Treatment of Childhood Diarrhoea in Nigeria: Need for Adaptation of Health Policy and Programmes to Cultural Norms

Olayemi O. Omotade1, Adebowale A. Adeyemo2, Clara M. Kayode1, and Oladimeji Oladepo3

1Institute of Child Health, University College Hospital, 2Department of Paediatrics, and 3Department of Preventive and Social Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria

ABSTRACT A community survey of treatment regimens for acute diarrhoea in children was carried out in 10 villages in the Ona Ara Local Government Area of Oyo State, Nigeria, using a combination of qualitative (focus-group discussions) and quantitative (weekly surveillance of diarrhoea) methods. Focus-group discussions were conducted with parents of children aged less than 5 years, while a surveillance of diarrhoea among 550 children of same age was carried out during a 6-month period. The findings of the study showed that not all types of diarrhoea were recognized as illnesses, and only those considered to be illnesses were treated. Treatment often involved an adhoc group which comprised adults who were present at the time the illness occurred (including parents, neighbours, relatives, and elders). Certain beliefs and practices, such as associating types of diarrhoea with occupation or ethnic groups, categorizing the severity on perceived causes, and withholding certain foods during episodes of diarrhoea, were common factors in decision-making for seeking treatment. Antimicrobial agents were used in the case of 46.8% of 205 diarrhoeal episodes, and 28.5% were not at all treated. The usual practice of focusing on a target group, such as mothers, during educational interventions may need to be modified in communities where nearly every adult has a role in decision-making in relation to health. The need to adapt health policy and programmes to cultural norms should be addressed to improve the impact of programmes.

Key words: Diarrhoea; Diarrhoea, Infantile; Oral rehydration therapy; Drug therapy; Ethnomedicine; Perceptions; Healthcare-seeking behaviour; Knowledge, attitudes, practice; Health policy

INTRODUCTION its apparent cause and severity. For example, igbe eyin or ‘teething stools’ is not perceived by the Yorubas in Most illnesses, including diarrhoea, receive home- or southwest Nigeria as a disease, and is not treated unless self-treatment first. Since this is a cultural practice in there is accompanying vomiting and mucous in stools most communities, it is important to learn about the (1). The actual treatment given to children varies from various ways by which illnesses are treated at home. place to place in Nigeria (2,3). Herbs, other indigenous Choice of treatment for diarrhoeal diseases in children remedies, antibiotics, and other drugs are widely used usually depends on the perceived type of diarrhoea and (2,4). Educational interventions that do not take these Correspondence and reprint requests should be practices into consideration may account for the wide addressed to: Dr. Olayemi O. Omotade gap between knowledge and practice regarding optimal Institute of Child Health, University College Hospital treatment for diarrhoea at home (5). Ibadan, Nigeria Fax: 234-2-271-1768 As part of a project to develop, test, implement, and Email: [email protected] evaluate an educational programme to modify behaviour 140 J Health Popul Nutr Dec 2000 Omotade OO et al. for the prevention of diarrhoea, we conducted a series Surveillance of diarrhoea: A census of all households of group discussions and a prospective survey in a rural in the selected village-clusters was carried out in July area of Oyo State in southwest Nigeria to document the 1993, and a household identification number (called pre-intervention patterns of treatment for diarrhoeal ADDR household number) was allocated to each eligible diseases in the community. household. An eligible household was defined as a household with at least one child who is aged less than METHODS AND MATERIALS 5 years at the time of the study. A list of all children aged less than 5 years in the study communities was Study site then compiled. One child per household was randomly The Ona Ara Local Government Area (LGA) of Oyo selected from among these children to participate in the State lies southeast of Ibadan, capital of Nigeria. It covers project. Mothers and, in their absence, child caregivers an area of about 330 sq km, and has a population of were interviewed, and their responses were recorded in 122,387 (3). It has about 200 communities, all of which a structured questionnaire. are rural, except one village-cluster (Olorunsogo/ The questionnaire contained items on education and Olunloyo) in the outskirts of Ibadan. Except two, all occupation of mothers, education and occupation of roads in the Ona Ara LGA are untarred, and some are household heads, distance from a government health often a little more than footpaths. Electricity and piped centre, environmental hygiene, and source of water water supply are available in only 3 village-clusters: supply. A diarrhoea-surveillance booklet was opened for Badeku, Akanran, and Olunloyo/Olorunsogo. There are each child. This booklet contained questions on whether 4 government health centres in the Ona Ara LGA, one the child had diarrhoea or not in the preceding week, of which (Badeku) was used as an outreach station of and if so, what the type of stool and the colour were, the Institute of Child Health, College of Medicine, and what treatment was given. Each child was visited University of Ibadan until 1992. Private medical and weekly for 6 months (16 August 1993 to 15 February traditional practitioners also provide healthcare to the 1994), and the appropriate page of the booklet was filled various communities. Most men are farmers, while the up for each visit. Six visits were missed during the study women are both farmers and petty traders. The people period due to political unrest and frequent petrol are of Yoruba tribe. shortages in the country during the period. The data collected through the baseline surveillance of diarrhoea Data collection and from the mother’s questionnaires formed the basis of the quantitative aspect of the study. Data were collected through a qualitative method (using focus-group discussions) and a quantitative method Data were analyzed using the Epi Info software. (surveillance of diarrhoea in children aged less than 5 years and reported treatment of each episode). RESULTS Treatment for diarrhoea Focus-group discussions: A series of focus-group discussions (FGD) were conducted during 26 July 1993– FGDs revealed that several treatment patterns were 2 August 1993 with parents of children aged less than 5 followed in the management of diarrhoea in children years. The composition of the groups and the villages (Table 1). The choice of a treatment pattern depended selected were as follows: (a) one group with male on the perceived causal/associated factors, severity, and parents, (b) one group with female parents, and (c) 2 type of diarrhoea. Types of diarrhoea identified in the groups with male and female parents. No participants in FGDs included igbe jedi, igbe tapa, igbe asule, and igbe group (a) and (b) were married to one another. The orin (Table 2). The significance of the various terms used influential community leaders identified the participants in describing the types of diarrhoea was not always the of FGDs. The number of participants in each group same. Igbe jewo jewo was mentioned by only one group; it was not considered an illness but was considered ranged from 8 to 12. A trained facilitator and a note- abnormal, the perceived cause being due to thick infant taker conducted each FGD. All FGDs were also recorded feeds or over-concentrated artificial feeds. Igbe eyin was on audio tape. The authors transcribed the tapes, and not considered an illness at all but was considered part analyzed the transcripts and notes on the perceptions of of the normal process of teething in infancy; therefore, diarrhoea and its treatment. The responses were it was not treated unless associated with vomiting, poor summarized under ‘male’ and ‘female’ categories. The feeding, or mucoid. Igbe arunsu was considered to be responses from mixed groups were included under these illness due to over-eating but was not considered a 2 categories, depending on whether the participant was serious illness. Igbe orin, igbe tapa, and igbe asule were a male or a female in the group that proffered the idea. considered to be bloody diarrhoea, but the distinction Little difference was found in the responses between between them was not always clear. When associated the groups, and the findings are, therefore, summarized with eating groundnuts or kulikuli (groundnut biscuits), together. it was termed as igbe tapa after the name of the ethnic Treatment patterns of diarrhoea in Ibadan, Nigeria 141 group in Nigeria, which commonly makes and sells these The treatments used for the management of diarrhoea at snacks. One type of diarrhoea that was considered to be home varied widely (Table 1). The way these patterns extremely dangerous was igbe igbalode which was of treatment are inter-related is illustrated in the figure. believed to lead to death if not taken to hospital The first decision was whether the diarrhoea needed to immediately. This type of diarrhoea was believed to be be treated for or not. Even when it was not initially treated a ‘new/imported’ disease. Cholera was not believed to for as in igbe eyin, failure of diarrhoea to resolve or be spread by flies; in the words of a 70-year-old woman, deterioration of the child’s condition usually led to some “there were flies before this type of diarrhoea came, but form of treatment or care-seeking. In all groups, herbs the disease was not here then.” and drugs were mentioned as treatment used for diarrhoea. The use of sugar-salt Table 1. Summary of treatment patterns in childhood diarrhoea from FGDs solution was also mentioned, but Response to diarrhoea one woman would only give salt- sugar solution if diarrhoea No action This is the response if the diarrhoea is believed to be igbe eyin (teething diarrhoea) or if believed to be due to exceeded 3 days. over-feeding Decision-making about Specific treatment Herbs, such as esinile, lapalapa pupa, efinrin treatment of diarrhoea Sugar-salt solution Tetracycline, ampicillin Decision-making about whether to Efunle (native chalk deposits) use home care and/or to consult a Home remedies, e.g. alcohol with starch paste, ‘stout’ professional is usually not a simple (to make the child sleep) action taken by the immediate Feeding/fluids Give clean water family members concerned, but Avoid the following: may involve neighbours and elders - beans in the community. This ‘therapy - hard food (e.g. boiled yam) management group’ (7) may - hot (temperature) food include, apart from the parents of - ’okele’ (solid morsels) children, relatives, neighbours, and - sweet/sugary food elders in the community. These Stop all foods and give water only people usually offer suggestions on what should be done when the children suffer from diarrhoea. In Table 2. Terms used for describing diarrhoeal diseases and their significance addition, they may provide herbs or Local term Significance Terms used as synonym drugs that ‘worked’ the last time “Teething” diarrhoea their children or someone else had Igbe eyin Not an illness, Normal such an illness. Help from outside feature of teething the home was usually sought only Diarrhoeal diseases when the child did not get better, Igbe jedi Illness Distinction not always there was blood in the stools, or if Igbe asule Illness clear between these it was thought to be due to cholera. Igbe tapa Illness 3 terms Distance from the nearest Igbe gburu Illness government health centre and Igbe orin Illness care-seeking Igbe arunsu Illness The distance of health facilities Igbe igbalode Severe illness Maybe life-threatening Igbe onigbameji from household was assessed in Igbe masu mabi walking time, and was compared Igbe cholera with walking time to the facilities Diarrhoea associated with other conditions usually used at the times of need, Igbe jewo jewo Not an illness, associated not just during the previous episode with colic of diarrhoea. 29.2% of the parents spent less than 5 minutes walking Igbe oka Serious illness, associated with Oka ori to the nearest health facilities, but only 16.9% used facilities that are Igbe iletutu Illness, associated with the within 5 minutes away. Twenty- wet season (literally ‘cold earth’) nine percent spent between 5 and Igbe ilegbona Illness, associated with the hot 10 minutes walking to the nearest season, skin rash, convulsions health facilities, and 18% used 142 J Health Popul Nutr Dec 2000 Omotade OO et al.

Father Mother

NO ACTION HOME TREATMENT OUTSIDE HELP

Neighbours Father/mother-in-law

Elders

Treatment options are in capitals. Arrows represent decision flow and actions Fig. People involved in decision-making on diarrhoeal illness in Ona-Ara LGA, Oyo state, Nigeria facilities that were less than 10 minutes away. 23.5% episode was treated was available in the case of 158 spent more than 30 minutes walking to the nearest health (77%) episodes. The commonest treatments used in acute facilities, and 51.8% actually used these far-away diarrhoeal episodes were antimicrobials in 46.8% of the facilities (Table 3). Some reasons given for using more cases and oral rehydration therapy (ORT) in 20.9% of distant facilities included: lack of availability of the cases. Of the latter, sugar-salt solution was used in healthcare at the government facilities on week-ends, 9.5% and ORS sachets in 11.4% of the episodes. No lack of equipment and drugs at the nearby health treatment was given in 28.5% of the episodes. Surprisingly, only 2.5% were given herbal remedies in Table 3. Distance from the nearest government health contrast to the findings of FGDs in which herbs were facilities and frequency of use of these and other facilities mentioned as remedies in the home management of diarrhoea. The sources of antibiotics and other Time Walking time to Walking time to medications included: chemist shops 27 (37%), health (in minutes) nearest health health facility institution 24 (33%), and the home, i.e. left-over drugs facility (%) used (%) from a previous consultation 9 (12%). 8.2% of those <5 29 17 interviewed obtained their antibiotics from roadside 5-10 29 18 vendors/drug hawkers, while 5.5% purchased their 11-20 8 4 medicines from pharmacies in the peri-urban areas of the Ona Ara LGA, bordering the city of Ibadan. Three 21-30 10 9 (4.1%) of the 74 respondents obtained their antibiotics >30 24 52 from neighbours/relatives. facilities, delay in receiving treatment, and unfriendly/ DISCUSSION hostile attitude of the health staff. Therefore, many people did not visit the nearest health facility. The present study has described the perceptions of Treatment of diarrhoea during surveillance parents about diarrhoea, the significance of various types of diarrhoea, and the treatment patterns in a cluster of A total of 205 diarrhoeal episodes occurred during the villages in southwest Nigeria. More importantly, their period of surveillance. Information on how the diarrhoeal emergent behaviour in terms of actual treatment for Treatment patterns of diarrhoea in Ibadan, Nigeria 143 diarrhoeal episodes during the surveillance was studied. the death of the child and be labelled as ‘bad’ or ‘careless’ Diarrhoea is still a major child health problem in Nigeria, who refuse to listen to advice. Therefore, it is necessary although the country has had a national Control of that any intervention to succeed should involve all Diarrhoeal Diseases (CDD) programme since 1988 (8). segments of the society. Failure to involve everyone in The results of the present study showed that management the community, especially the men who are traditionally of childhood diarrhoea remained sub-optimal in the study the decision-makers in the home, elders, and community area with only 1 in 5 children receiving ORT, while about leaders, in the development and implementation of any 47% received antibiotics. Some reasons for this educational intervention programme may result in sub- observation may lie in perceptions, care-seeking optimal practice of the desired behaviour in spite of a behaviour, and problems with access to healthcare as high level of awareness (5). It is for this reason that the found in this study. The problems of designing and present study included these influential people in FGDs. implementing an effective diarrhoea-control programme for a country, like Nigeria, with over 250 ethnic groups The 47% frequency of antibiotic use in this study are formidable. Too rigid or too narrow an approach will does not differ significantly from the 54% use of fail as will the attempt to incorporate every single nuance antibiotics recorded in Ilorin, Nigeria (11)-–about 150 of the peculiarities of each ethnic group. Local adaptation km north of the study site. The sources of procurement of the generic programme, based on locally-collected of the drugs varied widely, but the role of chemist shops/ data, is likely to enhance programme effectiveness. pharmacies, roadside vendors, and health institutions in supplying drugs is notable. If these remain the sources Results of the study showed that not all cases of of therapy of inappropriate antibiotics, any health- diarrhoea were considered illnesses, and consequently, education intervention that emphasizes appropriate not all cases of diarrhoea were treated. This finding has replacement of fluid losses—rather than the use of been documented previously in this study area (1) and antibiotics and antidiarrhoeal agents—is likely to fail. elsewhere (2). Some types of diarrhoea were seen as an Therefore, the intervention must involve health accompaniment of normal development as in ‘teething education of drug vendors and health workers. They diarrhoea’ (igbe eyin) or as a result of over-eating or should be persuaded to promote the use of ORS (rather dietary indiscretion. While this practice may be of than antibiotics except when indicated) as a life-saving concern, it should be noted that the people would treat measure and that their profits could be made from drugs such cases if they were associated with some other than antibiotics used inappropriately to treat complications, such as vomiting and refusal of foods or diarrhoea. Factors that must be taken into consideration if the condition of the child deteriorates. The real problem in the design and implementation of the educational occurs when the condition of the child becomes worse intervention programme for the above prescribers are during the night or during a rainstorm when it might be their beliefs and evaluation of the outcome of prescribing impossible to obtain a transport to go to a health centre. ORT only, their beliefs about expectation of their clients, Given the rapidity with which dehydration may develop and their readiness to comply with the existing policy in a child and the low frequency of ORT use (21%) in on the management of diarrhoeal diseases. this community, a health-education intervention in these communities must emphasize early and appropriate use The findings of the present study suggest that the of rehydration fluids in the home management of process of management of diarrhoea at the community diarrhoea. In addition, the local health centres must be level and its relevance in the development of educational strengthened to perform their role of providing primary intervention in the Ona Ara LGA are understood better care to the communities at all hours of the day and night. when viewed within the cultural context of the people. The problems of limited working hours at the public Major policy implications of this study include the need health centres, lack of drugs, and long waiting time to: (i) use the perceptions of the people and practices of accounted for the finding that many people do not go to treatment of diarrhoea as input into educational the nearest health centre. These shortcomings of the programmes, (ii) strengthen the primary healthcare healthcare system must be addressed to provide better system to meet the requirements of the community they service. serve, (iii) train not only healthcare workers in the formal health sector but also chemists, patent medicine vendors, It was also found that decision-making might not be and roadside vendors in the appropriate management of a simple action taken by the mother alone or by the diarrhoea, and (iv) include not only mothers of young immediate family members but might involve the children but also fathers, grandmothers, and other people neighbours and elders in the community. The role of in an intervention because of their influence in the these ‘therapy management groups’ cannot be decision-making process. overlooked. The consequences for neglecting their input may be far-reaching in the community. For example, if In conclusion, we recommend that such studies as such suggestions are ignored and the child turns out to the present one be carried out in the early phases of an be worse, the mother/parents may be accused of causing intervention to provide a framework and input into 144 J Health Popul Nutr Dec 2000 Omotade OO et al. national programmes on health issues. In addition, proper 4. Odujinrin OMT, Akitoye CO, Odugbemi T, Oyerinde follow-up after the intervention and monitoring and/or JPO, Esumeh FI. Ethnographic study of childhood evaluation of programmes are necessary to observe those diarrhoeal diseases in a rural Nigerian community. behavioural patterns/practices that are easily lost and West Afr J Med 1993;12:185-8. those that are retained. 5. Igun UA. The knowledge-practice gap: an empirical example from prescription for diarrhoea in Nigeria J ACKNOWLEDGMENTS Diarrhoeal Dis Res 1994;12:65-9. Financial support for this study was provided by the 6. Nigeria. 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