From the M.S. Ramaiah Medical College, Community Medicine Department, Bangalore 560 054, India.
Reprint requests: Dr. Shivaram C, Professor, Community Medicine Department, M.S. Ramaiah Medical College, Bangalore 560054, India.

Manuscript received: July 2, 1998;
Initial review completed: August 4, 1998;
Revision accepted: August 27, 1999

Diarrhea claims the lives of 32 million children in the under five age group in developing countries(1). Global communication efforts have concentrated on assisting national programs to promote the three rules of case management at home: (i) increase fluid intake, (ii) continue feeding, and (iii) seek medical care when needed(2). The present study was taken up with the main objective of assessing the impact of educational intervention on the knowledge, attitude and practices of mothers in home management of diarrhea as there are few intervention studies in this area.

This study was conducted in a slum at Anjanappa Garden, Bangalore, which is the field practice area of M.S. Ramaiah Medical College, from April 1995 to June 1996. A sample size of 225 mothers (at 5% level of significance at 20% relative error) was estimated based on reports which showed that 30% of children with diarrheal episodes received increased fluid and continued feeding(2).

The study was conducted in three stages. In the first stage, mothers of under five children in the slum were identified and the initial knowledge, attitude and practices of the mothers in the management of diarrhoeal diseases was assessed using a pretested, structured questionnaire. Based on the initial KAP, the areas for educational intervention were identified. During the educational intervention the following points were stressed: (i) Importance of continued feeding during diarrheal attacks to prevent malnutrition; (ii) Home available foods which could be given during diarrhea; (iii) Modification of food preparation during diarrhea; (iv) Quantity and frequency of feeding during diarrhea; and (v) One extra meal a day for at least two weeks after cessation of diarrhea.

A one to one discussion with the mothers was carried out, each session lasting 30 to 40 minutes. The media used were pictures from books, charts and home available foods which were identified in the households.

Two months after the educational inter-vention, the third stage of the study was conducted to assess the knowledge and attitude among all the mothers. Practices, however, were assessed among the mothers (n = 84) whose children suffered from diarrheal episodes in the intervening period using the same pretested structured questionnaire as in the first stage of the study. McNemar test was done to find out the change before and after the educational intervention.

The present study revealed that frequency of breastfeeding during diarrhea improved significantly (p <0.001) after the educational intervention. Modification of food preparation during diarrhea also improved significantly (p <0.001) after the educational intervention. The educational intervention empowered the mothers to give extra food after the cessation of diarrhea in the children (1.2% to 16.7%; p <0.001). Out of the 20.2% of the mothers who administered extra food, a significant number of them (p <0.001) administered extra food for at least two weeks after cessation of diarrhea. However, practices such as administering foods other than breastmilk during diarrhea, relative quantity of food and frequency of feeding during diarrheal episodes did not improve significantly (p >0.05) even after the educational intervention.

The practice of breastfeeding is almost universal in India and it has been shown by previous studies that breastfed babies suffer less from diarrhea than artificially fed babies(3). In several studies mothers continued to breastfeed children during diarrhea(4,5). In the present study 92.4% of the mothers breastfed their children during diarrhea. However, only 15.1% of the mothers breastfed their children more frequently during diarrhea as advocated by WHO(6) prior to the educational intervention. It is heartening to note that after the educational intervention there was a significant positive change (p <0.001) in 47.2% of the mothers towards the positive practice of breastfeeding more frequently during diarrhea.

Interventional studies(7,8) conducted earlier showed a significant positive change in feeding practices during diarrhea after the intervention. However, in the present study even after the educational intervention there was no significant change (p >0.05) with regard to administering foods other than breastmilk and with regard to the quantity and frequency of feeding during diarrhea. It may require repeated interventions to improve practices regarding feeding as these are part and parcel of the culture of people.

WHO(6) recommends that foods should be cooked well, mashed or ground so that it would be easier to digest during diarrhea. Viswanathan and Rohde(9) observed that cooking practices were changed during diarrhea to make food soft and bland throughout India. In the present study only 2.4% of the mothers modified the food preparation during diarrhea prior to the educational intervention. After the intervention, however, there was a significant positive change (p <0.001) in 26.2% of the mothers who modified food preparation to make it soft and more easily digestible.

In the present study, none of the mothers were in favor of giving extra food after cessation of diarrhea, prior to the educational intervention. After the intervention there was a significant favourable practice (p <.001) of administering extra food after cessation of diarrhea among 20.2% of mothers.

WHO(6) advocates that children should be given one extra meal each day after cessation of diarrhoea. For most children this extra meal should be given for about two weeks. On the contrary, Srinivasa and Afonso(10) noted that 83% of mothers restricted food for two to three days during the convalescence period. Viswanathan and Rohde(9) observed that the concept of extra feeding during convalescence was unknown to mothers. In the present study there was a significant change after the educational intervention with regard to the duration of administering extra food after the cessation of diarrhea. This aspect has not been studied earlier in intervention studies.

In conclusion, feeding practices during diarrhea and after cessation of diarrhea can be improved with educational intervention. Some aspects like administering foods other than breastmilk during diarrhea, relative quantity of food offered during diarrhea and frequency of feeding during diarrhea, however, may require repeated interventions to enable mothers to change over to a favorable practice.

The authors express their gratitude to the Karnataka State Council for Science and Technology, Bangalore for funding the above project.

Contributors: MS collected data, carried out intervention program and will act as guarantor of the paper. N designed the study and conducted the analysis. GD and SC Interpreted the data and helped in drafting the paper

Funding: Karnataka State Council for Science and Technology, Indian Institute of Science, Bangalore 560 012.
Competing interests: None stated.

1. WHO Readings in Diarrhea, Student Manual. Geneva, World Health Organization, 1992.

2. World Health Organization Ninth Programme Report, 1992-93, Programme for Control of Diarrheal Diseases, WHO/CDD/94.46. Geneva, World Health Organization, 1994.

3. Ghosh S. The Feeding and Care of Infants and Young Children, 6th Revised Edition, New Delhi, Voluntary Health Association of India, 1992; pp 53-56.

4. Kapoor P, Rajput VJ. Maternal knowledge, attitude and practices in diarrhea. Indian Pediatr 1993; 30: 85-88.

5. Anand K, Lobo J, Sundaram KR, Kapoor S. Knowledge and practices regarding diarrhea in rural mothers of Haryana. Indian Pediatr 1992; 29: 914-917.

6. World Health Organization. The Management and Prevention of Diarrhea, 3rd edn. Geneva, World Health Organization, 1993.

7. Kaur P. Singh G. Food practices during diarrhea, Indian Pub Hlth 1994; 38: 58-61.

8. Mishra CP, Satish Kumar, Tiwari IC. A study on some diarrhea related practices in urban Mirzapur, Indian J Pub Hlth. 1990; 34: 6-10.

9. Viswanathan H, Rohde JE. Diarrhea in Rural India; A Nationwide Study of Mothers and Practitioners (South Zone). New Delhi, Vision Books, 1990.

10. Srinivas DK, Afonso E. Community perceptions and practices in childhood diarrhea. Indian Pediatr 1983; 20: 859-864.