Diarrhoeal diseases in the Gelukspan Health Ward 1983-94

Diarrhoeal diseasesin the
Gelukspan Health Ward
1983-94

Paulo Ferrinho

Part three of a three-partarticle.

Summary ABBREVIATIONS

Tlxi"sarticle is diuidedinto 3 parts. In ANC - AnteNatal Clinics
Part I a generalintro&rction tn the BF - Breast-feeding
Health Seruiresin the Gelukspan DD - Dianhoeal Diseases
Distrbt is giuenwith thereasonsfor FP - Family Planning
sucha suruey.The datn from children
admittedwith dinrrhoealdiseosesto HDD - Household where at least one of the underfive children
our ward ouera period of 7 months
are annlysedw, ith regardtn seasonal, has had diarrhoea over the study period
ogg sucunland nutritinnnlfactorsas NDD - Households where none of the underfive children
well as rnortality.Then tlw 70
questionnairecsompletedwith the ORS - had diarrhoea over the study period.
caretnkersof theabouechiJdrenare PNC - Oral rehydration solution
discussedand analysed SSS - Postnatal Clinic
UFC - Salt-Sugar Solution
Part II representtsheresultsof a Underfive children
cornmunitysuruqton dinrrhoeal
diseasesconductpdin 1984,irrcIuding
the attittdes and knowledgeof the
caretnhersconcemingthis diseaseand
aspechof domesti.chygLerle.
In Part III thefindings are
disansedin relationto othersuruq/s
in NrW to undersnnd what is
hnppenirryregardirrydinrrhoeal
diseasesin the Gelukspanarea.Some
corrclusionasnd recommend,atioanrse
made.

Dr Paulo Ferinho MB ChB
Gelukspan Community Hospital
Private BrgX25
RADITHUSO
2746
Republic of Bophuthatswana

SAFAMILYPRACTICEJI.-TN1E985 I75 SA HUISARTSPRAKTYK JI'NIE 1985

Diamhoeal diseases

DISCUSSION 6 years in their sample had been weaned before the age
In this discussion we will try to integrate the data from of four months.
our study and to understand iL We will review some
Iiterature, where relevant and we will make use of data Our own figures (Table 3.3 in Part 2) about mothers
from the previous sruveys conducted in our health ward. that ever breast-fed their babies (rather than babies
We will concentrate on the decreasedincidence and the that were breast-fed at the time) show a less favourable
mortality of DD in our district picture - only about 60% of the mothers ever breast-
fed their babies. The limitations of the way in which the
TFIE INCIDENCE OF DIARRHOEA question was asked have already been discussed and
Table 4.1 summarizes the situation in our district and therefore our numbers may not be representative. What
the changing picture concerning the incidence of DD may be more imporfant is that in HDD, 55% of the
and its mortality between1980 and now (1983). mothers admitted to breast-feeding their children vs.
61% n NDD; although the difference is not significanl
TABLE 4.I it is suggestive(0,5 > p > 0,1). Still more sigrrificant is
THE INCIDENCE ANID MORTALII'Y OI'DI) the fact that of all children admitted with caretalers,
only 7% (under five years) or I9,2% (under 6 months)
1980(2) 1983 were exclusively breast-fed.

Total underfive population 1 03 1 1 11303 Table 4.3 compares the rate of breast-feeding in DD of
children admitted with caretakers to our wards, with the
Rate of DD (UTC) 49,a% 25,gVo rate of breast-feeding children in the same age groups in
the disfict
Total number of UFC wit]r DD 5052 29L6

Case fatalily rate 5,4y. 3,0%

numberof UFC tbat died wi* 213 8? TABLF 4.3
DISTR.ICT5
;$al AGE WARD
62,8vo e' . 60, 3%%
orUFCdueto DDPer 26 I2-24 months rr,9V",
iSAfrFE } 24 months

DD deathsas Voof all UFC deaths 22,0% 4L,27t

There was a sharp decrease over 3 years in the The above numbers could either reflect the protective
incidence of DD. We were unable to obtain data with role of breast-feeding which some authors deny after the
reliable figures indicating the incidence of DD in other age of 6-8 monthsl3, or could reflect other factors
rural areas of RSA. Most of the data in the world association with non-breast-feeding eg absence of the
literature concerns surveys canducted in the late 1970's mother on seasonal work, having the child under the
and therefore our data is not comparable. Another care of an inexperienced caretaker, our data does not
aspect is that we look at children that had diarrhoea allow further explanation of this matter.
and not at the number of episodes of diarrhoea. The picture that emergesis therefore that the percentage
of children breast-fed now is the same as in 1980 ; in the
How can we explain such a significant decrease in the district the samepercentageof mothers in HDD asin NDD
incidence of DD ? It is linown that some factors do have breast-fed their children; a significant proportion of
mothers stop breast-feedingvery early and DD appearsto
an impact in the incidence of diarrhoeal diseases: select these children, or at least these children more
breast-feeding weaning practices, the nuh:itional status frequently have DD that need hospital heatmenl
of the underfive population, measles immunization,
water and domestic hygiene. We will look at each of NUTRITIONAL STATUS
these asoects in detail.

Diarrhoea and malnuhition are associated in a twoway

In this suruey we Inoh at cause and effect relationship; diarrhoea causes and
childrcn who hnd d,inrrhoea
and rwt a,tthe rutmber of aggravates malnuh:ition and malnutrition predisposes
episod,esof dinrrhoea.
children to a diarrhoe4 which is more common and severe

in malnourished children than in their well-nourished

counterparts 1 5 ' 1 6 ' 1 ? ' 1 8 ' 1 e ' 2 0 2 32 ' 731' 7'41' 75 ' 7 6 ' 7 78' 7,

BREAST-FEEDING AND WEANING PRACTICES Our results in Graph 1-3 in Paft 1 show that the average
Several studies have demonstrated a lower incidence of weight of children admitted with diarrhoeal diseases is
diarhoea in breast-fed infants than in partially brest-fed consistently lower than the averageweight of our district
or artificially fed infants during the first months of children. Also shown(Table 1.2 in Part 1) is the association
lifel2'r3.It is therefore not surprising to find that when between malnutrition and mortality. Suweys conducted
weaning is early the incidence of diarhoeal diseases over the years in our health ward showthat the prevalence
tends to peak early when it is prolonged, the reverse is of weight for height of lessthan 80% of the Haward mean
truera. was33% in 19791and this has droppedto 1% in 19835
after an active nutrition intervention program€.
In our health ward at least 87% of our children are
breast-fed for some time and this was true for 1979 as We believe that the above aspect is possibly the main
it is for 1984I'5. More worrisome is the fact mentioned contributing factor for the decreasedincidence of DD in
by Knaap and Bekkers' that36% of the children under the district, which in return further contributed to the
decreasein the amount of malnutrition.

SAFAMILYPRACTICEJLINE1985 176 SA HUISARTSPRAKTYKJUNM 1985

Diarrhoeal diseases casesof DD admitted to the hospital only 50% of those
admitted with caretakers were routinely boiling water
MEASLES IMMIINIZATTON before consumption The sigrrificanceof this observatiorl if
The traditional healers in our health ward recognize any, is not clear but it seemsto point to the fact that boiling
measlesas one of the causesof diar:rhoeaand some of the of water might protect against the most severe forms of
remediesusedfor the treatment of DD are equallyusedfor DD, those requiring hospital admission.
the treatment of measles. This association is also
recognized in the medical literature and has been Diinwlwefr,eg,uaesand'
extensivelystudied22'24.25'2S6o.m2?e. of the authors have a,ggr&uates.tnalnutritinn, and
pointed to the importance and the likely impact of measles malnutrft ionprcdispo$.es
immunization in reducing the incidence and mortality of ehild.rcn to dinrrhoea.
DD in underfive children2;. The primary health care
programme in our district has had a significant impact on Concerning water availability in 1981'z,I00% of all the
the measles immunization status of our underfive householdsin a random samplewere within 500 metres of
population. While in 1980 only 56% of the preschool the nearestwater sourcewhich in the majority of caseswas
populationhad had oneortwo measlesvaccinationsi,n the a pubLicborehole (underground water). Since then a few
last survey conducted in our district in 1984 the number more boreholes have been drilled. This distance seemsto
had increasedtD 82,4%.This level of immunization would be adequateascomparedto other third world rural areas83.
prevent I,3a/ato 3,87aof all diarrhoealepisodesand 12 to A worrying finding of the 1981 report'zwas that in summer
25% of all diarrhoealdeaths'z?. 35% of the sample and in winter 45%, admiLtedto water
shorbage,particularly in associationwith wind-dependent
ASPECTS OF DOMESTIC HYGMNE water supplies,in the same study 22% of the boreholes
werefound to be out of order. The situation at the moment
Water is not known
The classicalview of diarrhoeal diseasestransmission
through faecally contaminated drinking water has been Pit Intrines
modified and now it seems more probable that in Disposal of faecal material is imporbant in the control of
underdevelopedareasmost of diarrhoealepisodesare due diarrhoeal disease,but if not properly implemented it can
to anus-hand-mouthspread'zeT. his is consistentwith some have a deleterious effecl In our districl over 90% of all
reports that the contamination of drinking water does not households admitted to the availability of latrines. Their
correlate with the rate of intestinal infections or DD in the use was not assessedbut it is my impression that there is
communityl2r8'?ea, lthough other studies seem to show a room for great improvements in the building (siting, for
relationship between water quality and DD30.What all the example)and hygienicuse(hand washing)of latrines in our
evidenceseemsto point at is that in the presenceof poor districL There was no difference between the percentage
hygienic practices there seemsto be little or no benefit in of HDD and NDD that had pit latrines. Van As and
improving water quality. What seemsmore important is Kasbergen indicate that contamination of underground
water quantity, the amount of water availablefor personal water seemsto be a problem in our district2.
and domestic hygiene and the evidence seemsto indicate
that modest increases in water availability may have a Other
significant impact on the incidence of diarrhoeal Other aspects may play a significant r6le in the
diseasessl'333fna.our district no recent studieshave been epidemiologyand incidenceof diarrhoealdiseases.Some
aspects of knowledge (for example, boiling of water) have
We found it mnrc importnnt to already been discussed, but what is the impact of
imprnue tlw qunntity of water educational levels and individual knowledge, attitudes
than ta imprcue tfrp qi,a,li$' and practices with regard to household hygiene and the
hygienic management of children on the transmission
conductedon water quality exceptfor the one in 1981 by cycle? A Colombian study shows that a mother's
Van As and Kasberger? and this study failed to show any perception of malnutrition in her child, the age of the
relationship between water contamination of the source mother, the houseappearanceand the mother's knowledge
and diarrhoeal diseases.Another way of assessingwater were important predictive variables concerning the
qualiflr, and maybe a more important way as it assesses prevalence of diarrhoeal disease in the two weeks
water quality and handling before domestic consumptiorq preceding the study8.It is possible,I believe,that this
would be to askabout boiling of water before consumption
In the study already mentioned in 198f it was found that DD rs u laarniq e$peri,gTtceto
the frequency of diarrhoeal episodeswas related to boiling the mnthprs eorrnempd
of ',\,aterbefore consumption. In households where there
wasone DD episode,73% of the familieswere not boiling increasein knowledgemight be due to an increasedcontact
water and this increased to 85%, 9l% and 100% with diarrhoea in the period preceding the hryoweeks of
respectivelyfor 2,3 and.4or more episodesper household. study period. If that was the casethe abovefindings will be
In the samestudy it wasfound that betweenilZo and82"/o in line with our own findings, that mothers of children from
of all the families (varied from village to village) were not HDD out-performed mothers of children belonging to
boiling their water before consumingit. In this study we fail NDD, in the questions in our community survey,
to demonstrate any difference between NDD and HDD
concerningthe practice of boiling water before consuming
it. What is more interesting is that while in our community
70% of aJlthehouseholdsboil water before consumingif in

SAFAMILYPRACTICEJUNE1985 177 SA HUISARTSPRAKT\XJTINIEI985

Diarrhoeal diseases their children for 5-6 months following delivery then most
of these children together with the ones born in the
concernedwith knowledge and attitudes (scoresof 61,7% following months will be taken over the "diar:rhoeal
vs55,67o),which oncemore illustrates thatDD is a learning season" with a lower mortality rate. The management of
experienceto the mothers concerned. intercurrent infection, the distance from the health centre,
the home management of diarrhoea and the skill of the
Other studies seem to indicate that high educational health workers are all important aspectsthatrequire some
achievements are associated with poor health detailed discussion
practices3T'3T8h. is wasnot found in this study. We find that
educational levels in our suvey are not significantly Inte rlalrent infectians
different from educational levels of caretakersthree years Diarrhoea in a child is no more tlran a presenting symptom
ago'. The average education of caretakers belonging to of a whole range of conditions. Our results in Table 1.2
HDD wasthe sameasthat of caretakersbelongingto NDD. in Part 1 suggestthe important contributions of parenteral
We might conclude that despite the fact that mother- infections to the mortality of children with diarrhoea Our
education correlates with the malnutrition of the child' it own experienceat poshnorbemsofthese unforbunatecases
does not appear to relate to the incidence of DD in the shows that by far the commonest finding in fatal casesof
district DD is bronchopneumonia. This has been recognizedin at
least another report: Greenhough reports from
TI{E MORTALITY OF DIARRHOEA Bangladesh that respiratory diseases,are by far the most
Diarrhoeal diseaseshavea significant impact on childhood common complications and cause of fatalif in the
morbidity and mortality. Even in developed counhies diarrhoeal patients treated in Matlab Hospitala3. The
gastroenteritis is still among the ten leading causes of significance of this is that a further reduction in DD
death for children under 5 years of age3e.In Africa the mortality will, to a large extenf depend on the prevention
averageUFC mortality due to DD is 13,8 per 100041 and proper management of respiratory tract infections.
(range8,9-F5,7tD 76,8+L9,3) deaths per 1000 tIFCn). This brings us to an important and controversial aspectin
In South African black children in 1970 the LIFC morta the management of DD: the use of antibiotics. The
lity due to gashrrenteritiswas 12,5 per 100ff0 being 9 to literahre in general hies to play down its use and
32 times that of white children 76'80T.he morality rate varies recognizes very few indications for themffi, 6s'70'55M. y
betweeninpatient and outpatient reports but the mortality experience and at least one other reportsl are not in
for inpatient black children remains very high between agreementwith the above-mentionedliterature. As already
23,0% n some urban a-reas7a8nd over 40% n some rural discussed, diarrhoeal diseases not infrequently €ue
areas (Dr M. Hlalele, personal communicatiorl February accompanied by systemic infections that are often fatal
1985). The picture in our district seemsto be better, not The need therefore arises to recognize that although the
only in relation to our recent past but alsoin relation to the indications for the use of antibiotics in gastroenteritis is
rest of Africa. By consulting Table 4.1 again we see that limited in DD, the indications should be liberal and should
not only has the incidenceof DD decreasedbut there was read as follows:-
also a significant reduction in diarrhoeal deaths. The
1. Severe malnutrition
DD hns a signifinant impact 2. Pus or red cells in the stools
on ehi,Idhoodmorbidity and 3. Ctuonic or currecnt diarrhoea (Giardia lambia being
mofteliw. the commonest cause)
4. Obvious bacterial parenteral infections
case fatality rate for hospital inpatients has been reduced 5. Recognizablepathogens- choler4 shigell4 giardiasis,
from 12,2"/ain 1982 tn 6,7% in 1983 and5,77oduring the campylobacter jejuni
present study period. Still very significant is that while in 6. Diarrhoea associatedwith measles?O
1980DD accountedfor only22,0% of all underfive deaths,
in 1983/4 they accounted for 4I,2%. This means that No harm is done and many lives will be saved
aggressive atfempts at curbing DD mortality will have a
signifrcant impact in under{ive mortality. Management of DD by thc carctaherc at hom.e
Home management of DD wiU depend on culh:ral factors,
What are the reasonsforthese improvements?Some of the previous experiences, educational levels, accessibilif of
reasonssuch as improved nutritional status and improved the health services and the successof these same health
immunization status against measles have already been servicesasT. he use of self-medicationmust definately have
discussed. Some factors such as age of child, are not an impact on the mortality of DD as it might unduly delay
amenableto intervention (most studies report the highest the presentation to the adequate health centre. Studies
morbalities for children under 1 year of age). But if we from other counhies and from other cultures in SA indi-
considerthat children bom just before and at the height of cate a high rate of medication at home before atbending
"diarrhoea season" have the lowest death rates for a health centrer5'3aA. study conducted amongst semi-
diarrhoeal diseasesduring the first year of life (becauseof urbanized Tswanas appearc to indicate that home
exclusive breast feeding during this period) la then we medication for DD is not commonly practiceda6.
might have good reason for rejoicing in the fact that the
month of September is the one with the highestmidwifery The evidence of our own survey is somewhat conflicting:
activity in our district, (this is a result of the fact that about 15% of the respondents in the community suwey
migrant Iabourers return home over Christmas). If we mentioned that they would attempt treating DD
could encouragethese mothers to exclusively breast-feed themselves before looking for further help, but this
contrasts with the fact that over 60% of the respondents to

SAFAMILYPRACTICEJLTNE1985 178 SA HUISARTSPRAKTYK JLINIE 1985

Diarrhoeal diseases incomplete formula was Yz of those not receiving any
formula at all but figures are too small to take this further.
the samequestionnairementioned that they would givean What warrants someattention is the fact that the only child
enemato their children if they had gotten diarrhoea Three amongst those that received ORS before admission that
interpretations are possible: 1sl that more respondents died following admission had a dehydration of l0% and a
attempt self-medication but they do not admit to it: potassium of l,8mm0/L Studies conducted somewhere
second, that an enema is such a common household else a-lsorevealed the same problemso.A deficiency of our
treatment that it is not perceived as self-medication; and sh-rdyis tlut we did not enquire about dietary supplements
finally, that the respondents that replied "yes" to the rich in potassium,the time betweenonsetof diarrhoeaand
question "would you give an enemato your child in caseof admission is not linowr! the electro\'tes were checked at
DD ?" were mentioning the fact that they do not object to different intervals from the time of admissionand, in some
the useof enemasrather than admitting to its use.In Part 2 cases,the children had already had intravenous fluids. It
of this paper we mentioned that the great majority of our appears that, in the absenceofbicarbonate, connection of
acidosiswill be slowerin adults; this aspecthasnot been
DD in a ehild. fs &q more than studied in children but I personally believe that by
a pnesentingqrmptom of a preventing the onset of dehydration by the use of
whole range of conditians. incomplete solution we will be preventing most cases of
acidosis It is most important to emphasizethat the earlier
caretakersof children admitted with DD (84,3%)admitted the ORS is given, in an episode of diarrhoea the less
to the use of somehome remedy for DD before admission important its precise composition becomes, because the
(very few mentioned enemas).The reason for this high body's mechanisms can make the necessaryhomeostatic
percentage could be that admission rates are highest adjustments65.
among those that first attempt home heatment
Most of the d,ea,thsdue tn DD
This is not to say that home treatment is wrong: on the occur duriq the fi,rst yea,r;
contrary. Nowadays we actively try to promote the use of teaehing about OftS shoald
oral therapy for diarrhoea. To be effective oral therapy start during A/VC ulsif,s.
should be availableat the household level, should have an
acceptable composition, should be given frequently Puzzling and distressing is the fact that the percentageof
enouglr,should be complemented by dietary manipulation dehydrated children on admission was the same in the
and should not delay referral to the health centre oncethe group that receivedORS at home and the group that did
dangersignsare there. Oral therapy hasproved its worth in not receive it. We might be tempted to attribute this
preventing dehydrationaT reducing hospitaliza- apparent failure to the use of sucroserather than glucoseif
tion48le'5{),sr,s2a'sn3d'sd1ecreasingthe casemorlalif rate. it was not for the abundant literature that proves its
efficiency and, except for minor side effects, in most
For the past yearswe have been promoting an incomplete studies no significant differenceswere noted when glucose
solutionpreparedby adding8 teaspoonsofsugarand one is replacedby sucrose5?,58'5eT'6h0e'6m1o. st likely reasonfor
teaspoon of salt to one litre of water, to be used at the this failure is inadequate health education either with
household level for the prevention of dehfdration. Sugar resultant infrequent use of the SSS or failure to recognize
and salt are almost universally available and in promoting the danger signsthat warant immediate attendanceof the
this type of solution specialattention must be paid to the clinic (only 1% of the respondentsin the field surueyknew
measuring container. The risk of too much sodium in the at least 2 signs and syrnptoms of dehydration).
solution precipitating hypernatraemiais to a large extent a
theoretical consideration in our children as it is extremelv It is still encouraging to find that 23% of caretakers of
rare in our population children that had diarrhoeaover the past year knew how to
prepare SSS.It is discouragingto seethis percentagedrop
As in other developing countries5556hyponatraemia tD I2%, in caretakersthat look after children that did not
appearsto be the main problem and it is a seriousfactor to have DD over the past year. We cannot compare these
be considered as it is directly related to the degree of figures to previous figures but in 1982'r in reply to the
malnutrition and can be associated with high mortality question what sort of advicethe caretakercould remember
rates82H. ow this data might apply to us is not clear : all our from our health workers, less than 4% of the respondents
deaths occured in isonahaemic children. mentioned SSS. This knowledge is not related to
availability of a clinic in the village,type of caretaker,ageof
Absenceof potassiumin the incompletesolutionis a more caretaker or attitude of the mother to breast-feeding.Of
realproblem aswe canseefrom Table 1.1 in Part 1, where the respondents knowing about ORS a higher percentage
40% of all the children having received ORS before recognised death and dehydration as complications of
admissionwere hypokalaemic(K <3,5) as compared to diarrhoeal diseases.It also seemsthat although the level of
2l% of thosethatdid notreceivethe incompleteformulaat education doesnot haveany impact in the incidenceof DD
home. The mortality rate of the group receiving the it might play a rdle in the knowledgeof ORS : 30% of HDD
caretakershave never been to school,this drops ta26% n
Note: Conections received for Diar*ioeal Diseases ... part two, casesof caretakersfrom NDD and further drops tn 16% n
AppendixV,4lh columnfrom the left, Iinefor PostMatric percenlage casesof caretakers that know how to prepare ORS.
should read 1,1% instead ofi i,l%. :ReferenceI should read: Beftsnd
WE, Walnun BF. Matemal knowledge.attiurdes and practice as
prediction of diarrhoeai disease in young children. lnt i Epuleminl
1 9 8 3 ;l 2 : 2 0 5 - 1 0 .

SA FAMILY PRACTICEJUNE 1985 SA HUISARTSPRAKTYKJUNIE 1985

Dianhoeal diseases 2. There is still room for improvement concerningbreast-
feeding practices.
The last aspect in home management to be considered
here is nutritional managemenL The importance of this 3. A very important"wrong" practice to be corrected is the
aspectis obvious ascan be seenfrom the discussioncarried giving of enemas to children with DD.
on the relation of diarrhoea to malnutrition. The fact that
55,7% of all caretakers practiced some sort of 4. Starvation therapy is uncommon. Our caretakers have
manipulation of their children s diet in casesof children the right attitude to the giving of fluids and food during the
admitted with DD is an important factor. The imporbance episode. They dont however, have the right knowledge.
of this aspectis further emphasizedby the fact that3L% of
120 children admitted for the first 4 months of 1982 in the 5. Emphasizing the complications and the seriousnessof
nutrition rehabilitation ward of our hospital had chronic or DD might encourage the mothers to adopt the health
relapsing diarrhoea3.One fifth of the caretakersadmitted behaviour that we believe to be more correcl
with our children to the diarrhoea ward still admit to the
practice of starvation. In the district sruvey only 8% said 6. Our health servicesare widely accepted.The only way to
that food should be withheld from children with diarrhoea make them readily accessibleto the population will be by
implementing the policy of having primary health care
G te4@@ $ti[t' workers with rudimentary but meaningful training at the
the tqn Lead,W co;llqesof village level
d,eathfor ehild,rcn under fwe
yeo;r$. 7. Boiling of water before consumption is widely practiced,
but it appears to have no impact in the incidence of DD ;
It thus appears that children on whom starvation was this points to the fact that clean water must go together
practised are overrepresented in our hospital sample as with appropriate hygienic practices at home.
expected. Less than t/s of the caretakers in the district
recommended that breast-feeding should be stopped 8. There is potential for expansion of our OR programme
during a diarrhoeal episode. These figures and the but specialattention will have to be paid to the measuring
associatiorl shown in our district of diarrhoea with unit being used.
malnutrition and hypokalaemia points again to the fact that
this is a very important aspect not only in diarrhoeal 9. The fact that most of our deaths due to DD occur during
mortality but also in the prevention of malnutrition the first year of life points to the need to start teaching
about ORS during ANC visits. The rapid expansionof our
The skills of tlw health worh.ers health education programme will depend on the adequate
The skills of the health workers are important not only in useof ourlimited resources.Songsshould be emphasized;
the field of heahnent of diarrhoea but above all, in their the opporbunity to promote them through the radio would
abilities to convey the messageof ORS and nutritional have,we believe,a profound impact on the educationof the
management to the mothers of IIF children This is the population The use of posters is limited by our inability to
most important skill needed by our primary health worters reproduce the few we developed. The need to revise the
and not the easiestto acquire or to teachn. Health Education Curriculum in our schools is obvious.

In 1983 we carried out an assessmentof the knowledge of 10. The maintenance of water sourcesin our district is an
our clinic nursesconcerningthe managementof diarrhoeal important aspect of health" To keep communication
diseases.TWelvenursesreplied and of these, all lmow how channels open and for befrer coordination of efforts I
to diagrrose dehydration but only 25% lo:,ew how to would suggest that representatives of the water
differentiate mild from severe dehydration Thirty four maintenance services should be invited to participate in
percent (34%) dtd not know how to prepare SS. Eleven our monthly Regional Health meetings. The emphasis of
(92%) werenot clearon the sort of adviceto be givento the our water policy should be on quantity rather than quality.
mothers of children with diarrhoeal disease.Only two were
clear on the adequate heatment for mild dehydration 11. When carrying out studies of a similar nature it is
Most recognized the need for IV rehydration in severe essential that while questioning the respondents, more
dehydration but only one admitted to having the skill to time should be spent in clarifying their definition of
establish an fV line. In reaction to this inadequate diarrhoea
preparation of our nurses, it was decided to standardize
managementof diarrhoealdiseasesand for this a flow chart 12. Our research priorities in the field of DD are:
was drawn up, spellingoutthe diagnosisand management (a) omranv pRACTrcEsrN ASsocrATroNwrrH DD
of different degreesof dehydration and what sort of health (b) eppnopnrATE TEcHNoLocms FoR WATER AND
education to gve in diarrhoeal diseases.
DOMESTTCHYGMNE
CONCLUSIONS AND RECOMMENDATIONS (c) FIEALTHEDUCATTONTECHNIQUESAND MATERIALS
1. The picture that emerges from this suwey is an
optimistic one. As it can be seen in Table 4.1 there is a ABOUTDD
decreasein the incidence of diarrhoeal diseasesboth in
relative and absolutenumbers and the sameappliesfor the 13. The most imporbant conclusion to be drawn from this
mortality rate. Many of the factors that emerged from our report is that a PRIMARY fmALTH PROJECT, wide in
study support the findings of other studiesand they will not its scope,resulting in a decreaseof malnutrition rates and a
be mentioned further. general improvement of the health status and
immunization status and in better hygienic practices (eg
boiling of water) is effective in reducing both the incidence
and the mortality of DD.

I should like to thank the following people for their assistance,or
permission to use their data: Dr M Bac; Staff GB 7 Ward '
(Gelukspan Communiff Hospitai) ; Mr J Phinias ; Nurse Helen Lekhu;
Mabon Moutshe ; Mr Seriba; Mr Gimbel & Mr de Ruiter; Mrs R
Msimanga-

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