CONCLUSIONS AND RECOMMENDATIONS
The findings of this study show that the hospital admission rate of persistent diarrhoea was high (19.3%) among children under 5 years of age admitted to Mukalla MCH Hospital for the period 9 months, with the highest rates occurring in the first year of life and with no gender differences.
This study found a significant association between the risk of persistent diarrhoea and child’s age, breastfeeding status, nutritional status (under-weight), other diarrhoeal episodes within previous two months, presence of mucus in stool, giving less amount of food to diarrhoeal child and using mixture treatment in the acute stage of the diarrhoea episode. This study also indicated a significant association between the risk of acute diarrhoea and breastfeeding status, educational level of caretakers, caretakers’ knowledge score, number of the children under five years of age in the same household, type of drinking water, caretakers’ hand washing habit before preparing the food or giving the bottle and using soap for hand washing.
This study reconfirmed that similar risk factors identified in other children in developing countries were responsible for the occurrence of acute and persistent diarrhoea in Mukalla district. Although some risk factors were not significantly associated with the risk of acute and persistent diarrhoea it might be due to some differences in locality and cultural beliefs. However, the risk factors identified could not infer to all Yemeni children in general.
In the context of breastfeeding and supplementary food patterns, the present study shows a low rate of exclusive breastfeeding among Yemeni mothers in the study area. However, artificial milk, food and other liquids were introduced early before the recommended age (<4 months). Mixed feeding with breast and bottle is the most popular method of infant feeding in Mukalla district.
The findings of this study also show that mothers/caretakers' infant-feeding practices during diarrhoea episodes are partly indoctrinated by cultural aspects, including advice from the elderly (their own mothers, their mothers-in-law, other family members) and home-based practices passed from generation to generation. It shows confusion among caretakers on the regime to be given to the diarrhoeal child. Therefore, there is a large proportion of caretakers who decrease the amount of food for their children during diarrhoeal attacks and many mothers stop breastfeeding their children during the episode and they feed their children diluted cow's milk because they believe that breastfeeding may cause diarrhoea in their children.
This study demonstrated that the majority of caretakers of all three groups studied seem to have low knowledge scores about many aspects of diarrhoea, dehydration, ORS and its use. It was found that caretakers can define and describe diarrhoea; however, awareness about the prevention, etiology and the importance of germs in its causation was low. As a result, diarrhoea prevention and treatment are traditionally very different from that offered by the health services. The most distressing fact observed in this study was that the majority of caretakers, even the caretakers from more educated group believe that teething and accidental falls causing diarrhoea, and using antibiotics, drinking bee honey and some herbal medications can prevented it. Furthermore, the majority of caretakers did not consider some types of diarrhoea as illness and consequently, not all cases of diarrhoea were treated. The majority of caretakers could not identify the danger signs of severe dehydration and the using rate of ORS was very low.
The present study also confirms that traditional beliefs and practices continue to exist in Mukalla district and have a direct influence on the manner in which mothers/caretakers respond to diarrhoea in their children. The incorrect perceptions by caretakers about the causes of diarrhoea were reflected in cases management and help seeking behaviors. The mode of treatment practiced by them varied. It is obvious that in most cases the caretakers had more confidence in folkloric treatment that they themselves or traditional healers applied than in the services offered at health centers and most of the children with diarrhoea are taken to clinics or hospitals only after home treatments and those traditional healers have failed, by which time a child may be severely dehydrated. This attitude limited their use of health services and ORT, although it was observed that in certain cases traditional treatments were used in combination with those of western medicine.
As was found from this study, caretakers have their own sets of beliefs and treatment options concerning specific health problems. Thus, it is quite important to understand the cosmology of local caretakers to plan health development. The study highlights the need for a well-planned, intensive health education programme based on these findings. Traditional treatments should be studied to evaluate their effectiveness and adapt them, to the extent possible, to "modern" medicine. Traditional medicine can and should play an important role in designing programs for the prevention of diarrhoea. The results of our study can contribute as an additional input for planning health programs. A promotional programme must recognize the importance of popular knowledge, respect it and use it as a guide in the modification of potentially harmful practices.
In Yemen, popular knowledge is a result of both traditional and modern medicine. A good programme must take into account this plurality and seek the means for explaining the causes of diarrhoea, combining traditional and modern concepts. Mothers/caretakers will feel motivated to change their habits only if they understood the relationship between harmful hygienic practices and their children's diarrhoea. Infant mortality caused by diarrhoea could be reduced considerably in Yemen and other countries with similar societies and cultures if popular knowledge of diarrhoea were recognized, if communication between mothers/caretakers and health personnel were improved and if programs were designed to prevent diarrhoea and promote ORS in accordance with local cultures.
Based on the findings obtained in this study, and especially following the field experience encountered, it may be feasible to divide the recommendations into two areas: programme implementation and research.
6.2.1 Programme implementation
There are a number of roles that can be played by the government and by non-government organizations (NGOs) in attempts to improve the health status and condition of Yemeni women and children. Government officials and religious leaders should be targeted to influence the community as well as provide moral support for such programs.
This study highlights the urgent need for a well-planned and intensive health community education programme regarding children health care, including diarrhoeal diseases, to change some incorrect beliefs and to educate mothers /caretakers about the role of infection in causing diarrhoea, and the role of good personal and general hygiene in preventing diarrhoea as well as the importance of ORS. All educational efforts regarding feeding and diarrhoea should urge mothers to continue breast-feeding and other feeding during and after their child’s episode of diarrhoea. As well as to treat all episodes of acute diarrhoea promptly with adequate attention to early institution of feeding and oral rehydration therapy. Despite the limited epidemiological information on the association of early artificial milk feeds and persistent diarrhoea, such feeding should not be advocated in young children.
It is important to emphasize to mothers/caretakers regarding stool losses and daily needs for rehydration fluids. In most cases the response to dietary therapy is slow and clinical improvement being evident in 3-4 days. It is also important, especially in home-based management of persistent diarrhoea to avoid unnecessary dietary changes and medications. While the nutritional therapy of the vast majority of children with persistent diarrhoea can take place in the home/community setting, certain high-risk groups need to be identified for hospitalization. These include young infants (<12 months) and those with severe, bloody or mucoid diarrhoea, and severe malnutrition. Thus, programs geared toward providing home-based therapy for persistent diarrhoea should incorporate aspects of mothers/caretakers and health-worker education for early recognition of children at a high risk of failure, with associated complications, and clinical indicators of those who do not satisfactorily respond to therapy.
Furthermore these messages must contain specific dietary recommendations that target literate and illiterate mothers/caretakers. In order to spread these health messages most effectively, these messages must be provided to mothers/caretakers and health care providers through special training programs, through the TV and radio broadcasts, and instructive pamphlets. The materials designed for and used in the program will be pre-tested to ensure clarity and success on a larger scale.
The proposed programme should teach general health information to all students through a partnership between the health and education departments. A joint effort between these two departments will be channeled to provide health education to students quickly and regularly. If all students learn health information in school early on, it allows the spread these health messages throughout their community.
Furthermore, an expert committee consisting of intellectuals and interested physicians may be established to develop ties with traditional healers to investigate the efficacy of different traditional therapies and to encourage traditional healers to share their experiences, knowledge and skills handed down to them by previous generations. It is recognized that establishing such a relationship cannot be an easy task, especially because of the prevailing view among practitioners that the only paradigm of value in health and healing is technology-intensive modern medicine, as they attribute little or no value to traditional therapies. In contrast, the example of the growing complementary and traditional medicines, associated by the establishment of traditional medicine academies appears to have positive effects. In societies with traditional social structures, this procedure seems to work well with modern medical practice working in collaboration with traditional healing to increase the awareness of the advantages of both (Ogunbode 1991).
Last, but not least, such studies should be expanded to include wider parts of the community, as well other community-based diseases.
The high prevalence of persistent diarrhoea among the children in the study area draws attention to the importance of this disease, therefore studies and intervention programs should be initiated to reduce diarrhoea occurrence. The occurrence of diarrhoea could be reduced considerably in Mukalla district if popular knowledge of diarrhoea and etiologies of diarrhoea were recognized, if communication between caretakers and health personnel were improved and if programs were designed to prevent diarrhoea and promote oral rehydration therapy in accordance with local cultures. This study has shown that piped water in the household is a risk factor for acute diarrhoea. It is suggested that water from public or municipal water system should be safe for drinking, and it should be regularly tested for contaminants such as microbial pathogens by federal and state authorities. Based on this findings, further study is needed for testing the water quality in the study area, to determine if the water meets the minimum criteria for bacterial content (for coliform bacteria).
Since our study included questions about some practices such as hand washing and water storage, the need for observational studies for reliable results is necessary.
The findings of the present study suggest that the process of management of diarrhoea at the community level will be understood better in the study area when viewed in the cultural context. Therefore the need to:
a. Use the perceptions of the people and practices of treatment of diarrhoea as input into educational programs.
b. Strengthen the primary healthcare system to meet the requirements of the community they serve.
c. Train not only healthcare workers in the formal health sector but also doctors, medical staff, pharmacists and patent medicine vendors in the appropriate management of diarrhoea.
d. Include not only mothers of young children but also fathers, grandmothers, and in-laws in an intervention because of their influence in the decision-making process.
It can also be suggested that more studies be carried out in the early phases of an intervention to provide a framework and input into national programs on health issues. In addition, proper follow-up after the intervention and monitoring and/or evaluation of programs are necessary to observe those unhealthy behavioral patterns/practices that can be given up. In order to reduce the consumption of unnecessary pharmaceuticals during diarrhoea episodes, the regulation of pharmaceuticals market should be a matter for consideration. The results of this study suggested that studying the effects of massage, herbal and other traditional treatments in order to evaluate their effectiveness and adopt them within “modern” medicine, should be carried out. Health services providers should become familiar with traditional nomenclature and beliefs in order to improve their communication with mothers and caretakers, and re-orient harmful practices to obtain better results in programs for the prevention of infant diarrhoea. The Ministry of Health should pay attention and encourage more research to be conducted.