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TABLE OF CONTENTS
DECLARATION…………………………………………………………………………………………………….. iii
DEDICATION…………………………………………………………………………………………………………. iv
ACKNOWLEDGEMENT………………………………………………………………………………………… v
TABLE OF CONTENTS…………………………………………………………………………………………. vi
LIST OF TABLES……………………………………………………………………………………………………. x
LIST OF FIGURES…………………………………………………………………………………………………. xi
ABBREVIATIONS AND ACRONYMS………………………………………………………………….. xii
DEFINITION OF OPERATIONAL TERMS…………………………………………………………. xiii
ABSTRACT…………………………………………………………………………………………………………… xiv
CHAPTER ONE: INTRODUCTION………………………………………………………………………… 1
CHAPTER TWO: LITERATURE REVIEW………………………………………………………….. 10
CHAPTER THREE: MATERIALS AND METHODS……………………………………………. 19
CHAPTER FOUR: RESULTS………………………………………………………………………………… 26
…………………………………………………………………………………………………………………………. 27
…………………………………………………………………………………………………………………………. 35
……………………………………………………………………………………………………………………………. 36 4.3.1. Preference for diarrhoea management ………………………………………………………….. 36
CHAPTER FIVE: DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS.. 50
5.3.2 Recommendation for further studies……………………………………………………………… 56
REFERENCES………………………………………………………………………………………………………. 57
APPENDICES………………………………………………………………………………………………………… 61
Appendix 1: Informed consent for participants in the study………………………………………… 61
Appendix 3: Questionnaire……………………………………………………………………………………… 64
Appendix 4: Observation check list………………………………………………………………………….. 68
Appendix 5: Approval of research proposal by Graduate School………………………………….. 69
Appendix 6: Approval by Kenyatta University Ethical Review Committee…………………… 70
Appendix 7: Approval by the National Commission for Science, Technology and Innovation 71
Appendix 8: Approval by the County Director of Education……………………………………….. 73
LIST OF TABLES
Table 3. 1: Sample size distribution matrix……………………………………………………………………. 21
Table 4. 1: Demographic characteristics……………………………………………………………………….. 27
Table 4. 2: Prevalence of diarrhoea among children under five years in the selected households 28
Table 4. 3: Demographic factors and prevalence of diarrhoea among children under five years in the selected households…………………………………………………………………………………………………… 29
Table 4. 4: General knowledge of caregivers on diarrhoea………………………………………………. 30
Table 4. 5 : Knowledge of caregivers on preventive strategies in management of diarrhoea… 32
Table 4. 6: Knowledge of caregivers on the treatments of diarrhoea………………………………… 33
Table 4. 7: Summary of knowledge level on management practices of acute diarrhoea………. 34
Table 4. 8 : Overall knowledge level of caregivers on management practices of acute diarrhoea 35
Table 4. 9: Overall knowledge level of caregivers and prevalence of diarrhoea in children under five years in the selected households………………………………………………………………………………….. 36
Table 4. 10: Preference for diarrhoea management………………………………………………………… 36
Table 4. 11: Current practices of caregivers on diarrhoea management and prevalence of diarrhoea in children under five years in the selected households……………………………………………………… 41
Table 4. 12: Socio-economic factors…………………………………………………………………………….. 42
Table 4. 13 : Environmental factors……………………………………………………………………………… 43
Table 4 14 : Behavioural factors………………………………………………………………………………….. 45
Table 4. 15 : Factors influencing management practices and diarrhoea prevalence……………… 49
LIST OF FIGURES
Figure 1.1: Conceptual framework on management practices of acute diarrhoea by caregivers of children under the age of five……………………………………………………………………………………………………. 9
Figure 2.1: Flow chart of the management of diarrhoea and dehydration…………………………. 13
Figure 4. 1: Treatment practices for diarrhoea management…………………………………………….. 37
Figure 4. 2 : Breastfeeding practices……………………………………………………………………………. 38
Figure 4. 3: Reason for breastfeeding…………………………………………………………………………… 39
Figure 4. 4 : Reason for not breastfeeding……………………………………………………………………. 40
Figure 4. 5: Reasons of child immunization by caregivers……………………………………………….. 46
Figure 4. 6 : Reasons for taking the child sometimes for immunization…………………………….. 47
Figure 4. 7 : Reasons for non-immunization of the child by caregivers……………………………… 48
ABBREVIATIONS AND ACRONYMSETEC:Enterotoxigenic Escherichia coli Hb: Hemoglobin HH: Household IV: Intravenous KNBS: Kenya National Bureau of StatisticsKPHC:Kenya Population and Housing Census KUERC: Kenyatta University Ethical Review Committee LMIC: Low and Middle-Income Countries NACOSTI: National Commission for Science, Technology and InnovationNGO:Non-Governmental Organization NPM: National Programme Managers ORS: Oral Rehydration Salts ORT: Oral Rehydration Therapy SPSS: Statistical Package for Social ScienceUNICEF:United Nation Children’s Fund WHO: World Health OrganizationDEFINITION OF OPERATIONAL TERMS
Acute diarrhoea: Diarrhoea within a period less than fourteen days
Caregivers: It refers to a family member or paid helper who regularly looks
after a child
Dehydration: Loss of electrolytes and fluids
Diarrhoea: Not less than 3 times a day passing of stools or loose
Exclusive breastfeeding: Breastfeed without any extra nutrients for at least 6 months
Food intake: It refers to the consumption of any ingredient consisting of
proteins, carbohydrates, fats, minerals and vitamins
Illiteracy: The deep of ignorance. It refers to a person who cannot read and write. This refers to level one of literacy.
Poor family: Group of individuals who have inadequate financial resources and earn less than 1.99 dollars a day
Tap water: Refers to the County government’s water supplied
Treated water: Refers to water that has undergone a process to improve it
quality and to make it more acceptable for drinking.
ABSTRACT
Diarrhoea continues to remain one of the main and the second most significant cause of death globally in children under five years. The number of diarrhoea cases continues to increase every year and is estimated to be 1.7 billion annually. In 2018, in Kenya, 1,499,146 cases of diarrhoea were reported among children under five years and Nairobi accounted for 136, 028 cases. A research in Nairobi Informal Settlements showed that 25.6% of children living in the Informal Settlement had diarrhoea. Caregivers in Mathare reported that their children contract diarrhoea at least once every two weeks. As diarrhoea is mostly managed at home by caregivers there is need to determine the management practices of acute diarrhoea by caregivers of children under five years. The main objective of the research was to determine the management practices of acute diarrhoea by caregivers of children under five years in Mathare Informal Settlement. To achieve this objective, a cross-sectional study design was used. It was preferred because it is a one point of time study. Due to its pollution and diarrhoea frequency reported by caregivers, Mathare Informal Settlement was purposively selected. For the choice of households and respondents, simple random sampling was used. Researcher administered questionnaire and observation checklist were completed appropriately. Fisher’s and exact test, Pearson Chi-square as well as Pearson correlation were utilized in the analysis. P < 0.05 was considered as statistically significant. Age of the caregivers ranged from 18-72 years old. The main age group of caregivers was 25-31 years old with 56.17%. The household size ranged from 2 to 15. Children under five years living in the selected households of the study ranged from 1 to 7 per household. Children who were 1 per household accounted for 49.4%. Mothers accounted for 83.6%. Prevalence of diarrhoea among children was 18.7%. Sex of the caregiver (p=0.008), relationship of the caregiver (p<0.001), number of household residents (p<0.001), and number of children under five years in the household (p<0.001) were found to be statistically significant with diarrhoea prevalence among children aged zero to less than five years. Knowledge level of caregivers regarding management practices of acute diarrhoea was found to be statistically significant with prevalence of diarrhoea in children under five years (p=0.020). Majority of the respondents (63.89%) used drugs from hospitals to manage diarrhoea. In 63.89%, water was given like any other day during diarrhoea. One hundred and seventy six caregivers breastfed the child during the survey. The majority of the respondents (52.78%) had no formal education. Faeces, flies and open garbage were present near or within the household in 37.72%, 59.26%, and 80.25% respectively. All the respondents washed their hands during the study. However 27.78% of the respondents did not wash their hands after disposing the child faeces. Caregivers disposed the child stool in garbage in 38.89 %. Fifty caregivers did not take their children for immunization. Statistical significance was observed between diarrhoea prevalence and the caregiver’s educational level (p<0.001), renting (p=0.024), existence of flies near or within the household (p<0.001), existence of faeces near or within the household (p<0.001), existence of open garbage near or within the household (p<0.001), immunization of children (p<0.001), age when the children start using latrine (p<0.001).In conclusion, low knowledge level was a predictor of diarrhoea among children under five years. Many factors such as existence of open garbage near or within the household and immunization practices were found to be associated with diarrhoeal prevalence among children under five years. It is therefore recommended that there is need for public health education and promotion in the study area.
CHAPTER ONE: INTRODUCTION Background information
Risk of acute diarrhoea is still high worldwide in children aged zero to less than five years. Diarrhoea continues to remain one of the most important causes of death. It is the second major cause of mortality globally in children aged zero to less than five years. Every year, the number of diarrhoea cases continues to increase and is estimated to be 1.7 billion annually. Diarrhoea accounts for up to 7.7% of deaths in Africa according to the World Health Organsition (WHO). In Africa, an estimated 5 episodes of diarrhoea are observed every year in each infant. Eight hundred thousand children under five years die from diarrhoea and dehydration each year in Africa (WHO, 2018). During the year 2018, in Kenya, 1,499,146 cases of acute diarrhoea were reported among childrenunder the age of five. Among the cases of acute diarrhoea in 2018 in Kenya, Nairobi accounted for 136, 028 cases (DHIS, 2019).
Diarrhoea leads to loss of electrolytes and fluids which will result in dehydration and malnutrition. Three main agents cause diarrhoea: bacteria, parasites, and viruses. In most of the cases, diarrhoea caused by bacterial infections, parasitological infections, and viral infections occurs after improper hygiene and sanitation conditions or unsafe drinking water (Mokomane et al., 2018). The main virus responsible for acute diarrhoea in children under five year is rotavirus (WHO, 2009).
Rotavirus accounted for about one third of deaths as a result of diarrhoea and 9,000,000 globally hospital admissions of children under the age of 5 years (Carmo et al., 2011, Troeger et al., 2018). Rotavirus is responsible for 41 percent of the burden of childhood diarrhea in Kenya (Otieno et al., 2020). In a recent study led by Gikonyo et al., (2019) which aimed to estimate the post vaccine prevalence and seasonal distribution of rotavirus in children under five years in Nairobi County, the hospital based prevalence of rotavirus was 15.2%. The
WHO introduced rotavirus immunization in July 2009 into the national immunization programmes of all countries after finding that rotavirus is one of the main cause of diarrhoea among children (WHO, 2009). There are two types of rotavirus vaccine: the monovalent formulation (RotatrixTM) and the pentavalent formulation (RotaTeqTM). The routine immunization on rotavirus recommended by the WHO consists of two doses composed of the single-dose vaccine sequence which should be given for the monovalent formulation. The first dose will be given from 6 to 14 weeks, and the second from 14 to 24 weeks. The dosage period does not exceed 4 weeks. The pentavalent formulation consists of three doses. The very first dose must be taken at the age of 6-12 weeks, the two further doses at 4-10 weeks interval. All three doses must be finished before a child is 32 weeks old. Kenya implemented the rotavirus vaccine into the national immunization programme in July 2014. Since then, in the framework of the routine child immunization programme, two doses of live attenuated rotavirus vaccine (Rotarix) are administered orally at 6 and 10 weeks of life. (Government of Kenya, 2013, WHO, 2019).
Children aged between 0-59 months have several reasons for a higher death rate due to diarrhoea. Poverty is one of the primary causes of death from diarrhoea. Studies have demonstrated that poor families or families without funding are more risky than others. Illiteracy by caregivers or parents is also one of the primary causes of diarrhoea mortality in children aged between 0-59 months. Researches also illustrated that uneducated parents or caregivers have a greater frequency of diarrhoea than educated caregivers. In young mothers, knowledge on Oral Re-hydration Salts (ORS) is poor compared to in their older counterparts. Low knowledge on the management practices of acute diarrhoea by caregivers can also raise death rates and incidence of diarrhoea among children under five years (Ansari et al., 2009).
Improper prevention measures such as non-exclusive breastfeeding, improper hygiene and sanitation conditions, non-immunization, and unsafe drinking water are risk factors of
diarrhoea. Consequently, proper domestic practice regarding diarrhoea management will reduce the death rate. Quick administration of ORS is one the proper home diarrhoea management strategies (Apa et al., 2015). Several studies also demonstrated that good practices reduce the burden of acute diarrhoea among children (Thiam et al., 2019, Hillow, 2018).
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