Fighting Diarrheal Diseases/Cholera in Bangladesh

Fighting Diarrheal Diseases/Cholera in Bangladesh
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Evaluation Oral Re-hydration Therapy Communication Campaign (ORTCC)
fighting the Cholera and other Diarrheal Diseases in Bangladesh

Evaluation of the largest Communication Campaign in the history of
Bangladesh

In the last decade, thousands of people, mainly children used to die
from diarrheal diseases in Bangladesh (approx. 300,000/year), as it
is one of the most densely populated countries (over 864 people/sq.
kilometer) in the world with yearly massive flood and poor sanita-
tion.

With the efforts from different concerned agencies, the situation has
now markedly improved. The people became increasingly conscious about
safe drinking and sanitary habits. The most remarkable achievement is
almost all of them now understand the effect of diarrheal disease and
the requirement of extra fluid to replenish the lack of fluid in the
body of a diarrhea patient. Although, mentioning "Cholera" is forbid-
den by the government health authorities, along with the shigellosis
it has been predicted as the common cause of diarrhea in Bangladesh.

We are still poor, but we have been able to constitute a nationwide
system, the CDD, which is capable of dealing with any emergency
situation regarding diarrheal diseases. One might be happy to know
that in last devastating flush flood in the south-western Bangladesh
(September-October, 2000, when I was engaged in the area as the Medi-
cal Officer of MSF-Holland), out of approx. 100,000 diarrheal pa-
tients, only a few were detected severely dehydrated and the number
of death was non-significant frustrating many international agencies
that came there to set up Diarrhea Treatment Centers (DTC) and to see
thousands of helpless people! Local doctors and paramedics - with ap-
plication of their locally evolved participatory methods - proved
highly effective and low-expensed.

I think all of you know that Bangladesh has the maximum number of
NGVDOs working in the grass root levels in various fields including
the health. In one stage, MSF-Holland was waiting loosely until the
flood water receded (instead of starting mobile OPDs to treat the
thousands distressed in emergency peak periods, even after proposed
by the local staffs repeatedly!) and preferred to chlorinate the
tube-wells with bleaching powder flown from Europe with the expatri-
ate in very high cost, who had almost no knowledge of indigenous
health seeking behaviours, no knowledge of trends of the local dis-
eases and almost totally failed to achieve and initiate the vital
participatory approach, which resulted in their total isolation from
the people in emergency in the field of disaster.

Another important thing - please do not confuse the well advertised
role of International Center for Diarrheal Diseases Research, Bangla-
desh. The latter one is only involved in a hospital in the capital
city of Dhaka and in two or three project sites. Its main role is the
research. But the great service for diarrhea for more than 120 mil-
lions of people have been almost solely planned and delivered by Con-
trol of Diarrheal Disease, Directorate of Health, Ministry of Health
and Family Welfare, Government of Bangladesh in collaboration with
mainly UNICEF.
(Synopsis from "Evaluation of Oral Re-hydration Therapy Communication
Campaign", the evaluation of the largest communication campaign in
Bangladesh conducted by Associates for Family Health Research (AFHR),
a reputed health and Family Planning research firm of Bangladesh. Dr.
Shamim ul Moula was the Principal Investigator and main author of the
study report. The study has been funded by UNICEF, BCO and Royal
Netherlands Government. The outcome of the study is now the basis of
Control of the Diarrheal Disease in Bangladesh).

* This synopsis exposed on the Internet is strictly for non-
commercial purpose and for the benefit of the diarrhoeal disease pa-
tients. I shall be happy if any quarter engaged in the public health
field will benefit from the experiences and findings.


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National Control of Diarrhoeal Diseases (CDD) programme, Government
of Bangladesh and UNICEF, Bangladesh had been engaged in Oral Rehy-
dration Therapy Communication Campaign (ORTCC) to increase ORT use in
diarrhoeal diseases by the caretakers of children under five years of
age in the country. The campaign started in October 1996. CDD program
and UNICEF, BCO have initiated this study to evaluate the outcome of
the ORTCC to get a comprehensive feedback from the caretakers to spe-
cifically look into the degree of behavior change in diarrhoeal dis-
eases management imparted to them.

The fieldwork of the study has been conducted among the primary re-
spondents or caretakers (mothers mainly-over 16,000 in number),
Health Workers, Primary school teachers and Students as the secondary
respondents. For a qualitative assessment, in-depth interviews were
held with the program managers and Focus Group Discussions (FGD) were
conducted with Health Workers (Health Assistants) and Primary School
Teachers.

Study Findings

From the caretaker interview
Knowledge and perception

* Caretakers' knowledge of all the three golden rules has substan-
tially increased to 46.4 percent in the evaluation from 4.9 percent
in that of the baseline for ORTCC. Knowledge about the rule 1 (give
extra fluids), rule 2 (continue normal feeding including breast milk)
and 3 (referral) were increased to 98.8, 58.9, and 79.3 percents in
the evaluation respectively from those of the 37.4, 12.3 and 56.7
percents respectively in the baseline of ORTCC.

* The most important disseminators of knowledge about the three
"golden rules" have been found as the Health Assistants (60.2%), TV
and Radio (52.7%), Government service outlets (29.2%), Village Doc-
tors (26.0%), NGO workers and their facilities (16.6%), MBBS doctors
(9.2%), and Pharmacy/Drug sellers (8.8%).

* Caretakers' knowledge on diarrhoeal drinks had been found in the
evaluation as ORS (packet saline) of 89.7 percent followed by Molas-
ses Salt Solution (LGS-labon gur sharbat) of 73.8 percent . Other im-
portant fluids for diarrhoea known by the caretakers in home remedy
of diarrhoeal diseases were Green Coconut water of 51.7 percent,
boiled rice water or "Bhater Mar" (49.6%), husked rice water or
"Chirar Pani" about 38.7 percent. Knowledge in plain water was found
to be 16.7 percent.

* The most important sources of knowledge of the fluids for the diar-
rhoeal diseases are the Health Assistants (59.0 percent) and Radio/TV
(50.9 percent nationally of which the urban's share is greater as
87.4 percent) as found in the evaluation. Government Hospitals and
other outlets have accounted for 27.8 percent and Village doctors for
24.4 percent as found in the evaluation. NGOs and their associates
contributed for only 16.9 percent in the issue. The MBBS doctors are
accounted for 8.8 percent as the sources.

* About 75.4 percent of the caretakers in evaluation informed of the
perception of giving extra fluids to the diarrhoea patients in con-
trast to that of the 37.4 percent in the baseline study for ORTCC.
About 12.4 percent caretakers had the knowledge of continuing normal
quantity fluid in the diarrhoeal episodes of their children as found
in the evaluation.

* In evaluation, nationally 67.8 percent of the caretakers have the
knowledge of practicing normal or grater quantities of food during
the diarrhoeal episodes of their children in contrast to 12.3 percent
normal feeding in the baseline study of ORTCC.

* Nationally, about 65.5 percent of the respondent caretakers have
been breast-feeding their children during the time of the study.

* Nationally, about 80.8 percent of the respondent caretakers have
the correct knowledge of breast-feeding their children during diar-
rhoeal episodes.

* Nationally in evaluation, about 85.1 percent of the respondents
have the knowledge of referral in frequent watery loose motion in
contrast to 62.6 percent in the baseline study for ORTCC. About 83.3
percent of the respondents in evaluation have the knowledge of refer-
ral in patient's conditions of not getting better.

* Repeated vomiting is accounted for 37.4 percent in evaluation in
contrast to 27.4 percent in baseline study for ORTCC. Almost all
other percentages regarding to the referral knowledge have increased.

* About 73.9 percent caretakers have got knowledge about correct
preparation of ORS (packet saline) found in evaluation in contrast to
that of about 38.3 percent in the baseline study of ORTCC.

* Nationally in evaluation, about 36.0 percent caretakers have the
knowledge of the adverse effects with in-appropriate volume of water
in ORS preparation.

* About 41.4 percent of the respondents know the ineffectiveness of
the ORS solution prepared with the volume of water less than 500 ml.
Among them, 18.1 percent respondents knew the correct most informa-
tion i.e. " intensity of the loose motion is increased ".

* Most important sources of the knowledge regarding the adverse ef-
fects with the lesser volume water in packet saline preparation are
the Health Assistants (44.8 percent), TV and Radio (43.5 percent),
Government hospitals and other service outlets (22.4 percent) as
found in the evaluation.

* Nationally in evaluation, 52.9 percent of the respondents have been
found knowledgeable of the correct preservation time of the prepared
ORS of 12 hours in contrast to 19.3 percent of the baseline for
ORTCC.

Prevalence
* Nationally, two week and 24 hours prevalence of diarrhoeal disease
has been found as 9.0 and 4.1 respectively in the evaluation.

Practice
* Nationally, about 57.0 percent of the caretakers had been treating
or consulting for the diarrhoeal episodes of their patients.

* Nationally, Village Doctors (42.5%), Drug Sellers (22.3%), Govern-
ment hospitals and other service outlets (16.6%) and Health Assis-
tants (15.8%) are the major groups found to contribute in treatment
and consultation for the diarrhoea patients as described by the care-
takers in evaluation.

* Nationally, NGOs contribution in the issue is 3.6 percent, among
which, 1.7 percent is accounted for the rural.

* Nationally, about 52.9 percent of the respondents used medications
in the diarrhoeal episodes of their patients.

* In evaluation, it has been revealed that 95.5 percent caretakers
reported frequent watery stool and 61.1 percent observed their pa-
tients as not getting better. About 42.6 percent caretakers reported
of fever, whereas 33.8 percent informed of insufficient ingestion of
food and fluid by the patients.

* In evaluation, 59.3 percent of the caretakers provided increased
quantity of fluids to their patient in diarrhoeal episodes. In the
urban, the trend is higher as 71.1 percent in contrast to 56.4 per-
cent in the in the rural in the evaluation study.

* Nationally, in evaluation, about 71.6 percent of the respondents
have been found to practice normal or higher amount of food including
breast milk in the diarrhoeal episodes of their children.

* In evaluation, nationally 25.9 percent caretakers attempted feeding
of their children in the diarrhoeal episodes 8 times or more in a
day, 17.2 percent did it 5 times a day, 16.5 percent and 15.4 percent
did it for 4 and 6 times respectively in a day. Nationally 0.3 per-
cent did not give any food to their children in diarrhoea whereas 0.8
percent and 3.2 percent of the respondents did it for one and two
times a day respectively.

* In evaluation, nationally 53.9 percent of the respondents used
packet saline (ORS) as the diarrhoeal fluid, which is the highest
amongst its kind. Other frequently used fluids are Molasses Salt So-
lution (Labon Gur or Chini Sharbat) of 46.1 percent, Plain water
(53.0%), boiled rice water or "Bhater Mar" (27.5%)), husked rice wa-
ter or "Chirar Pani" (24.7%) and Green coconut water (22.7%).

* Nationally, in evaluation, Health Assistants are accounted for 48.9
percent as the source of recommendations of diarrhoeal fluids fol-
lowed by Radio/TV (30.4%). Health Assistants are major in the rural
area (54.6%). Village Doctors have been revealed as an important
source for the fluid knowledge (25.7% nationally). Government hospi-
tals and other outlets accounted for 24.3 percent nationally. MBBS
doctors are accounted for 7.7 as the source nationally.

* NGO clinic/NGO workers have been accounted for 10.1 percent nation-
ally as the source of knowledge; it is 12.8 percent in the urban and
9.4 percent in the rural areas as described by the caretakers in
evaluation study.

* Nationally, 81.6 percent caretakers used brand saline of SMC (OR-
Saline). Other commercial brands used were only 4.1 percent. Govern-
ment brands accounted for 14.2 percent.

* On observation by the AFHR Field Investigators, nationally 87.0
percent of the caretakers have used entire contents of ORS packet
while preparing packet saline. About 89.7 percent respondent caretak-
ers nationally dissolved the entire ORS packet content in the water
with higher proportion in urban areas (94.5%).

* Nationally, 65.5 percent of the caretakers have been observed to
use appropriate volume of water for the preparation of ORS solution.

* Nationally, 58.9 percent of the caretakers have been observed pre-
paring ORS solution correctly.

N.B. Any question regarding the study will be welcomed. Other inter-
esting features of the study can be sent through afro-
nets@usa.healthnet.org if anybody is interested.

Please contact:
Dr. S. M. Shamim ul Moula

N.B. Any question regarding the study will be welcomed. Other inter-
esting features of the study can be sent to you directly if anybody
is interested.