary how to supply food for children with acute diarrhea 26

8 Number and percentage of respondents classified by socio-demographic characteristics 51

9 Percentage o f respondents classified by mothers' perception toward diarrhea in children 53

10 Number and percentage of respondents' by level o f perception 55

11 Number and percentage o f respondents classified by cues to action 57

12 Number and percentage of respondents' by level o f cues to | actio n 58

13 Number and percentage o f mothers by their practice on home care management o f acute diarrhea in children 60

14 Number and percentage o f mothers by their correct practice on home care m management o f acute diarrhea in children 61

15 Number and percentage o f respondents by level o f their practice score 62

16 Association between mothers' home practice score and their occupation by Kruskal-Waliss te st 63

17 Correlation analysis between test 64

18 Correlation analysis between practice sore and perception score by Spearman rank correlation te st 65

LIST OF TABLES

LIST OF TABLE (Cont.)

19 Correlation analysis between cues to action score and practice score by

Spearman rank correlation T est 66

20 The result test normal distribution ( Kolmogorov-Smirnov test) 98

21 Correlation analysis between socio-demographic factors and susceptibility by Spearman rank correlation te s t 99

22 Correlation analysis between other items o f perception and susceptibility 99

23 Correlation analysis between susceptibility and cues to action 99

24 Correlation analysis between barrier and socio-demographic facto rs 99

* 25 Correlation analysis between barrier and others items o f perception 100

26 Correlation analysis between and diarrheal episodes o f children 100

27 Correlation analysis between benefit and socio-demographic factors 100

28 Correlation analysis between benefit and other items o f perception 100

29 Correlation analysis between cues to action and socio-demographic factors by Spearman rank correlation test 101

30 Correlation analysis between cues to action and diarrheal episodes o f children by Spearman rank correlation test 101

31 Correlatiion analysis between diarrheal episodes o f children and scocio-demographic factors o f mothers by Spearman rank correlation te s t 101

32 Correlation analysis between diarrheal episodes o f children and practice 101

33 Correlation analysis between diarrheal episodes o f children and perception by Spearman rank correlation te s t 102

34 Correlation analysis between income and socio-demographic facto rs 102

35 Correlation analysis between total perception and m otivation 102

FIGURES Page

1 Trend in diarrheal disease in Vietnam, 1992-1998 17

2 The Health Belief M odel 35

3 Diagram for data collection processing 46

4 Percentage o f respondents’ by level of perception score 56

5 Histogram o f respondents' by cues to action 58

6 Histogram o f respondent by practice 62

IMCI Integrated Management o f Childhood IllnessMoH: Ministry o f Health.

M.P.H.M: Master Primary Health Care ManagementORT: Oral Rehydration Therapy

VND: Vietnamese Dong (Vietnam Currency Unit)

Exchange rates: 1 US$ « 15,010 VNDUS$: United States' currency unit: DollarWHO: World Health Organization

CHAPTER I INTRODUCTION

1.1 Rationale and justification of the study

1.1.1 Magnitude of diarrhea among children worldwide and in VietnamEach year, globally more than eleven million children die from the effects

o f many diseases and inadequate nutrition In some countries, more than one in five children die before they reach their birthday, and many o f those who do survive are unable to grow and develop to their full potential Seven out o f ten childhood deaths

in developing countries can be attributed to just one main cause, or often to a combination o f diseases such as pneumonia, diarrhea, measles, malaria and malnutrition (1)

Diarrheal diseases are a leading cause o f childhood mortality in developing countries and an important cause o f malnutrition On average, children below 3 years o f age in developing countries experience three episodes of diarrhea each year In 1993, an estimated 3.2 million children below 5 years died from diarrhea (2) Diarrheal disease is related to more than 3 million deaths and more than 4 billion episodes in 1995, o f which more than 80% were among children under five years old About 50% o f deaths from diarrhea are due to acute watery stool, 35% to persistent diarrhea and 15% to dysentery (3.)

In 1999, causes o f 10.5 million deaths among children under five years in developing countries were pneumonia 18%, diarrhea 15%, malnutrition 49%, measles 8%, malaria 7% and HIV/AIDS 3% One in every two-child death in developing countries is due to the above infectious diseases and malnutrition (4)

Fac of Grad Studies, Mahidol Univ. M.P.H.M (PHC Management*/ 2

Dehydration caused by diarrhea is a major cause o f death among children

in Vietnam In 1998, as recorded in hospitals among the children, diarrhea is the second disease in ten leading causes o f morbidity and it is the ninth in ten leading causes o f death (5) Especially, in the Mekong delta diarrheal diseases are prevalent, ubiquitous and the mortality and morbidity rates are the highest compared to other areas in Vietnam Gastrointestinal diseases (including diarrhea diseases) represent 60% among the total number o f cases for 24 communicable diseases reported to the Ministry of Health (MOH) Among gastroenteritis, diarrhea contributes approximately 90% o f cases In 1998 there were 2701.6 diarrhea cases per 100 thousand children, which was rather high (6)

Diarrhea is not the only direct cause o f death, but also the cause o f malnutrition, especially in infants and children under five years old Repeated episodes o f diarrhea contribute to malnutrition and are more likely to cause death in children who are malnourished Therefore, diarrheal diseases and malnutrition constitute a vicious cycle leading to increased rate o f child morbidity and mortality Diarrhea also presents an economic burden for the developing countries In many of these countries, children with diarrhea occupy a large amount o f hospital beds each year They also require expensive intravenous fluids, which in the long run affect the country's economy by reducing the health o f its work force (7)

1.1.2 Case management of acute diarrhea

Seven out o f ten childhood deaths in developing countries can be attributed to just five main causes or combination o f them: pneumonia, diarrhea, measles, malaria, and malnutrition Around the world, three out o f every four children who seek health care suffer from at least one o f these conditions However, better health management can prevent many o f these deaths World Health Organization (WHO) recommends the Integrated Management o f Childhood Illness (EMCI) approach in the management of these diseases

World Health Organization's treatment guidelines are based on the major features o f the disease The following principles guide the treatment of the diarrhea include:

- Watery diarrhea requires replacement of fluids and electrolytes, regardless o f the cause o f the diarrhea For most patients, this can be accomplished with an Oral Rehydration Salt (ORS) solution or Sugar Salt Solution (SSS) Severely dehydrated patients can be rehydrated intravenously with Ringer's Lactate solution

- Feeding should be continued during all types o f diarrhea to the greatest extent possible It also should be increased after the diarrhea stops to avoid the effects

o f malnutrition

- Increase fluids as soon as diarrhea starts and continue feeding These two keys can ensure that 90% o f diarrhea cases can be treated successfully at home, without requiring the assistance o f health workers (1)

- Drugs should not be used routinely Drug treatment does not help in most episodes o f diarrhea, including severe diarrhea with fever The only exception to this is dysentery (with bloody stool), suspected case o f cholera and some cases of persistent diarrhea The WHO recommendation is that antidiarrheal and antiemetic drugs should never be used to treat diarrhea in children None o f these drugs has practical value and some are dangerous (2)

*

1.1.3 Practice of mother on management of acute diarrhea in children at home

Practice o f mother on management o f acute diarrhea in children at home

or home care for acute diarrhea in children under five years old was defined as the following included 3 rule as:

Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 4

- Rule 1: Give extra fluids intake,

- Rule 2: Continuing food

- Rule3: Recognize danger signs and bring the child to the health worker for check up Six danger signs o f acute diarrhea in children under five years old are: fever, repeated vomiting, bloody stool, not able to drink or breast-feed adequately, does not better (the passage o f many watery stool)(2)

And recommendation: do not give a child any antidiarrheal preparation, antibiotic drugs and adopt significant preventive behavior

1.1.4 Problem statement

Many children die because their parents do not recognize warning signs that indicate their children might be suffering from one or more o f the above illness Changing family habits and the kinds o f food offered to children is an important element o f Integrated Management of Childhood Illness (IMCI) approach Correct management o f diarrhea could save the lives of up to 90% o f children who currently die from the effects o f the disease

An important element o f IMCI approach is the encouragement of a healthier home life Through IMCI, health workers can counsel parents on how to improve care for their sick children Workers teach them how to administer drugs to combat pneumonia, how to follow the three rules o f home care for diarrhea- increase fluids, continue feeding and recognize the danger signs that mean their children needs further treatment in a health facility (7)

M ore than 20 countries have begun to implement the IMCI strategy at regional and local levels since treatment guidelines and training materials first became available in 1996 Representatives o f many o f these countries have reported in conferences their success in reducing child mortality rates Other 20 countries have expressed interest in IMCI approach (8)

Acute watery diarrhea is the most common form and the most easily treated It may cause dehydration, which can usually be avoided by giving extra fluidsand food with a little extra salt Oral Rehydration Salt solution can safely correct

idehydration without the need for intravenous therapy in all but the most severe cases

(7)

The situation o f diarrhea in Vietnam with a population o f 78.7 million, diarrhea in children is a major public health problem Although mortality rates attributable to diarrheal diseases have been progressively decreasing in recent years Morbidity rate has been one o f the most important health problems Mortality rate of children under five years old is 40 per 1,000 live births (9) Only 18% of rural households have access to proper sanitation facilities Poor environmental sanitation, lack o f knowledge and failure to put knowledge into practice contribute significantly

to this problem (10)

In Vietnam, mothers are mainly responsible in taking care o f childrenduring the childhood and hence they are the ones who mostly influence the health oftheir children The health beliefs o f mother toward diarrheal disease in children play acrucial role in their practice o f child feeding, drinking, personal hygiene, sanitation

*

and care o f their children when they have acute diarrheal disease at home

Therefore, the study o f factors related to mothers' home practice on management o f acute diarrhea among children under five years old, in Namdinh City, Vietnam is plausible and a priority

It is important to explore the factors related to correct and incorrect practice o f mothers on management o f acute diarrhea in children at home This information can be used as baseline data for future diarrheal prevention and treatment program in this area

Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 6

1.2.2 Specific objectives

1.2.2.1 Determine Socio-Demographic factors o f mothers who have children under five years old with acute diarrhea

1.2.2.2 Identify perception of mother about diarrhea in children

1.2.2.3 Identify the cues to action toward managing acute diarrhea* inchildren

1.2.2.4 Identify practice of mother on management o f acute diarrhea in children at home

1.2.2.5 Determine association between Socio-Demographic factors of mother with their perception o f diarrhea and their practice on managing acute diarrhea

in children, under five years old at home

1.3 C onceptual fram e w ork

toward diarrhea in children

under five years old

- Increasing fluid: ORS, SSS breast milk

- Continue feeding

- Medication

- Recognized dangerous signs

- Behaviors o f hygiene practice

Cues to action

- Mass media campaigns

- Advice from family

Fac of Grad Studies, Mahidol Univ M.P.H.M (PHC Management) / 8

1.4 Operational definition

Diarrhea: Diarrhea is a group of signs and symptoms which describes how frequent “defecation” is and what are characteristics o f the fecal matter It is a usually defined as the passage o f three or more loose or watery stool in 24-hour period (11)

Classification of diarrhea, according to World Health Organization, there are three main types o f diarrhea

1 Acute watery diarrhea is the most common form and the most easily treated (an episode o f diarrhea lasts less than 2 weeks) It may cause dehydration, which can usually be avoided by giving extra fluids and food with a little extra salt Oral Rehydration Salts solution can safely correct dehydration without the need for intravenous therapy in all but the most severe cases

2 Dysentery is diagnosed by the presence o f blood in the stools and is treated with antibiotics

3 Persistent diarrhea is defined as an episode that lasts for more than 14 days *

Diarrheal episode: An episode o f diarrhea o f children is an interval in which the definition o f diarrhea is met and starts at the beginning to the end o f the disease Two subsequent episodes o f diarrhea are separated by an interval o f normal stool at least 3 days

Dehydration: During diarrhea there is an increased loss o f water and electrolytes (sodium, chloride, potassium, and bicarbonate) in the liquid stool Water and electrolytes are also through vomit, urine and breathing (2)

The classification of dehydration is graded according to the signs and symptoms that reflect the amount o f fluid lost:

- In the early stages of dehydration, there are no signs or symptoms

- As Dehydration increases, signs and symptoms develop These include: thirst, restless or irritable behavior, decreased skin turgor, dry mucous membranes, sunken eyes, sunken fontanel (infants), and absence o f tears when crying vigorously

- In severe dehydration, these effects become more pronounced and the patient may develop evidence o f hypovolaemic shock Death follows soon if rehydration is not started quickly

Oral Rehydration Therapy (ORT), This is method o f rehydration by oral administration o f fluids, in order to correct and prevent dehydration, which is a consequence o f diarrhea

- Oral Rehydration Salt (ORS) refers to fluid for treatment o f diarrheal disease

to reduce the severity o f dehydration and to prevent deaths Universally recommended formula containing o f Sodium Chloride: 3.5 grams, Sodium Bicarbonate: 2.5 grams, Potassium Chloride: 1.5 grams, Glucose: 20 gram to be dissolved in one liter of drinking water

- Homemade Sugar Salt Solution (SSS): a special drink (salt, sugar and water) can be made to treat o f diarrhea and prevent dehydration at home In one liter of drinking water add: sugar: 8 teaspoons (making level full o f each), salt: 1 level teaspoonful (2)

Malnutrition in Diarrhea: during diarrhea, decreased food intake, decreased nutrient absorption, and increased nutrient requirements often combine to cause weight loss and failure to grow (2)

Fac of Grad Studies, Mahidol Univ. M.P.H.M (PHC Management) / 10

Use of antimicrobials drugs in diarrhea: antimicrobial drugs should be able to fight effectively against bacteria like Shigella, Chorelra such as: Amoxycillin, Metronidazole, chloramphenicol, Nitrofurans, Cephaleuxin.(2)

Use of " antidiarrheal" drugs: these agents, though commonly used, have no practical benefits and are never indicated for the treatment o f acute diarrhea in children Products in this category include adsorbents and antimicrobility drugs such as: smectite, kaolin, loperamid hydrochloride, etc They do not prevent dehydration or improve nutritional status, which should be the main objective o f treatment Some have dangerous, and sometimes fatal, side effects These drugs should never be given

to children below 5 years (2)

Beliefs of mothers following health beliefs model: means the result of repeated perception closely related to his/her own experiences, culture, customs and the age o f the person in that society This study takes into consideration, the belief o f the diarrheal disease related to management of acute diarrhea in children at home

Perceived Susceptibility: maternal believes or perception to the high or low opportunities o f her child having acute diarrhea and its complicated symptoms

Perceived Severity: maternal believes or perception regarding seriousness of acute diarrhea in her child such as dehydration due to acute diarrhea causing death

Perceived Benefit: maternal believes or perception to the expected outcome of primary practices at home when her child having diarrhea

Perceived Barrier: maternal believes or perception to various factors under real situations which limit conditions in maternal practices when her child'having diarrhea

Health Motivation: maternal attention and concern to child health and her health with respect to management o f acute diarrhea in children

Cues to action are some things mass media campaigns, advice from family member or other, experienced o f mother about diarrhea in children, diarrheal episodes

o f children in the last six months Those stimulate mother to take the recommended actions on home care management o f acute diarrhea in children under five years old

Home practices on management of acute diarrheal disease among children under five years old are the performance of the duties and responsibilities of mother,

as practices toward management o f acute diarrhea in children includes:

Increasing fluids means during episode diarrhea o f children, mother have to give him extra fluid (ORS, SSS) to correct or prevent dehydration In case infant, increasing fluid means mother give children more milk or breasted than as usual

Continuing food means during episode diarrhea o f children, mothers have to continue to feed their children as usual to prevent malnutrition

Recognize danger signs means when children get diarrhea, mother observes and take care o f them recognize the signs fever, blood in the stool, vomits repeatedly, drink poorly, not able to drink or breast-feeding, do not better, to seek medical care

Using drugs means when children get acute diarrhea mother should not gives them any antidiarrheal preparation and antimicrobiotic drugs

Behavior o f hygiene practice o f mother on management o f acute diarrhea at home, in this study concern about hand washing o f mother to limit transmission diarrhea to another people

1.5 Usefulness of the study

This study is expected to show factors related to mothers' home practices on management o f acute diarrhea among children under five years old in Namdinh City,

Fac of Grad Studies, Mahidol Univ. M.P.H.M (PHC Management) / 12

Vietnam This study is also expected to provide information on the existing practice

o f mothers about management acute diarrheal disease in children This information can be used as baseline data information for future diarrhea prevention and treatment program Furthermore, this study will also provide information about relationship between socio-demographic factors o f mother, their perception toward diarrhea and mothers' practice on management o f acute diarrhea among children under five years old at home, which will be helpful for health education program in the community of Vietnam

1.6 Scope and Limitations of the study

The study was carried out in four villages in urban Namdinh City, Vietnam Therefore, it may not be generalized to the whole Namdinh City Since this study needs to be completed in a short period of time, information about practice o f mother was based on a set o f questions given to them, rather than actual observation during their practice

1.7 Hypotheses

1) There is association between Socio-demographic factors o f mother and their home practice on management o f acute diarrhea in children under five years old

I2) There is association between perception o f mother toward diarrheal diseases

in children and their home practice on management o f acute diarrhea in children

3) There is association between cues to actions o f mother toward diarrhea in children and their home practice on managing acute diarrheal disease among children

CHAPTER II LITERATURE REVIEW

Tablel: The main types of diarrhea

Type of diarrhea Case of

diarrhea(%)

Death due to diarrhea(%)

Death preventable by standard case

Source: WHO; fact sheet No 180 September 1997

Pathogens are most frequently associated with diarrhea in young children in developing countries Particular pathogens are Rotavirus, bacterias such as E.coli(the toxic form), Vibriocholera, Shigella, and Salmonella or protozoa like Crytosporidium, E.hystolytica, Giardia lambia(12)

In a prospective epidemiological and clinical study o f acute diarrhea, among children less than five years old conducted at King M ongkut Prachomklao hospital (Thailand) The study showed that among 105 cases o f acute diarrhea, the causative pathogens were identified in only 64 cases, in which Rotavirus alone occupied 17.2%,

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Escherichia coli 14%, Campylobater 14.1%, Shigella 12.5%, Entamoba histolytica 7.8% and Salmonella 3.1% (13)

The incidence o f rotavirus infection was studied among 704 children under five years old who were suffering from acute gastroenteritis in Tehran The frequency of Rotavirus infection was significantly (p< 0.001) higher among patients under 24 months o f age w asl9.7% as compare to children two years old or more (5.1%) (14)

According to an epidemiological study conducted in Vietnam in 2000, the Sentinel surveillance at 6 hospitals showed that disease burden o f Rotavirus diarrhea

as assessed by surveillance o f children under 5 years old who were hospitalized for diarrhea at 3 centers in the North and 3 centers in the South., was identified in 56%(range 47%-60%) o f 5768 patients between July 1998 to June 2000 (15)

Mode o f transmission o f acute diarrhea was mainly through the oral-fecal route,which included the ingestion o f fecal contaminated water or food, and the spread ofinfectious agent o f diarrhea and direct contact with infected feces (12) The majorcause of death from acute diarrhea might have come from dehydration, which resulted

in loss of fluids and electrolytes in diarrhea stools Other important causes o f deathwere dysentery, malnutrition and serious infections, such as pneumonia But correctmanagement could save nearly 1.8 million lives per year; EMCI reduces the death toll

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from diarrhea by promoting:

1 Rapid and effective treatment through standard case management

2 Prompt recognition and treatment o f conditions that occur due to diarrhea

3 Improved home management

4 Improved nutrition

5 Prevention through increased breast-feeding and measles immunization (1)

2.1.1 Present global situation of diarrheal diseases

In the year 2000, World Health Organization and United Nations Children Fund announced three million children died o f dehydration caused by diarrhea

- Eighty percent o f them in the first two years o f their life

- Fifty-seven thousand (57,000) a week, 8,000 a day and six every minute

(16)

Diarrhea was estimated to account for 35.8% o f deaths in children under five years old, in 1981 -1986 Based on this data and the demographic data from 1989, young children in developing countries experience an estimated 1500 million episodes

o f diarrhea per year and 9 million associated deaths (12.0 per 1000 children under five years old) (17) The incidence rate o f diarrhea was found to be 3.6 episodes per child semi annually and the point prevalence was 19.5% The average duration of current episodes was 4.8 + or - 3.7 days, 33.6% o f children had diarrhea more than three times (18)

I

In developing countries, diarrhea attributes to an estimate o f 1.3 billion episode and 3.2 million deaths each year in children under five years old Overall, children experience an average o f 3.3 episodes of diarrheal disease per years In some areas the average number o f episodes per year is 9 (19) A study carried out by Ryland S; RaggersII for 34 developing countries, The executive summary indicated that prevalence o f diarrhea was 16% for children under five years old Diarrhea prevalence peaked at 12 - 17 months and declined there after Prevalence was highest among children o f young mother (20)

In the Southeast Asia Regions (SEAR), diarrheal disease is still a problem, especially when occurring in children under five years old For instance, In Bangladesh, diarrhea was the leading cause o f mortality and morbidity among children Similarly in Bhutan, DPR Korea, Myanmar, India, Indonesia, Siri Lanka, and Thailand, diarrheal disease was one o f the ten leading causes o f morbidity and mortality (Table 2) (21)

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Table 2: Estimates of diarrhea associated deaths (1995)

(aged < 5 years in million)

Total number of under-five years old deaths

Diarrhea associated deaths

Source: UNICEF, The state o f the World's Children, 1996

Every year, there are over one million deaths from diarrhea in children one year o f age Diarrhea accounted for about 25 percent o f death o f children less than five years of age in most o f SEAR countries (see table 3) This is a tragic because 90% of these deaths were preventable (21)

Table 3 Selected communicable disease in SEAR countries, 1995

Source: WHO/ SEARO, Division of integrated control o f disease, 1996

Study in Guatemala, Bangladesh and Indonesia found that 100-300 episodes o f diarrhea occurred per 100 children per year during the first three years of life (22)

2.1.2 Present situation of diarrheal disease in Vietnam

In Vietnam, the situation o f diarrheal disease is similar to the countries in SEAR Vietnam's diarrheal disease control program began in 1982 in four provinces and expanded over the last decade to cover the whole country Although the number

o f deaths from diarrhea is on the gradual decline, but the number of cases had

Figure 1: Trend in diarrheal diseases in Vietnam, 1992-1998

Source: MOH of Vietnam, Health statistic yearbooks 1992-1998

According to the annual report o f the Ministry o f Health-Vietnam, in

1998 diarrheal disease was placed second in the top-ten leading causes o f morbidity among children in almost all provincial and district hospitals The number of episodes

o f diarrhea per child per year is 1.4 and the rate o f children under five years o f age died o f diarrhea was 19.11 percent (23)

j

In several studies that were conducted in Vietnam, children experienced

an average o f 2.1 episodes o f diarrheal diseases per year in Uong Bi district Another study in 3 villages in Ha Tay was found that an average o f 3.5 episodes / child / year (24) In 1999, diarrhea was still the leading cause o f child morbidity The report from the general statistical office indicated that 11.32% o f children under five years old suffered from diarrhea In some regions, prevalence o f diarrhea in children was even

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higher, for instance, Northeast 17.72%, South Central Coast 14.68% Moreover, they found that children from 6-11 months and 12-23 months had the highest prevalence o f diarrhea (25)

Since the World Bank's World Development Report 1993 described the Integrated Management o f Childhood Illness as the intervention is likely to have the greatest impact in reducing the global burden o f disease It is also among the most cost-effective health interventions in low and moderate-income countries Indeed, adoption and implementation of this approach are now deemed essential to reaching the goal set by the 1990 World summit for children for reducing childhood mortality

is entirely the responsibility o f the mother or other child caretakers If correctly carried out, it can have a significant impact on the health o f children (26)

In many countries, diarrheal diseases remain a major cause o f infant and child mortality Inappropriate treatment o f diarrhea in this age group is a widespread problem in both the public and private sectors A survey on health centers in a South East Asian countries found that in some locations, less than half o f children were diagnosed with simple watery stool diarrhea, received Oral Rehydration Therapy (ORT), while over 80% received hydroxyquinolone, a so-called antidiaưheal drug known to have dangerous side effects (27)

Correct management o f acute diarrhea in children at home, should be done as the following (2)

2.2.1 Give the children more fluid than usual (increasing fluid)

In order to prevent dehydration in children with diarrhea should begiven fluids containing salts, such as ORS solution, salted drink (e.g salted rice water

Other fluids to avoid are central nervous system stimulants, diuretics or purgatives as for example coffee, some medicinal tea or infusions

Fluid should be given to the children according to the general rule, that

is give as much fluid as the child wants until diarrhea stops Or as a guide, after each loose stool, give children under 2 years o f age 50-100 ml (quarter to half a large cup)

o f fluid, children aged 2 up to 10 years, 100-200ml (a half to one large cup) (27)

A Rao KV's study was carried out in India, through data from the 1992 -

1993 National Family Health Surveys The data set included 38,161 women who gave birth in 4 years The study found that children with diarrhea were twice as likely to receive decreased amounts of breast milk and another fluids than to be given increased amounts The low use o f ORS is especially alarming since 61% o f children with diarrhea in the previous 2 weeks were taken to a health facility (28)

A study was carried out in Coatepec, Vera Cruz showed that 47% o f the mothers, who reported using oral rehydration solution, 57% o f mothers gave contraindicated medications to their children with diarrhea (29) A cross - sectional survey was carried out among mothers o f children aged less than five years in two

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markets in Ibadan, Nigeria The study took place between September 1996 and March

1997, 266 o f mothers were interviewed in the first market and 260 in the other, 33% and 32% gave ORS at home for their child with acute diarrhea respectively (30)

Another study was designed to determine the fluid intake and feeding practice among under five years old children during episodes of diarrhea, in Nigeria The findings showed that fluid in take (ORS or SSS) was low Only 43.3% of children received more fluid respectively as compared to before the diarrhea (31) A study on the management o f diarrhea, in young children at community level in Thailand was reformed, among 15,466 children who were randomly selected from households o f 30 clusters o f twelve provinces from twelve regions o f Thailand The results showed that the utilization o f ORS was 25.6% while the rate o f using sugar salt solution (SSS) and the use o f recommended home fluids was 2.8 and 33.8 % respectively Only 23.7% of patients could correctly prepare the ORS (32)

An Indonesian study in West Lombok reported factors associated with the use o f oral rehydration solution among 293 mothers in six villages It was found that more than 66% o f mothers had used oral rehydration therapy for home management

o f diarrhea, either as packaged oral rehydration solution (ORS) or as salt-sugar solution (SSS) Fifty-six percent o f mothers reported giving ORS and 10% reported giving SSS Only 37% o f mothers, however were able to prepare ORS properly, and 9% were able to prepare SSS properly (33)

A study on households in different parts o f Vietnam during 1986 - 1987 revealed several areas o f concern about a very low rate o f ORS and SSS usage (7 per cent and 13 per cent respectively) Moreover, with only just over half o f mothers (54 per cent) continued to feed children during diarrhea, slightly more than 45% continued breast- feeding during diarrhea (34) Kim Sac, (Vietnam-1997) reported that among 50% o f mothers using ORS at home, the amount o f ORS solution given to the child with diarrhea was no more than 60 ml during 24 hours; and they do not give fluid right away at the onset o f diarrhea (35) These findings are similar to the finding from a study by Sabchareon (1992) in central Thailand

A cross-sectional study was done in Tien Giang province, in Mekong delta in 1998 The finding showed that the majority o f mothers (95%) gave fluids when children had diarrhea and they knew fluids would make the children better Most o f them (83%) used ORS solution, they thought ORS solution could stop

idiarrhea, but only half o f them (50%) prepared the ORS solution correctly (36) Sixty- eight percent o f mothers do not read the instructions printed on the ORS packets Some o f them read but did not mix the whole packet, because they thought that one liter o f ORS solution was too much, so the children could not finish it Mothers liked

to save ORS solution (37)

Table 4: Sum m ary of findings about using ORS or o th er fluid for children with

other fluid1996-1997 Coatepec, Vera

Cruz

Nigeria 32% mother use ORS for children

1996 Edel EE Nigeria 43.3% o f children received more fluid

1997 Wongsaroj T,

Thvornnunthj

Thailand 25.6% ORS 2.8% SSS, 3 3 8 % other

fluids

1994 W idarsa KT Indonexia 6 6% use ORS,SSS,

1986-1987 Nguyen Dung Vietnam low rate o f ORS 7% and SSS 13%

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Table 5: Summarized guideline of WHO/CDD about amount fluid supplied for children with acute diarrhea at home

Method Standard of using fluids for children with acute diarrhea at home

_ (based on guideline WHO/CDD) _Rule 1 - Give as much fluid as the children want

♦

Rule 2 - As a guide:

+ Under 2 years old: 50-100ml after each loose stool

+ M ore than 2yeas old: 100-200ml after each loose stool

Source: The treatment o f diarrhea WHO/CDD/80.2 R 2(1990)

2.2.2 Continuously feeding the children with diarrhea

In order to prevent malnutrition, feeding should be continued during diarrhea and increased afterwards Food should never be withheld and the child's usual foods should not be diluted Breast-feeding should always be continued The aim is to give as much nutrient rich food as the child can accept

M ost children with watery diarrhea regain their appetite after dehydration

is corrected, whereas those with bloody diarrhea often eat poorly until the illness resolves When food is given, sufficient nutrients are usually absorbed In contrast, children whose food is restricted or diluted lose weight, have diarrhea for longer duration and intestinal functions are recovered more slowly

Therefore which food to give a child depends on the child's age, food preferences and pre-illness feeding pattern, cultural practices In general, food suitable for a child with diarrhea is the same as required by healthy children Specific recommendations are given below

Milk

-Breast fed infants should be allowed to take milk as often and as long asthey want

-Infants who are not breast fed should be given their routine milk feeding

at least every three hours

-Infants below 4 months of age who take breast milk and other foods should receive increased breast-feeding As the child recovers and the supply of breast milk increases, other foods should be decreased.

-After diarrhea stops, continue giving the same energy rich foods in addition to an extra meal each day for at least two weeks (2)

Breast-feeding has a substantial role for protection o f infectious diseases and diarrhea VanDerslice et al conducted a follow-up study in metropolitan Cebu City They showed that there was little difference in diarrhea prevalence between mixed-fed and non-breasted group, after 6 months o f age The study also indicated that full breast-feeding provided the highest effect in prevention o f diarrhea among children who lived in crowded family under low sanitation conditions (38)

To compare the difference between effective feeding frequencies and the speed o f recovery from diarrhea, Chaomin Wan showed in his study that frequently fed infants had a significantly greater weight gain and significantly lower fecal frequency and fecal weight Frequently fed group had a significantly shorter duration

of diarrheal proportion (hazard ratio, 1.29, 95% Cl = 1.002- 1.653) (39)

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Halliday K and his colleague carried out a study in 168 consecutive

♦

patients admitted to the Royal Children's hospital, Brisbane They found that severity and out- come varied with most cases requiring a defined formula diet (40) The results from study in Sudan: 45% mothers stopped breast-feeding and foods while their children had diarrhea (41)

Perception o f mothers towards diarrhea and taking care o f children when their child had diarrhea is very important In the study, " Feeding practices of mothers during childhood diarrhea in rural area o f Nigeria " (1996), 335 randomly selected mothers with children under 5 years of age were interviewed The diets chosen by mothers reflected cultural perceptions o f the etiology o f illness and of the therapeutic properties o f local foodstuffs Raw cornstarch was believed to be an antidiarrheal agent and therefore given for all types of diarrhea, while rice was avoided Sugar, sweet foods and groundnut preparation, which were perceived as causes o f bloody diarrhea and related illness, were proscribed (42)

Home management of diarrhea was studied in 1,638 children under 5 years o f age whose 1,160 mothers were randomly selected in Suleja (Nigeria) local government area in 1994 by Babaniyi During episodes o f diarrhea, almost all mothers continued breast-feeding and gave available home fluids, but 42% stopped feeding solid food (43)

♦

In Thailand 1997, a study on the management o f diarrhea in young children at community levels Wongsaroj T and his colleague evaluated 15,466 young children from randomly selected clusters in 12 provinces 84.3 % o f mothers breastfed their child during the diarrheal episodes (44)

In Vietnam, Kin Hung pointed out that knowledge among mothers about feeding is insufficient Mothers thought that expensive food was nourishing, vegetables and fluids were not seen as necessary for children When children got diarrhea, mothers abstained from some common daily food such as small fish, shrimp and oil (45)

Kim Sac ct al.-Vietnam indicated that the majority o f mothers 91% abstained from animal and vegetable oil when their child had diarrhea, because they thought that a child could not digest these One- fourth o f mothers 25% abstained from fish, shrimp, and crab when their child had diarrhea, because they thought seafood could cause the child to have more serious diarrhea Approximately 30% o f them gave only rice gruel with sugar or salt to their children when they had a diarrhea, Fifty-one (51%) o f them reduced feeding and 12% stopped breast-feeding the child The authors concluded that mothers lacked knowledge in feeding their children while having diarrhea (35).

Table 6: Summary of findings about mothers' home practices on feeding children

Formula diet, more severity case: 45% stop breast feeding when diarrhea42%stoppedsolidfood

Raw com is belied to be an antidiarrhea Rice, groundnut were avoided

84.3% continue feedAbstained from some common daily food30% only rice gruel with sugar 25% abstain from fish 51% o f reduce feeding, 1 2% stop breast fed

Frequently feeding greater than weight gain, lower fecal frequency

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Table7: Summary how to supply food for children with acute diarrhea

(Following guide line o f WHO/CDD)

Age of children Standard feeding for children with acute diarrhea at home

(following guide line WHO/CDD)Infant -Infant: breast feeding as long as they want

-Infant below 4 months: increase breast-feeding

Children more -At least 6months: milk, vegetable other food with high energy

than 4 month mashed, well cooked

-After diarrhea stop: continue the same energy rich foodSource: The treatment of diarrhea WHO/CDD/80.2 R 2(1990)

2.2.3 Take the child to a health worker if there are the signs of dehydration

or other problems

Mothers are needed to know what signs to watch for, to decide whether the child needs medical care or not Since understanding and recognizing dehydration may be difficult, the CDD program suggests a few simple signs that most mothers can recognize easily These are

the child is very thirsty

the child passes many watery stools

the child is vomiting

the child has a fever

there is blood in the child's stool

the child is not getting better

It is very important that the mother should understand these signs and can practice when her child has a diarrhea (2)

A survey and non participant observation were conducted by Agbere AD

in late 1995, in rural Togo to evaluate the home care given by mothers to their under - five years old children with diarrhea One hundred mothers in 7 villages were questioned about signs o f severe diarrrhea The mothers said would prompt them to visit a health facility, included increased numbers o f stools for 63%, sunken eye

sockets for 39%, duration for more than 2 days for 36%, fatigue for 6% and thirsty For 4% (46)

In 1999, Sodemann M and his colleague carried out a study about the management o f childhood diarrhea and use of oral rehydration salts in a suburban West African community In household survey in Bandim, Guinea-Bissau, on 319 episodes o f diarrhea in children of mean age 10.5 months old were followed by interviews every second day o f episodes until the mother reported that the diarrhea had stopped, the child was hospitalized, or 14 days had elapsed Children with diarrhea were considered to be caused by teething were less likely to receive ORS during the acute phase By univariate analysis it was found that there was relationship between the use o f ORS for breast-fed children and the number o f reported symptom, but mothers being the caretaker did not know how to recognize the symptoms and lack o f knowledge o f ORS Although most mothers knew about oral rehydration salts, only 58% o f diarrhea episodes were treated with ORS and inadequate amount was given to the children (47)

Kim Sac in Vietnam had indicated that 87% o f mothers could not

i

recognize all 6 dangerous signs There were some dangerous signs that mothers did not know such as: drink poorly and not able to drink or take milk (35) These findings were consistent with study by Ahmed et al (1994) in Sudan who found that 90% of mothers could not recognize the dangerous signs

A study dealt with the issue o f incorrect home care for children under five years o f age in the Mekong delta, Vietnam Le van Tuan found that most o f mothers (83.3%) did not know the dangerous signs o f diarrhea in children (48)

2.2.4 Using antimicrobial and antidiarrheal drugs

Antimicrobials should not be used routinely This is because, it is not possible to distinguish clinically which episode might respond well, such as diarrhea caused by enteroxigenic Ecoli, from those caused by agents unresponsive to antimicrobials, such as Rotavirus or crytosporidium M ore over, even for potentially

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responsive infections, selecting an effective antimicrobial requires knowledge o f sensitivity o f the causative agent, information that is usually unavailable

Antidiarrheal drugs have no practical benefits for children with acute diarrhea They do not prevent dehydration or improve nutritional status, which should

be the main objective o f treatment Some have dangerous and sometimes fatal side effects These drugs should never be given (2)

In many countries, diarrheal diseases remain a major cause o f infant and child mortality Inappropriate treatment o f acute diarrhea in these age groups is a widespread problem in both the public and private sectors Furthermore, it is a problem with two dimensions: Under use of oral rehydration therapy (ORT), including oral rehydration salts (ORS) and use o f ineffective products such as antidiarrheal preparations and antimicrobial drugs in cases where their use is not indicated

i

In a survey of health centers in South East Asian countries, it was found that: in some locations, less than half o f children diagnosed with simple watery stool diarrhea received ORS, while over 80% received hydroxyquinoline, also called antidiarrheal drugs known to have dangerous side effects (27) A study in India, Rao

KV, M ishra VK and Retherford RD were selected 38,161 women who gave birth in the 4 years preceding the survey and 4558 children bom 1-47 months before survey who were sick with diarrhea at any time during the 2 weeks before interview 94% o f these children were given antibiotic or other unnecessary drug (28)

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A prospective epidemiological and clinical study o f acute diarrhea, among children under five years old was carried out by Suwatano O- Thailand One hundred and five (105) cases o f acute diarrhea were studied Causative pathogens were identified among 64 cases Rotavirus was the most common pathogen (17.2%), Shigella (12.5%) and Salmonella (3.1%) but antibiotic was prescribed to 51.4% (13)