Leeds Health Education Database 2015

Database entries with complete fields

6. Oral rehydration and the management of diarrhoea

October, 2012

6.1 General interventions

6.2 Clinic-based programmes

6.3 Mass media/social marketing programmes

Click on link for background information on Leeds Database Project, a list of all entries and details of oral rehydration interventions reviewed but not considered suitable for inclusion database.

6.1 General interventions

Akram, D.S. and Agboatwalla, M. A model for health intervention. Journal of Tropical Paediatrics 38(2):85-87, 1992. Ref ID : 2507 (Borderline for inclusion in database)

Target Group/Country  Women in urban slums, Karachi, Pakistan

Intervention Methodology  4 physicians taught 10 community health workers (CHW) certain health messages concerning reduction of the incidence of diarrhoea, respiratory infection, and fever. Using the same messages, each CHW then informed 10 women living in a squatter settlement of Karachi, Pakistan how to improve health practices using the simple health messages. Topics included breast feeding, child nutrition, immunization, household sanitation, and personal hygiene.

Evaluation Design Researchers evaluated the project with pre and post intervention survey 6 months later  and using a control group. It is stated that 100 households were reached in the intervention and 100 households were included in controls. It is also stated that results are based on 1551 households but it is not indicated how these were divided between intervention or controls and details are also not provided of sampling, and data collection procedures.

Impact Achieved  The snow balling effect reached 700 people. The health messages significantly improved management of diarrhoea, respiratory infection, and fever in the intervention group (p<.05). 6 months after hearing the health messages, >60% of mothers used oral rehydration solution (ORS) to treat diarrhoea and only 20% needed the advice of a physician. Literacy had a positive effect on home treatment for diarrhoea, but not on treatment for respiratory infection or fever. Further the incidence of all 3 conditions was considerably lower in the intervention group than the control group (p<.05). A weakness with this report is the lack of clarity on data collection and sampling.

Bhattacharya,R., Kaur,P. and Reddy,D.C. (1988)  Impact of education in the knowledge and practices of rural mothers and key family members on diarrhoea and its treatment at home.  Journal of Diarrhoeal Diseases Research  6, 15-20. Ref ID: 3274 (Borderline for inclusion in database)

Abstract: Target Group/Country
Mothers and key family members including grandmothers in Barain village in rural Uttar Pradesh State, North India.
Intervention Methodology
Following a pilot survey of 16 mothers/key persons an educational intervention was designed. Group sessions of 20 mothers or key family members e.g. grandmothers, 2 hours per day for two consecutive days. Trainers were three medical doctors and a social scientist. Methods: picture post cards, discussion, demonstration of the preparation and the administration of home made  sugar-salt solution. The purpose of the training was to enable them to identify diarrhoea, signs of dehydration, prepare salt, sugar solution (SSS)at home, use it to rehydrate their sick children and continue normal diet throughout the diarrhoea period
Evaluation Method
 66 mothers (key persons) received the intervention. A control sample comprising 50 matched mothers or key persons were taken in the study who did not get the education. Pre- and post (6 weeks later) intervention interviews were carried out using the same interview schedule.
Impact Achieved
Knowledge scores on the consequences and causes of diarrhoea and the beneficial effects of giving fluids during diarrhoea significantly increased in intervention and controls. The intervention group showed a greater increase (P<0.05). Knowledge scores on the signs and symptoms of dehydration showed significantly increased scores in intervention and controls -the intervention group showing a greater increase (P<0.001). There were no significant differences in breastfeeding, food and fluid restriction practices. - .people of the area already knew from beforehand about the beneficial effect of breast-feeding and not restricting food and fluid during diarrhea The use of homemade salt and sugar solution (SSS) showed significant increases in practice scores of both intervention (P<0.01) and control (P<0.05) groups but no difference between these groups (P> 0.05).  There was a significant increase in intervention mothers who used SSS (P<0.01) but not key persons (P>0.05).
The programme appears to have had a greater impact on knowledge than practice with the exception of SSS. The impact appears greater with mothers. The study was limited by the short time scale for evaluation of only 6 weeks, the lack of an objective method for evaluating mother's preparation of SSS and contamination of the intervention group when 8 mothers from the control group decided to attend the sessions.

De Swardt, R. and Ijsselmuiden, C.B. Knowledge and practice of oral rehydration therapy in a village in Gazankulu after the introduction of the Morley spoon. S.Afr.Med.J. 76(9):506-508, 1989. Ref ID : 2688 (Borderline for inclusion in database)

Target Group/Country  Rural Gazankulu, South Africa

Intervention Methodology  Each household in one village was given a Morely sugar and salt spoon  together with instructions on its use. The project was in the catchment of othe Elim Care group Programme but the health education activities of this wider project are not described.

Evaluation Design This study describes the effects of, on knowledge and practice of ORT in 1 community in Gazankulu, and compares 35 care group (CG) with 100 non-care group (non-CG) members. If the respondent knew about ORT, she was asked to prepare the solution in front of the interviewers and the method as well as the quantities of water, sugar and salt used were recorded. There was no baseline or control (while care group and non-care group members were compared, the non care group had received the spoons so are not controls).

Impact Achieved  97% of CG members could produce the spoon when asked to, as opposed to 55% of non-CG members (p<0.001). 82% of respondents had actually used ORT in the past. 53% mixed the ORS incorrectly. 61% believed that ORT would stop diarrhoea and 29% that it was used for rehydration. Only 26% would give ORS after every loose stool, but 54% would give ORT until the diarrhoea had stopped. 59% of women would feed their children soft porridge, 20% would continue breastfeeding, and 2% would starve the child while it had diarrhoea. Women who had retained the Morley spoon showed a greater knowledge of ORT (p<0.005) and had used ORT more often in the past (p<0.001). Possession of a Morley spoon was, however, not associated with a higher frequency of correct preparation of ORS. This study also showed that community members may have been confused by the different methods of ORT taught and a strong plea is made to teach only 1 method of ORT. Failure to retain Morley  spoon might be approximated to a control group however there is the alternative explanation that women who were more interested and knowledgeable about diarrhoea were more likely to keep the spoons. The comparison between participants in the Care groups and non-members of the Care groups is confusing as, from the report, it appears that both received the spoons. This is a weak borderline and its case for retaining in the database needs to be reviewed.

 Elder J.P, Louis T, Sutisnaputras O, Suleeiman N.S, Ware L, Shaw W, De Moor C, Graeff J. (1992). The use of counselling cards for community health volunteer training in Indonesia: the HealthCom project. Journal of Tropical Medicine and Hygiene, 95, pp.301-308. Ref ID 605

Target Group/Country  Mothers living six villages in West Java

Intervention Methodology  Kadar were women who received training in the use of the counselling cards and in turn were requested to instruct women. Counselling cards consisted of  five 11"x 5" cards, one diagnostic card and four counselling cards. Diagnostic card had a  "Yes-  No" answer format that leads to the diagnosis of four  types of diarrhoea; mild, moderate, severe, and chronic diarrhoea. The treatment cards: one side has specific advice and steps the care giver should take, the reverse side depicts the proper mixing of ORS

Evaluation Design An intervention group: kadar (n=15) and mothers (n=105) from three villages and a control group: kadar (n=16) and mothers (n=112) from three villages in neighbouring regency. Villages equivalent for socio-economical and environmental conditions. Kadar performance was measured by observation of role playing prior to community intervention. There was random selection of 94 of the 217 women ( 3 women per kadar) for validation interviews and observation

Impact Achieved  Diagnoses by kadars were performed significantly better than controls (81% v 30.55, P<0.001) and they also responded significantly more accurately to all but moderate diarrhoea than controls. Mild diarrhoea:78.3% correct v 7.7% controls P< 0.05. Moderate diarrhoea: - 46.7% correct v 21.7% controls NS. Severe diarrhoea:89.7% correct v 25.6% controls P<0.005. Chronic diarrhoea:73.9% correct v 20.9% controls P<0.005. The mean percentage of diarrhoea instruction, as reported by the mothers, given by the kadar in the intervention group was significantly higher than the controls P < 0.005. The mean percentage of Oralit preparation tasks performed correctly by the mothers in the intervention group was significantly higher than those in the control group (97% intervention group v 74% controls, P < 0.001).

Kumar,V., Kumar,R. and Raina,N. (1989)  Impact of oral rehydration therapy on maternal beliefs and practices related to acute diarrhea.  Indian J. Pediatr.  56, 219-225. Ref ID: 2685

Target Group/Country Mothers in a rural area of Nigeria

Intervention Methodology Verbal instructions and demonstration by public health nurses on preparation of ORT.

Evaluation Design 255 mothers were interviewed prior to the educational programme. 184 mothers were followed up 309 months after the session and interviewed and observed in the practice of ORT and preferred way of managing the disease. There were no controls.

Impact Achieved Although the proportion of mothers that knew how to prepare and give oral rehydration therapy (ORT) increased significantly from 6.2 to 47.0% (p<0.01), few (9.5%) were practicing it during subsequent episodes of diarrhoea. The use of starvation by the mothers also decreased significantly from 43.0 to 8.2% however the use of traditional medicines and medicines from chemists did not show any significant change. The beliefs that sugar worsens diarrhoea, that home-made ORT was not a medicine, and continued reliance of the mothers on traditional healers and medicine dealers for advice were factors constraining adoption of the ORT by the mothers. Given the largely negative outcome of the educational programme, lack of controls should not be seen as a constraint to its validity

Nations, M.K., de-Sousa, M.A., Correia, L.L., and da-Silva, D.M. Brazilian popular healers as effective promoters of oral rehydration therapy (ORT) and related child survival strategies. Bulletin of the Pan American Health Organization Y1 22(4):335-354, 1996. Ref ID : 3301

Target Group/Country  The village of Pacatuba in Ceara State in northeastern Brazil

Intervention Methodology  In 1984 a two year programme initiated in which 46 popular healers, including rezadeiras and oradores (prayers), Umbandistas (priests), espiritas (mediums), an herbalist, and a lay doctor, were recruited and trained. The healers were taught the basic biomedical concept of rehydration and how to mix the ORS -- 7 bottle cap-fulls of sugar and 1 of salt in a litre of unsweetened traditional tea. The healers were also taught how to use the World Health Organization's (WHO) ORS packets  for cases of moderate to severe dehydration. In addition, the healers were taught the 5 basic health messages: give ORS-tea for diarrhoea and dehydration (or any similar folk illness, such as evil eye, fallen fontanelle), continue feeding, encourage breast feeding, do not use drugs, and ask people to seek the healer quickly at the onset of diarrhoea. The healers continued to perform all the popular rites and prayers traditionally associated with curing diarrhoea.

Evaluation Design In 1984 a 2-year research project was initiated in to test the theory that mobilizing and Pacatuba was divided into 3 groups, each containing houses at 4 different income levels. The mothers in 204 Group 1 homes were interviewed concerning ORT and diarrhoea-related knowledge before intervention, and 226 households in Group 2 were interviewed after intervention.13 of 46 healers were asked to recite back the recipe for making ORS and 7 samples of ORS “tea” made by these halers was analysed. The healers distributed approximately 7400 liters of ORS-tea in 12 months at a unit cost of 48 cents (US). All 13 of popular healers correctly recalled the ORS tea recipe and the laboratory tests showed no ORS "tea" to be hypernatremic.

Impact Achieved  There was an increase in mothers awareness that ORS must be given when diarrhoea strikes (84.2% to 93% , P<0.01)) and of ORS "tea" ( 2.9% 71.2%, P<0.001). The greatest increase in awareness was among the poor and the authors suggest that this was due to the popular healers. 54.2% of all mothers started using ORS "tea"  There was an increase in mother awareness of free ORS packets (56.45 to 75.2%, P<0.001). However, the use of ORS packets did not rise significantly There was a decrease in mothers who said they restricted food (71.1% to 53.1%, P<0.001). There was an increase in mothers who believed in breastfeeding during diarrhoea (71.2% to 92%, P <0.001). There was a significant reduction in the use of anti diarrhoeal drugs (93.1% to 72.65, P <0.001) and in the use of commercial ORS (37.0% to 11.5%, P< 0.001). In both cases the greatest changes were among the poorest mothers. Note 100% of "richer" mother believed and used drugs this reduced to 87.5%. Following the introduction of the ORS-tea, purchases of the more costly WHO packets and other commercial medications and antibiotics fell off significantly. The people's belief in folk aetiologies remained unchanged, showing that traditional healers can be successfully integrated into an effective health care program. The success rate of the ORT program in Pacatuba, carried out entirely by word of mouth, compares favourably with expensive mass media campaigns in other places.


6.2  Clinic-based interventions

Bandyopadhyay, S., Banerjee, K., and Sharma, R.S. Practices of preparation of oral rehydration solution among mothers reporting to the drug distribution centres in Delhi, India, 1992. Journal of Diarrhoeal Diseases Research 11(4):249-251, 1993. Ref ID : 6367 (Borderline for inclusion in database)

Target Group/Country  Urban communities in Delhi, North India

Intervention Methodology  Routine function of Government service outlets including giving out of ORS packets.

Evaluation Design One centre from each of the municipal zones of Delhi was selected randomly.  Four hundred mothers who had taken a child having diarrhoea the nearest centre and had received ORS packets were studied using a standardized questionnaire adopted from the WHO household survey schedule. 85% of the interviews were competed within 7 days of the receipt of ORS from the drug distribution centre. Two paramedical personnel from each of the centres who were responsible for distribution of ORS were also interviewed regarding their knowledge of preparation of ORS. There were no controls and no baseline.

Impact Achieved  Results indicate that only 10.8% of mothers utilised the recommended full packet for the preparation of ORS and the rest used part of the packet only. Of the mothers who used a full packet 91.5% used the recommended one litre of water and the rest used less than one litre. prepared the ORS correctly. This showed the inadequacy of the accompanying health education on diarrhoea provided at these clinics (though the interviews showed that the majority (83%) of the paramedicals involved in ORS distribution that were interviewed had correct knowledge about its preparation.  Despite lack of controls and baseline, this is a useful practical evaluation. It is unfortunate that there is no data on whether health education/explanation was actually provided.  Given that the health workers displayed a satisfactory level of knowledge of diarrhoea, it would have been of value to have included some data gathering to explore why there was no impact on correct preparation. From the data it looks as if all the mothers actually tried to make up the ORS - however it is not clear. If that was the case, it would appear that the problem was not the mother's motivation to give ORS, but her understanding of the correct way of making it up. This is a good example of the kind or follow-up that can be carried out within routine services to find out the impact of educational activities. However, lack of controls, lack of baseline and insufficient data on the amount of health education provided limit the value of this study,

Brieger, W.R., Ramakrishna, J., Chirwa, B.U., and Arday-Kotei, M. Developing health education for oral rehydration therapy at a rural Nigerian clinic: part I. Patient Education and Counselling 11(3):189-202, 1988. Ref ID : 3273

Chirwa, B., Brieger, W.R., and Ramakrishna, J. Evaluating health education for oral rehydration therapy at a rural Nigerian clinic: part II. Patient Education and Counselling 11:203-213, 1988. Ref ID : 6410

Target Group/Country  Patients at rural community hospital in Nigeria

Intervention Methodology  Educational activities at the Oral Rehydration Therapy (ORT) Unit consisted of an interactive session between groups of 5-10 mothers who brought their children to the general preschool clinic because of diarrhoea and the health aides who manage the Unit.  A series of 8 posters about diarrhoea and its management served as prompts for the health aides who engaged mothers in discussion around what they perceived in the posters. Mothers beliefs were sought and attempts were made to guide discussion so that a synthesis or common ground between community ideas and medical knowledge was achieved. The session culminated in a participatory demonstration on the preparation of salt-sugar solution (SSS). Each mother had a chance to practice levelling the 10 3ml teaspoons of sugar and one teaspoon of salt that go into the 600ml (one beer bottle) of water required in the formula being promoted at that time.

Evaluation Design Pre- and post-test evaluation record forms were completed on a total of 524 attenders of the Diarrhoea Treatment Unit between late September 1985 and June 1986. Their ideas on diarrhoea prevention and treatment and SSS preparation were recorded. Each of the 524 homes were visited at least 3 times during the two months from September 1986. A total of 124 women could be traced. The were asked the same questions as at pre and post-test and in addition mothers were asked to mix the drink. And their performance was observed. Mothers were also asked for details of recent episodes of diarrhoea. 110 mothers from the same neighbourhood as clinic attenders were selected as controls.

Impact Achieved  Konowledge of mothers about diarrhoea rose from 49.2% at pre-test to 100% at post-test and remained high at follow-up (91.1%) which was significantly better (p<0.0005) better than the 53% of control mothers. 36.4% of controls listed SSS as part of treatment in contrast to 87.1% of women at follow-up (p<0.0001). All of the124  clinic attenders followed up knew about the beer bottle method and 74.7 (n=111) could correctly describe it. Only 27 out of 110  control mothers knew about the beer bottle method and of these only 14.8 could correctly describe it (p<0.0005).6.3% of Unit attenders added more salt than recommended compared to 25.9% of controls who attempted the method. There were 26 bouts of diarrhoea reported among the clinic attenders and 17 in the controls. More than double the number of attenders (80.8%) reported using SSS  during those episodes compared to 35.3% of controls (p<0.005).

el-Mougi,M., El-Akkad,N., El-Hadi Emam,M. and Talkhan,A.M. (1986)  Evaluation of a programme of teaching mothers the management of acute diarrhoea.  J. Trop. Pediatr.  32, 24-25. Ref. ID: 7855

Target Group/Country  Mothers whose children attended the Diarrhoeal Disease Research and Rehydration Centre, Bab El Sharreya  University Hospital, Egypt.

Intervention Methodology Mothers were taught after the treatment of their children at the clinic. Teaching was done by a doctor and nurse in groups of 10. Each session lasted 1-2 hours. Educational objectives: 1) to recognise two dehydration signs, 2)to correctly prepare and administer ORS as long as baby accepts it, 3) prepare two suitable foods ( breast/ formula) given during diarrhoea.  Method: Practical sessions used household utensils and the locally produced ORS packet. Skills were broken down into steps. Mothers practiced and were given plenty of praise. The doctor then prepared the ORS solution making mistakes for mothers to point out. Mothers then repeated the preparation of ORS. Lessons on feeding, diagnosis of dehydration were demonstrated followed by feedback from mothers. Signs and symptoms of dehydration were shown from children on the ward, photos or by pinching the back of the hand.

Evaluation Method Of a pool of 600 mothers who had attended the educational programme 100 were selected at random. Each mother was asked to identify a good friend and 100 of these formed the sample of 'neighbours'. 100 mothers from a distant neighbourhood formed the controls. Post intervention interviews were carried out with mothers in all three groups 3-7 months after the intervention. Mothers were asked to prepare ORS for the interviewers. There was no baseline.

Impact Achieved  There were significant differences between the three study groups (p<0.01) in the use of ORS (98% cf. 41% cf 8% for intervention, neighbours, controls) , the knowledge of correct preparation of ORS 100%, 82% and 73), continued feeding (84%, 24%, 3%). The intervention mothers scored highest, neighbours second and controls lowest.  Knowledge of the major signs of dehydration and continuing feeding ( breast / formula) showed no significant difference between neighbours and controls but significant differences between these groups and intervention mothers. Authors suggest (but present no evidence) that the controls scores are due to the promotion of ORS via the television and that the higher scores of neighbours scores are due to intervention mothers passing on information.

Jacoby,E.R., Benavides,B.M., Bartlett,J.C. and Figueroa,D. (1994)  Effectiveness of two methods of advising mothers on infant feeding and dietetic management of diarrhoea Peru.  Journal of Diarrhoeal Diseases Research  12, 59-64. Ref ID: 6372

Target Group/Country  Mothers of small children attending a hospital's Oral Rehydration Unit in Peru

Intervention Methodology The intervention was carried out in a room adjacent to an oral rehydration unit. The first intervention group received oral counselling and a recipe pamphlet. The nutritionist gave each mother a 5 min. explanation of infant feeding practices making three general recommendations: 1) a puree is the best food for infants instead of customary soups and broths; 2) additional oil/;butter is necessary to "strengthen" weaning foods; 3) the recipe should be used regularly and also when the infant has diarrhoea The nutritionist described how to prepare one of the recipes and used two posters as a visual aid and gave a pamphlet of recipes that had been designed and pre-tested for that specific community. The second intervention group received the same counselling and recipe book but also observed a cooking demonstration which lasted about 20 minutes.

Evaluation Design The sample was drawn from mothers of infants aged 5-15 months who had initiated weaning, were fully rehydrated and resided in one of 11 poor districts of Lima. Once the mother child pair was recruited, the educational intervention was randomly assigned and the nutritionist in charge of it was selected by lottery. There were 74 mothers in the group receiving oral counselling plus pamphlet and 70 in the group receiving the additional cooking demonstration. Each mother was interviewed prior to the intervention, 48 hr post intervention and 30 days post intervention during home visits. Mothers were asked to recall all the food preparations and main ingredients given to the child during the previous day. Mother's recall as also used to determine the consistency of the food which was used as a proxy for energy density. To avoid bias from the interviewers preferences for particular educational methods, they were kept blind to the study objectives, Also the interviewer presented her visits as part of a comprehensive infant health evaluation and not as an evaluation of the infant feeding education. There were no controls.

Impact Achieved Both interventions had a statistically significant (p < 0.05) impact on maternal knowledge and practices; differences between the impact of the two practices were negligible. After merging both groups into a single sample, it was observed that changes over time were significantly large (p < 0.05). Knowledge rates were 27.6% before the intervention, 73.7% 2 days later and 75% 30 days later. The corresponding figures for practices were 2.6%, 58.3% and 37.5% respectively. They  conclude that when place, time and message are adequately chosen, a simple method may be an effective way of good communication. There were no controls, however given that the practices being introduced were new, this is not a major shortcoming. The demonstration that a simple educational method is as effective as a more complex one has useful practical implications.

Jinadu, M.K., Olusi, S.O., Alade, O.M., and Ominiyi, C.L. Effectiveness of primary health-care nurses in the promotion of oral rehydration therapy in a rural area of Nigeria. International Journal of Nursing Studies 25(3):185-190, 1988. Ref ID : 103

Target Group/Country  Mothers in a rural area of Nigeria

Intervention Methodology  Verbal instructions and demonstration by public health nurses on preparation of ORT.

Evaluation Design 255 mothers were interviewed prior to the educational programme. 184 mothers were followed up 309 months after the session and interviewed and observed in the practice of ORT and preferred way of managing the disease. There were no controls.

Impact Achieved  Although the proportion of mothers that knew how to prepare and give oral rehydration therapy (ORT) increased significantly from 6.2 to 47.0% (p<0.01), few (9.5%) were practising it during subsequent episodes of diarrhoea. The use of starvation by the mothers also decreased significantly from 43.0 to 8.2% however the use of traditional medicines and medicines from chemists did not show any significant change. The beliefs that sugar worsens diarrhoea, that home-made ORT was not a medicine, and continued reliance of the mothers on traditional healers and medicine dealers for advice were factors constraining adoption of the ORT by the mothers. Given the largely negative outcome of the educational programme, lack of controls should not be seen as a constraint to its validity [JH]

Mushtaque, A., Chowdhury, A.M., Karim, F., and Ahmed, J. Teaching ORT to women: individually or in groups? Journal of Tropical Medicine & Hygiene 91(6):283-287, 1988.  Ref ID : 1444

Target Group/Country  Rural women in Bangladesh

Intervention Methodology  The Bangladesh Rural Advancement Committee (BRAC) sent its health workers to individual households, and mothers were trained through a one-to-one approach. The cost of training a mother was 72 US cents. Recently, an alternative approach was tried. Instead of individually, mothers were trained in groups which halved the cost. :Female health workers taught groups of five women in the intervention villages.  Messages: "Seven points to remember": 1) Definition of diarrhoea, 2) When loose motion turns to diarrhoea, 3) Treatment, 4) When to give LSG and why, 5) How much to give, 6) Prevention, 7) Nutrition (*Abed 1983). Mothers were asked to prepare the lobon-gur solution (LGS) under the supervision of the female health worker. Note: same content for intervention (group) and control (individual) groups

Evaluation Design Intervention study with intervention (n=2498) and control (n=3851) groups from differing districts Comparison of individual and group instruction one year later using 1) Structured interviews conducted by female interviewers to evaluate mothers knowledge (2500 households in each area selected by multi stage random sampling). 2) Usage of LGSA determined. 3) A random 5% of mothers asked to make LGS and sample analyzed for chloride to evaluate safety

Impact Achieved  69% (intervention) and 75% (controls) of mothers scored >70%. The control group had a slightly higher mean score but this was not significant ( 8.0 v 7.7, P>0.05). Overall usage rate for LGS was very low, intervention 4.1% and controls 4.5%, difference not significant (P>0.05). There was an increased in the use of LGS for severe diarrhoea in both groups. There was little difference in the preparation of LGS between intervention and control groups. The cost of teaching groups was less than that of individuals without apparent compromise to the quality of education. Authors suggest that a change from individual to group teaching is reasonable. However they do caution that differences in group/ individual sessions might be dependant on group size and differences might become apparent in group numbering >5.

Nagarajan,L., Majumdar,S., Natarajan,U., Ganguly,N.K. and Walia,B.N. (1989)  A comparative study of different methods of training of rural subjects for reconstitution of oral rehydration solutions.  Indian Pediatr.  26, 323-329. Ref ID: 7447

Target Group/Country  Women from three rural villages in Ropar District of Punjab State, North India

Intervention Methodology  The women in Group I were verbally instructed in the regional language regarding how to reconstitute the entire contents of a sachet containing oral rehydration salts in half a litre of water. Women from Group II, were given the same verbal instructions and in addition, were demonstrated the correct method of doing the same. Subjects from Group III were provided with plastic bags containing oral rehydration salts, which when filled with water up to the printed line, was expected to accommodate half a litre of water, when the bag was hung from a hook or held by another person from its upper ends

Evaluation Design Group I (n=21), Group II (n=20) and Group II (n=20) after receiving the intervention were given a sachet of ORS at told that they should reconstitute the solution 2-3 hours later in the presence of the community health worker and the doctor. A sample was taken so that the sodium, potassium, and glucose contents of the ORS reconstituted by the three groups of rural women could be determined. Details of the sampling are not provided although data is presented to show that there was no significant difference in age, monthly income and literacy status between the women in the three groups.

Impact Achieved  The contents of ORS reconstituted by Group II, who were demonstrated the actual procedure following verbal instructions, were near ideal followed by the ORS reconstituted by Group III and by Group I which both differed significantly from the ideal (p<0.001). The conclusions drawn by the authors is that the mothers were better able to prepare the solution when they are exposed to an actual demonstration. Note that this evaluation is a measure of comprehension of instructions and not an evaluation of actual use of ORS.

Nwoye, L.O., Uwagboe, P.E. and Madubuko, G.U. (1988) Evaluation of home-made salt-sugar oral rehydration solution in a rural Nigerian population. Journal of Tropical Medicine & Hygiene 91, 23-27. Ref ID : 1457

Target Group/Country  Mothers attending the outpatient Clinic at Obukpa Health Center, Nsukka, Anambra State of Nigeria

Intervention Methodology  45 illiterate mothers were taught through repeated demonstrations of how to prepare sugar-salt solutions (SSS). The formula being promoted is one level (3ml) spoonful of salt and 10 of granulated sugar (or 5 cubes) dissolved in one standard beer bottle or two soft drink bottles (650ml) of clean water. The levelling is done with either the edge of a knife or the little finger so that the edge of the spoon is visible and free from the ingredient.

Evaluation Design The mothers were asked to prepare the solution at home and to bring samples on the same day to the clinic. 40 mothers responded and the home made solutions were analysed. There were no controls and no baseline.

Impact Achieved  Analysis showed that 60% (924 mothers)of them made accurately composed solutions. All the rest made hypertonic solutions with too much salt (more than 80mmol/l) which might give rise to hypernatremia. Salt type, spoon size and levelling technique are all possible causes of their error. The tendency to err only on the side of greater rather than lower salt concentration may be culture based or simply due to natural maternal instinct to give a little extra. This simple evaluation is typical of the many that were carried out at that time in the history of ORT and provided the evidence that led to the abandonment of the promotion of home made sugar salt solution in favour of ORS sachets.


6.3 Mass media/social marketing programmes for promotion of oral rehydration

Kenya, P.R., Gatiti, S., Muthami, L.N., Agwanda, R., Mwenesi, H.A., Katsivo, M.N., Omondi-Odhiambo, Surrow, A., Juma, R., Ellison, R.H., and et a Oral rehydration therapy and social marketing in rural Kenya. Social Science & Medicine 31(9):979-987, 1990. Ref ID : 1886

Target Group/Country  Rural community in Kakamega Districtrural area in Western Kenya

Intervention Methodology  Knowledge behaviour and practice (KBP) surveys and focus group discussions were carried out as well as over the counter surveys of shops to design the social marketing intervention. Banana flavoured sachets of ORS standardised to be made up in commonly available 250 ml mugs were distributed through shops and clinics. A price was fixed to give some incentive  to shopkeepers who were also trained to give advice on how to makeup the ORS. The campaign started in January 1986 with a public rally ('baraza') in which officials and local chieftains prepared an ORS mixture and drank it publicly. A locally-produced film was shown by mobile cinemas, , posters, calendars, leaflets and packet instructions were prepared. In the control communities no major campaign inputs were made other than supply of the clinic with unflavoured ORS and the provision of basic instruction on its preparation and use.

Evaluation Design Two communities of similar population of about 17000 and health facilities (a single primary health care clinic) were selected as control and intervention community and the population enumerated for subsequent sampling. A baseline KBP survey using a standardised questionnaire  of 500 randomly selected mothers with three further KBP surveys of 500 mothers at 6 month intervals during the campaign. A request to prepare a sample of ORS was made to 100 mothers randomly selected from the 500 and samples of the prepared fluid were analysed for sodium content. Note it is not clearly stated what the sampling for the control community. However from the data presented it appears that the 500 figure for sample includes both control and intervention with the breakdown between the two not stated.

Impact Achieved  The 'ever administered ORS' increased from 18% to 54% in the experimental community and 9 t0 37% in the control community (p<0.05). There was an increasing trend by round for those obtaining sachets through commercial channels which was only significant in the experimental community were the advertising campaign was instituted (p0.05%). The uptake of ORS sachets through the primary care clinic was similar for both experimental and control communities, indicating that the increase in use by the experimental community was due to purchase from the shops. The mean ORS given per episode of diarrhoea was 2 litres in the experimental community compared to 1.5 litres in the control community (p<0.0001). 56% and 54%  of ORS in the experimental and control communities had safe and normal concentrations of sodium. (40-120mmol/l). However sodium concentrations above these clinically acceptable safe levels were found in 13% of both communities. The authors provide a good descriptions of methods and evaluation finds but do not provide any information on cost and sustainability of the social marketing programme.

Koul, P.B., Murali, M.V., Gupta, P. and Sharma, P.P. (1991) Evaluation of social marketing of oral rehydration therapy. Indian Pediatr. 28, 1013-1016.Ref ID : 8246 (Borderline for inclusion in database)

Target Group/Country  Urban poor in Delhi, India

Intervention Methodology  The Government of India (Ministry of |Health) with help from UNICEF has launched a mass media campaign to popularise ORT through television from 1989. Brief spots using popular TV personalities were shown in prime time viewing to convey simple and clear messages regarding ORT and WHO/ORS formula for ORT. Packets are freely available to the mothers through dispensaries and urban basic health services volunteers.,

Evaluation Design One hundred and eighty seven consecutive mothers appearing at a Diarrhoea treatment Unit of Paediatric Outpatient Department (38 excluded due to non use of ORT) were administered a pre-planned questionnaire to assess their socio-economic profile, educational status, concept of diarrhoea and correct use of ORT. Fifty nine mothers who watched these programmes on TV regularly formed the study group. These were compared with 90 mothers who had gained such knowledge from non-television sources including health workers at clinics.. There was no baseline

Impact Achieved  The correct knowledge of ORT and actual use of ORT was significantly better in the mothers who had seen the TV spots than the control group (P<0.01). When the sample was separated according to the level of education of the mothers, among the better educated mothers (n=58) there was a higher % of those who watched the TV spots who knew how to correctly prepare ORT (n=22, 81.5%) than those who had only received information from health staff (35%, n=11) could correctly prepare ORT (p<0.01). The authors use this to infer that mass media had more impact on educated women and that low education women were more influenced by clinic health workers. However, this raises the question of whether educational level of the mothers is a confounding variable of more importance than actual exposure to mass media [JH]

Miller, P. and Hirschhorn, N. The effect of a national control of diarrheal diseases program on mortality: the case of Egypt. Social Science & Medicine 40(10):S1-S30, 1995. Ref ID : 1157

Target Group/Country  Mass media programme in Egypt

Intervention Methodology  The National Control of Diarrhoeal Diseases Project (NCDDP) of Egypt began in 1981, became fully operational nation-wide by 1984, and concluded in 1991. The project was designed as a campaign to lower mortality from diarrhoeal disease in children under five by at least 25% within five years. The principal strategy employed was to improve case-management of diarrhoea through rehydration and better feeding: through assured production and distribution of oral rehydration salts, education of families through mass media and health workers through training programs, and rehydration corners throughout the established primary health care and hospital network. The educational component of the programme was mainly conveyed by mass media with TV spots by a well known motherly character actress., radio, articles in magazine and a campaign logo that appeared on all advertisements.

Evaluation Design Change in the population was monitored over time through periodic knowledge-and-practice surveys, successive national household surveys before and  after the summer diarrhoea season, review of the national civil register and local area controlled trials, the national Demographic and Health Surveys.

Impact Achieved  By its own terms, the NCDDP appears to have succeeded in improving case management; by several local and national mortality surveys, overall infant and childhood mortality fell by at least one-third with the majority proportion in diarrhoeal deaths. The declines coincided with the peak of NCDDP activities and results in improved case-management. The detailed analyses of their monograph provides evidence to demonstrate that: (a) the mortality decline and the diarrhoeal mortality decline in particular were actual events; (b) that case-management improved with plausible sufficiency to account for most of the diarrhoeal mortality reduction; and (c) that changes in other proximate determinants to lowered mortality, such as host resistance or diarrhoeal incidence, do not plausibly account for the magnitude of the reductions seen. Data are also presented on general socio-economic changes in the decade of the Project.  The impact of the mass media campaign is inferred by the findings from Knowledge-and practice studies that after 1985 nearly 100% of mothers knew about ORS and dehydration. One survey found that in 1988 nearly 90% of mothers could mix ORS correctly.


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