Awareness and practice of zinc therapy in diarrheal management among under-five caregivers in Enugu State, Nigeria

Joshua I Ugwu; Ikechukwu E Ezeagu; Madu D Ibegbu

doi:10.4103/1110-1067.271082

ORIGINAL ARTICLE

Year : 2019 | Volume : 24 | Issue : 2 | Page : 63-69

Awareness and practice of zinc therapy in diarrheal management among under-five caregivers in Enugu State, Nigeria

Joshua I Ugwu, Ikechukwu E Ezeagu, Madu D Ibegbu
Department of Medical Biochemistry, University of Nigeria, Enugu, Enugu State, Nigeria

Date of Web Publication

18-Nov-2019

Correspondence Address:
Prof. Ikechukwu E Ezeagu
Department of Medical Biochemistry, University of Nigeria, Enugu Campus, P.O. Box 15676, Enugu, Enugu State.
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1067.271082

Abstract

Background: Acute diarrhea remains one of the leading causes of under -five years of age (u-5) childhood deaths in Nigeria. Use of zinc (Zn) sulfate monohydrate with low-osmolality oral rehydration solution (ORS) therapy reduces both the duration and severity of the diarrhea episodes in children. There has been little progress in the widespread introduction and adoption of ORS plus Zn sulfate (ORS+Zn) therapy in Nigeria. Aims and Objectives: The aim of this study was to assess the level of awareness and practice of ORS+Zn therapy among u-5 caregivers. Materials and Methods: Two local government areas, each representing urban and rural settings, were randomly selected. Awareness and practice of ORS+Zn therapy by 386 caregivers was assessed using a semi-structured interviewer-administered questionnaire. Frequency and percentages were used for categorical data and the influence of sociodemography was analyzed by using Pearson’s correlation method. Results: Awareness and practice of Zn therapy was higher among the caregivers in the urban setting, who seems to be more exposed to information on the efficacy of ORS+Zn therapy (p < 0.05). Caregivers of u-5 children living in the rural settings were deficient in information on the use of ORS and Zn salts in the management of child diarrhea. In summary, of the 386 caregivers, 123 (62%) indicated awareness of Zn salt, and of these only 39 (10%) practiced Zn salt treatment. Level of education seems to influence awareness and practice positively in the urban setting (p < 0.05). Economic status underscored by employment type, clinic visits, and health campaigns influenced positively the adoption of ORS+Zn therapy in the rural and urban communities (p < 0.05). Tertiary education, which is the highest level of education, showed a positive association with awareness and practice of ORS+Zn treatment in both study areas (p < 0.05). One hundred and ninety-nine caregivers (52%) of all the respondents still preferred to treat child diarrhea with ORS with antibiotics adjuvant. Conclusion: Practice of ORS+Zn therapy is low and seems to be influenced by level of education, awareness, and location and availability. Advocacy and sensitization programs should be intensified, and intake of food rich in Zn and Zn supplement should be promoted in infant-feeding practices.

Keywords: Awareness, caregiver, children diarrhea, Nigeria, therapy, under-five, zinc supplement

How to cite this article:
Ugwu JI, Ezeagu IE, Ibegbu MD. Awareness and practice of zinc therapy in diarrheal management among under-five caregivers in Enugu State, Nigeria. Int J Med Health Dev 2019;24:63-9

How to cite this URL:
Ugwu JI, Ezeagu IE, Ibegbu MD. Awareness and practice of zinc therapy in diarrheal management among under-five caregivers in Enugu State, Nigeria. Int J Med Health Dev [serial online] 2019 [cited 2023 Jun 6];24:63-9. Available from: https://www.ijmhdev.com/text.asp?2019/24/2/63/271082

Introduction

Acute diarrhea remains a leading cause of pediatric morbidity and mortality, with 1.5 billion episodes and 1.5–2.5 million deaths estimated annually among children under-five years of age (u-5)^[1] in developing countries. Persistent diarrhea usually occurs with children living in poor or remote communities because effective interventions are not provided during this period.^[2] The prevalence rate of diarrhea in Nigeria is 18.8%, which is one of the worst prevalence of diarrhea in sub-Sahara Africa.^[3] Despite the undeniable success of oral rehydration therapy, diarrhea accounts for 16% of child deaths in Nigeria, and an estimated 150,000 deaths among u-5 children, occur annually mainly due to malnutrition, poor hygiene practices, unsafe water, and sanitation.^[4],[5]

The use of oral rehydration solution (ORS) saves children lives but does not seem to have any effect on the length of time the child suffers with diarrhea.^[6] Hence, new revised recommendation formulated by experts has been the use of zinc (Zn) sulfate monohydrate (Zn salt) with low-osmolality ORS (with reduced level of glucose and salt) during acute diarrhea.^[7],[8] This formulation is reported to reduce the duration and severity of the episode. Bajait and Thawani^[9] reported that Zn supplementation given for 10–14 days lowers the incidence of diarrhea in the following two to three months.

Despite the evidence-based benefits, there has been little progress in the widespread introduction of ORS and Zn salt combination (ORS+Zn) for the treatment of diarrhea. Many countries including Nigeria have changed diarrhea management policies to include low ORS+Zn, but there has been a gap between policy change and effective program implementation, with very few children currently being appropriately treated for diarrhea in Nigeria and several other countries.^[10] Awareness of ORS+Zn therapy ranged from 0% to 44.5% across six surveyed states in Northern Nigeria.^[11] Findings of Nigeria 2015 National Nutrition and Health Survey (NNHS)^[12] indicated that only 21% of children who had diarrhea were given ORS and only 6% received Zn tablets. This study, therefore, aims to assess the level of awareness and practice of ORS+Zn therapy in the management of child diarrhea in both urban and rural settings in Enugu State, Nigeria.

Materials and Methods

Study area

U-5 caregivers, from Enugu-South and Nkanu-West Local Government Areas (LGAs) (representing urban and rural settings, respectively), who gave their consent in the previous study (in this volume), were indirectly enrolled for this study.

Ethical clearance

Ethical clearance was obtained from Enugu State Ministry of Health and from the UNTH Ethical Committee, Nigeria. Informed consents were obtained from all caregivers of u-5 children who consented to be part of this study.

Study population

The study population included the caregivers of u-5 children, residing in Enugu-South and Nkanu-West LGAs in Enugu state, Nigeria, who were registered in nursery schools.

Inclusion criteria

The inclusion criteria of the study were caregivers of u-5 children, attending registered nursery schools in Enugu State, Nigeria, who gave their consent in the previous study (this volume).

Sample size

The sample size was calculated as follows^[15]:

where Ss is the sample size, Z is the z-value, P is the percentage of population, and C is the confidence interval.

The values for population >10,000 and <20,000 are as follows:

Sampling technique

A multistage random sampling technique was used in the selection of u-5 children and caregivers who consented to be part of the study. In the first stage, of the 17 LGAs, two LGAs, Enugu-South and Nkanu-West, representing urban and rural settings, respectively, were selected using a simple random technique (balloting). In the second stage, there were 13 and 12 wards in Enugu-South and Nkanu-West, respectively. Eight wards were selected using a simple random technique (balloting) in each of the two LGAs. In the third stage, in each of the wards, a school was selected also by a simple random technique by balloting. In the fourth stage, in each school that had more than 25 respondents, purposive sampling technique was used to select the u-5 pupils and caregivers that participated in the study. A total of 386 caregivers were eventually enrolled into this study (204 from Enugu-South LGA, an urban setting, and 182 from Nkanu-West LGA, a rural setting). A semi-structured interviewer-administered questionnaire was used to obtain information on the caregiver’s demographic profile and their knowledge and practice on the use of ORS+Zn therapy. A sample of the Zincfant^© was shown for identification

Data collection

A semi-structured interviewer-administered questionnaire was used to obtain information on caregiver’s demographic profile and their knowledge and practice on the use of ORS+Zn therapy. A sample of the Zn salt (Zincfant^©) was shown for identification.

Data analysis

The data collected were computed by Microsoft Excel and analyzed using the Statistical Package for Social Sciences software version 17.0, IBM SPSS (Armonk, New York, USA). Data were presented in tables and percentages. Pearson chi-square test was used to analyse relationship between awareness and practice and demographic parameters.

Results

The correlation analysis of awareness against practice of Zn therapy in the management of childhood diarrhea is shown in [Table 1]. Awareness had a significantly negative association with practice (r = −0.393, P = 0.035) in the rural, whereas a nonsignificant positive correlation (r = 0.366, P = 0.124) was observed in the urban. Awareness does not guarantee practice in the rural, but in the urban a positive correlation seems to agree with observed reports in other studies

Table 1: Correlation of awareness with practice of ORS+Zn therapy

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[Table 2] shows the extent to which awareness and source of information influenced the choice of caregivers in the management of childhood diarrhea. All caregivers interviewed were married. Among them, 167 (82%) and 177 (97%) in urban and rural, respectively, had child’s episode of diarrhea experience. Other caregivers either could not recall any diarrhea episode or had a less than six—month-old baby during the study. Awareness of Zn salt was significantly higher (P = 0.000) among the urban than rural dwellers. Eighty six caregivers (42%) in urban and 37 (20%) in the rural settings indicated awareness of Zn salt in diarrheal management. Only 24 (12%) and 15 (8%) caregivers practiced ORS+Zn therapy, respectively, among the urban and rural settings.

Table 2: Level of awareness, source of information, and practice of ORS and zinc therapy by u-5 caregivers

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Differences in the medium of information among the caregivers in the two locations were significant (P < 0.001) [Table 2]. The numbers of caregivers who became aware through clinic visits and Maternal, Neonatal and Child Health Week (MNCHW) programs in this study were 114 (56%) in the urban and 103 (57%) in rural areas, which were considerably higher than through the radio and personal contacts.

Demographic data of the caregivers show that the occupational difference in the urban and rural areas was significant (P < 0.001) [Table 3]. Although all urban caregivers were employed, 11 (6%) in the rural area were unemployed. One hundred and forty-seven (72%) of urban, and 37 (26%) of rural caregivers were civil servants or government employees. Self-employed (traders, artisans, or farmers) caregivers were higher in the rural (68%) than in the urban (28%) areas. Among the urban dwellers 196 caregivers (96%) have higher secondary education, whereas 133 (73%) of the rural dwellers had at least a secondary education or higher. The difference in the educational status among the rural and urban caregivers was significant (P < 0.001).

Table 3: Demographic profile of selected caregivers in Enugu State

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As shown in [Table 4], correlation analysis of the association between caregivers’ type of employment and the awareness and practices of ORS+Zn for the treatment of childhood diarrhea showed that nonemployment had a positive correlation with awareness but a negative association with practice of ORS+Zn therapy in the rural settings. Self-employment (artisans, farmers, or petty traders) has a positive association with both awareness and practice among caregivers in the urban setting. However, in the rural setting, self-employment showed a positive association with awareness, but negatively associated with the practice. On the contrary, civil service or government employment has a positive association with awareness and practice of ORS+Zn therapy in the urban setting but a negative association in the rural setting [Table 4].

Table 4: Correlation of employment status with awareness and practice of zinc therapy

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Pearson’s correlation analysis showed that educational status in both the rural and urban caregivers differed significantly (P < 0.001) [Table 5]. Formal education enhances the access of the urban dwellers to current information than their rural counterparts. Caregivers with only primary education showed a negative correlation with awareness and practice of ORS+Zn therapy in both the rural and urban settings. Only 46 (27%) of the rural caregivers possess primary education and therefore may be ignorant of Zn therapy as the best management option for child diarrhea.

Table 5: Correlation of educational status with awareness and practice of zinc therapy among u-5 caregivers

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The results also showed that secondary education had a nonsignificant positive correlation with awareness and practice of ORS+Zn therapy only among caregivers in the urban setting. Tertiary education, which is the highest level of education, showed a positive association with awareness and practice of ORS+Zn treatment in both study areas.

Discussion

The practice of ORS+Zn therapy among caregivers was dependent on their level of awareness and/or information on the drug efficacy. In this study, adoption was higher among the caregivers in the urban setting, who seems to be more exposed to information on the efficacy of ORS+Zn therapy for diarrhea treatment. Of the 386 caregivers enrolled in this study, 123 (62%) indicated awareness of Zn salt, of which only 39 (10%) practiced Zn salt treatment. The rate of use of ORS with Zn adjuvant by caregivers in this study was very low and this seems to be currently the trend in most developing countries. Similar observation was also reported in Tanzania.^[13] In a study in Bangladesh, Akhtaruzzaman et al.^[14] observed that in 400 cases of diarrhea in u-5 children, only 142 (35.5%) were treated with ORS+Zn. Another study in Northwestern, Nigeria, reported a 32% awareness of the use of Zn in the management of diarrhea,^[15] which is consistent with the results in this study.

The number of caregivers engaged in income-generating activities was higher in the urban setting and should be better off economically resulting in a higher level of practice than those living in the rural areas. Also those caregivers, especially in the rural setting, who were aware Zn salt, may be constrained by availability and cost and adopt the more common and cheaper ORS. A total of 119 (52%) caregivers still practice ORS with antibiotics adjuvant. Mazumder et al.^[16] reported that the use of Zn salt in controlled sites was significantly lower as compared with intervention sites in India.

About 30% of those living in the rural areas had primary education and this could dispose them to ignorance about diarrhea and its management. However, secondary and tertiary educational status was positively associated with awareness and practice of ORS+Zn treatment in both study areas. Formal education increases the capacity of people to access information. This is in line with several reports of positive association between knowledge level of ORS+Zn and educational status.^[17] All over the developing world, it is widely posited that mother’s education affects positively both her own and her children’s health.^[18]

One could assume that urban residence correlates positively with economic status and modernity of the caregivers. Thus, economic factors may have influenced the caregivers adoption of ORS+Zn therapy in the rural area. Okoh et al.^[19] reported that caregivers within the high-income class had a good practice of ORS+Zn therapy as compared with the low social class. Another study in rural western Kenya reported that caregivers who used Zn in combination with ORS were more satisfied and were willing to pay more for a course of ORS+Zn in the future than those in the nonuser group^[20] and adherence to were highly associated with having received appropriate provider instructions.^[21] This implies that a first experience or trial of the Zn and ORS therapy could influence the uninformed or nonusers to adopt the treatment regime. This could be facilitated by giving out free packs of the Zn salt (Zincfant^®) to caregivers as incentive.

In this study, the caregivers in the urban setting seems to be more educated than those in the rural settings, which could have influenced their level of awareness and choice of therapy in the management of diarrhea.^[22] Okoh et al.^[19] reported that caregivers who attended tertiary education had more knowledge and awareness on the proper practice of ORS+ Zn therapy.

This study also revealed that 199 (52%) of all the total caregivers (386) still prefer and treat child diarrhea with ORS+antibiotics and perceive it as the most effective. Most caregivers who were aware of ORS+Zn were either ignorant or uninformed of the efficacy. NNHS^[12] reported that diarrhea treatment survey in Nigeria showed that 21% children prevalently received ORS alone, whereas only 6% received Zn tablets. This is probably due to the fact that caregivers were much more familiar with ORS than Zn supplementation. This underscores the need for increased effort at sensitization of caregivers and the general public and to educate caregivers on the efficacy of Zn adjuvant in the management of diarrhea.

Therefore, a national sensitization program would be necessary to address the low-adoption ORS+Zn regime in diarrheal management. A study conducted in Zaria Nigeria showed that the proportion of caregivers with awareness on the treatment for diarrhea increased seven times after attending MNCHW programs.^[23] Providing opportunities for caregivers to receive a sample of ORS+Zn packs and information on its efficacy in the treatment for childhood diarrhea, especially from trained health personnel, will increase their awareness and raise the level of practice of Zn therapy in the management of diarrheal episodes. This approach can help achieve the sustainable developmental 2030 goal of ending preventable deaths of newborns and u-5 children.

Conclusion

Practice of ORS and Zn salts in the management of child diarrhea among caregivers in Enugu state, Nigeria, was generally low as compared with the level of the awareness already created. Caregivers living in the rural settings were deficient in information on the use of ORS and Zn salts in the management of child diarrhea. The old treatment approaches in diarrheal management, which includes antibiotics as adjuvant to ORS, are still prevalent among the caregivers.

Health facilities and health campaign programs especially in the rural areas have been proven to be good channels for awareness creation. Efforts should be intensified to increase the supply and raise awareness on the use and efficacy of ORS+Zn salts in the management of childhood diarrhea.

Acknowledgement

We wish to acknowledge the technical support received from Network on Behavioral Research for Child Survival in Nigeria (NETBRECSIN). We are deeply grateful to all the caregivers who gave their consent and participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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