The Influence of Primary Careg

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THE INFLUENCE OF PRIMARY CAREGIVERS'
COMMUNITY PARTICIPATION, HYGIENE CARE KNOWLEDGE, AND
HYGIENE PRACTICE ON EPISODES OF DIARRHEA IN CHILDREN
UNDER FIVE YEARS OF AGE IN RURAL ZIMBABWE.
by
MARGO B. MAPANGA
Submitted in partial fulfillment of the requirements
for the degree of Doctor of Philosophy
Dissertation Advisor: Dr. Diana L. Morris
Department of Nursing
CASE WESTERN RESERVE UNIVERSITY
May, 1998
UMI N u m b e r : 9911414
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Margo Bruce Mapanga
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Margo B. Mapanga
candidate for th e PhD______________________ degree.*
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(date) c ^ /V / 99
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any proprietary material contained therein.
THE INFLUENCE OF PRIMARY CAREGIVERS'
COMMUNITY PARTICIPATION, HYGIENE CARE KNOWLEDGE, AND
HYGIENE PRACTICE O N EPISODES OF DIARRHEA IN CHILDREN
UNDER FIVE YEARS OF AGE IN RURAL ZIMBABWE.
Abstract
by
M AR GO B. MAPANGA
Diarrhea in children five years and under is
potentially preventable but remains a major cause of
death and is ranked second out of ten conditions most
frequently managed by community health nurses at rural
health centers in Zimbabwe. Research and secondary health
programs in less developed countries have focused on
diarrhea management through feeding practices during
diarrhea, and the use of oral rehydration fluid, salt,
sugar and water solution and other fluids rather than
prevention. A health promotion model for the prevention
of diarrhea episodes, determining the influence of
primary caregivers' community participation, hygiene care
knowledge, and hygiene practice on diarrhea episodes in
children under five years has not been examined.
A health promotion model derived from the McGill
model of nursing proposed that primary caregivers'
community participation, as a social environment, hygiene
care knowledge as an aspect of a person's characteristics
ii
and hygiene practice as an aspect of behavior are
important factors to promote health through r ed uc ti o n of
diarrhea episodes in children under five years. This
study proposed that primary caregivers* community
participation, hygiene care knowledge, and hygiene
practice would e xplain diarrhea episodes in children
under five years.
A cross"Ssctiop.sl survsy dssi^n usln^ 3. inultists^s
random sample of six hundred primary caregivers' in rural
areas was used to examine the factors which may influence
diarrhea episodes in children under five years. The
instruments administered were: Community Participation
Index, Hygiene Care Knowledge Scale, Hygiene Behavior
Checklist Scale, and Diarrhea Episodes Questionnaire.
Multiple regression analysis was used to dete rm in e
the influence of c ommunity participation, hygiene care
knowledge, and hygiene practice on diarrhea episodes.
Multiple regression analysis supported the negative
relationship of hygiene practice on diarrhea episodes.
The effects of c ommunity participation and hygiene care
knowledge on d iarrhea episodes were not supported. The
health promotion model for prevention of diarrhea was
partially supported.
The study suggests that community health nurses
should strengthen the promotion of primary c a r e g i v e r s '
iii
hygiene practice to prevent episodes of diarrhea in
children under five years. Community health nurses should
also acknowledge that community participation and hygiene
care knowledge m a y still be important factors in reducing
episodes of diarrhea.
iv
ACKNOWLEDGEMENTS
I wish to express my sincere thanks to my
chairperson Dr D Morris for her continued support and
guidance throughout the proposal development, candidacy
and dissertation completion and defense. My further
sincere thanks is extended to m y dissertation panel Dr M
Wykle, Dr D Modly and Dr S Wottman for their
enccura gement and contributions. The W. K. Kellogg
Foundation provided sponsorship for the program for which
I am truly grateful.
Deep gratitude is extended towards the study site
Provincial Medical Directorate for their unfailing
support during the data collection phase. Sincere thanks
goes to the W. K. Foundation staff for their continued
support through my fellowship period. The University of
Zimbabwe is thanked for accommodating time needed for the
research and dissertation defense.
Above all I am indebted to m y husband Kudakwashe and
son Kenneth for their overwhelming and unfailing support
throughout the program leading to the completion of my
dissertation. In addition, special recognition is given
to my son Kenneth for his computer expertise. Finally I
w o ul d like to thank my parents, Mr and Mrs J. M. Ramage
for their words of encouragement.
TABLE OF CONTENTS
ABSTRACT.............................................. ii
A CK NO WLEDGEMENTS........................................ V
TABLE OF C O N T E N T S ...................................... vi
LIST OF F I G U R E S ..........................................X
LIST OF T A B L E S .......................................... xi
A P P E N D I C E S ............................................. xii
CHAPTER 1 - I NT RO DU CT I ON ............................... i
P u rp os e ............................................. 1
Statement of the P r o b l e m ..........................1
Diarrhea E p i s o d e s ............................ 4
Community P a r t i c i p a t i o n ..................... 5
Hygiene Care K n o w l e d g e ...................... 6
Hygiene P r a c t i c e ............................. 7
McGill Model of N u r s i n g ...........................8
Significance to N u r s i n g ........................... 8
Theoretical R a t i o n a l e ............................ 12
Organizing F r a m e w o r k ....................... 15
Conceptual Definition of T e r m s .................. 16
Community P a r t i c i p a t i o n .................... 16
Hygiene Care K n o w l e d g e ..................... 17
Hygiene P r a c t i c e ............................ 17
Diarrhea E p i s o d e s ........................... 17
S u m ma ry ............................................ 17
Questions and H y p o t h e s e s .........................18
vi
CHAPTER 2 - LITERATURE REVIEW......................... 22
Diarrhea E p i s o d e s .................................22
Community P a rt i ci pa ti on .......................... 26
Hygiene C a re K n o w l e d g e ........................... 30
Hygiene P r a c t i c e .................................. 33
S u m m a r y ............................................ 36
Theoretical M o d e l ................................. 36
CHAPTER 3 - RESEA RC H DESIGN / M E T H O D S ................ 40
Sampling P l a n ..................................... 41
Sample S i z e .................................. 41
S a m pl in g P r o ce du r e .......................... 42
Sample Characteristics..................... 43
V a r i a b l e s .......................................... 46
Independent Variables.......................46
Commu n it y Participation...............46
Hygiene Care Knowledge ................ 48
H ygiene p ractice.......................50
D ependent V a r i a b l e .......................... 52
Diarrhea Episodes..................... 52
D emographic Variables.......................53
Participant Demographic S h e e t ....... 53
Control V a r i a b l e s ........................... 54
T i me of Diarrhea.......................54
C o m m u n i t y .............................. 54
vi i
Number of Children Five Years
and u n d e r .............................. 55
Primary Caregiver's A g e ............. 55
Study Child's A g e .................... 55
Primary caregiver's Formal
E ducat io n ............................. 55
I n s t r u m e n t s ...................................... 55
D ata C o l l e c t i o n ................................ .56
Human Rights C o n s i d e r a t i o n s .............. 57
Data A n a l y s i s .................................... 59
Preliminary A n a l y s e s ...................... 59
Analysis of V a r i a n c e ................. 60
Pearson Product Moment
Correlation A n a l y s i s ................. 61
Residual A n a l y s i s .................... 64
Analysis for Hypotheses T e s t i n g .......... 67
Multiple Regression A n a l y s i s ........70
CHAPTER 4 - RESULTS AND D I S C U S S I O N .................. 73
C o m m u n i t y Participation I n d e x .................. 73
H y g i e n e Care Knowledge S c a l e ................... 78
H y g i e n e Behavior Checklist S c a l e ...............83
D i a r r h e a E p is o de s................................ 86
M u l t i p l e Regression A n a l y s i s ................... 90
H ypoth es es R e su lt s............................... 94
Post Hoc A n a l y s i s ................................ 96
viii
D i s c u s s i o n ........................................ 97
Community Pa rt ic i p a t i o n .................... 98
Hygiene Care K n o w l e d g e .................... 100
Hygiene P r a ct ic e........................... 101
Diarrhea E p i so de s..........................103
Community Participation, Hygiene
Care Knowledge and Hygiene Practice
Relationship to Diarrhea Epis od es....... 105
C H A P T E R 5 - SUMMARY, LIMITATIONS, IMPLICATIONS
AND R E C O M M E N D A T I O N S ................................... 115
S u m m a r y ........................................... 115
L i m i t a t i o n s ...................................... 117
I m p l i c a t i o n s ..................................... 119
R e c o m m e n d a t i o n s ..................................122
R E F E R E N C E S ............................................. 124
ix
List of Figures
Figure 1. Model of Organizing Framework.............19
Figure 2. Regression D i a g r a m ......................... 68
List of Tables
Tab l e 1. Caregiver's Age and E du ca ti o n............. 45
T abl e 2. Caregiver's Childrens Age and
R e l a t i o n s h i p .................................47
Tab le 3. Correlation Matrix of Independent and
Dependent V a r i a b l e s ......................... 62
Tab le 4. Correlation Matrix of Independent,
Dependent and Control V a r i a b l e s ........... 65
Tab le 5. Community Participation I n de x............. 74
Tab l e 6. Hygiene Education in Community M e e t i n g s . . 77
Table 7. Caregivers' Perception of C o mm un it y
P a r t i c i p a t i o n ................................79
T abl e 8. Caregivers' Hygiene Care K n o w l e d g e ....... 80
Tab l e 9. Caregivers' Hygiene Practice S c o r e s ...... 84
T a b le 10. Interviewer Latrine, Yard and Ch i l d
O b s e r v a t i o n s ................................. 87
Tab le 11. Children's Number of Diarrhea E p i s o d e s ... 89
Tab l e 12. Children with Diarrhea Episodes
in each W a r d ................................. 91
Table 13. Multiple Regression Analysis of Diarrhea
E p i s o d e s ..................................... 92
T ab l e 14. Multiple Regression Analysis of Diarrhea
Episodes with the C o n t r o l s ................. 95
xi
APPENDICES
APPENDIX A Participant Demographic S h e e t ..........132
A PPE ND IX B Diarrhea Episode Q u e s t i o n n a i r e ......... 133
APP EN DI X C Hygiene C a re Knowledge S c a l e ........... 134
APPE ND IX D Hygiene Behavior Check L i s t S c a l e 137
APPE N DI X E Community Participation I n d e x .......... 139
A PPENDIX F Informed C o n s e n t ......................... 140
xii
CHAPTER 1
INTRODUCTION
Purpose
The purpose of this cross-section correlational
study was to determine the influence of primary
c a r e g i v e r s ' community participation, hygiene care
children under five years of age. The m a j or it y of
diarrhea control studies have focused on the management
of diarrhea rather than prevention (Bentley, 1992). This
study examined the effect of community participation,
hygiene care knowledge and hygiene practice on episodes
of diarrhea. The study proposed that community
practice w ou ld predict diarrhea episodes. The development
of a theoretical model should contribute to nursing
knowledge and provide community health nurses with the
basis for practice to reduce diarrhea episodes in
children u nder five years of age in rural settings in
less developed countries.
Statement of the Problem
Nursing in less developed countries embraces the
primary health care philosophy that each individual,
family and community realize its potential for health at
every stage of development (Maglacas, 1988). Nurses as
2
the primary source of professional health care in less
developed countries, are challenged by major health
problems which are potentially preventable. One such
health problem is diarrhea in children under five years
of age in Zimbabwe.
Henderson and Nite (1978) define diarrhea as a
dysfunction of the activity of elimination that involves
the person experiencing an increased frequency of bowel
movements. Henderson and Nite (1978) state that
elimination is a basic fundamental need of living
contributing to the health and well being of the
individual. Diarrhea poses a danger to health because of
excessive loss of fluids and electrolytes, incomplete
absorption of nutrients leading to dehydration,
electrolyte imbalance, and loss of weight and strength
(Roper, Logan & Tierney, 1980). Children with diarrhea
are irritable, inactive, weak, and anorexic (Bentley,
1992). Diarrhea exacerbates conditions such as
malnutrition, lowered resistance to infection (Tagwireyi
and Greiner, 1994) and is a leading cause of illness and
death among young children in less developed countries
(Snyder & Merson, 1982).
The Zimbabwe Ministry of Health (1987) has
identified that diarrhea in children under five years is
a preventable health problem. Children under five years
3
in Zimbabwe comprise approximately 17% of the total
population. It is also estima te d that 80% of the total
population live in the rural areas thus the majority of
children und er five years live in the rural areas.
C h i l d r e n under five years in Zimbabwe experience an
average of four episodes of diarrhea per year. Compar ab le
less d e v e l o p e d countries collectively report a global
mean of 3.4 episodes of diarr he a per child per ye ar
(World Healt h Organization, 1990). Episodes of diarrhea
per child are based on c l in ic al ly reported episodes of
diarrhea, and may well be an under estimate of the true
nature of the problem (Zimbabwe Ministry of Health,
1987) .
Diarrhea is ranked second out of ten conditions most
frequently managed by c ommunity health nurses at rural
health centers nationwide (Zimbabwe Ministry of Heal th &
Child Welfare, 1992). Spradley (1990) emphasized that the
major function of the commun it y health nurse is to engage
the individual, family and c ommunity in the establishment
and mainten an c e of health and positive health behaviors.
Despite c o mm un it y based nursing practice to control
diarrhea, and the provision of clean water and sanitation
facilities, the incidence of diarrhea in children under
five years of age remains high leading to morbidity and
mortality in rural areas of Zimbabwe (Zimbabwe M in i s t r y
4
of Health & Child Welfare, 1992). Research a nd secondary
h ealth programs in less developed countries have focused
on diarrhea management through feeding practices during
diarrhea, and the use of oral rehydration fluid, salt,
s ug ar and water solution and other fluids (Bentley,
1992) .
Diarrhea Episodes
Diarrhea is a d ysfunction of elimination. In order
to maintain elimination, as a basic physiologic need
contributing to health and well-being in children under
five years, there is a need to determine the influence of
p r i m ar y caregivers' community participation, hygiene care
knowledge, and hygiene practice on diarrhea episodes.
Primary caregivers in rural Zimbabwe are exclusively
female, in particular mothers and grandmothers, who
pr ov id e dependent care for their children and
grandchildren respectively. Primary caregivers' provide
d ependent care (Orem, 1991) by maintaining normative
e limination patterns in children under five. Children
u n d e r five years do not have the capability to provide
their own self-care, and therefore rely on p r i m ar y
caregivers' dependent care abilities.
There are two approaches used to control diarrhea in
chi ld re n under five years in less developed countries
n a m e l y the provision of clean water and sanitation
5
facilities {Isley, 1984; Lindskog, Lindskog & Wall 1987;
Narayon-Parker, 1988; Nichter, 1985; Weidner, Noss ie r &
Hughs, 1985) and the management of diarrhea through
continued feeding, and use of oral rehydration fluid,
salt, sugar and wa te r solution, and other fluids
(Bentley, 1988; Eisemon, Patel & Sena, 1987; Nyatoti,
Nyate & Mtero, 1993; Walsh & Warren, 1979; World Health
Organization, 1995a).
Provision of clean water and good sanitation
facilities as a preventative measure does not
automatically reduce diarrhea episodes (Huttly, 1990).
The use of food and fluids during diarrhea indicates a
focus on case management (World Health Organization,
1993), rather than prevention.
Community Participation
Community participation as a component of pri ma ry
health care has been suggested as an important factor in
diarrhea control programs in the community (Tumwine,
1989; Woelk, 1994; World Health Organization, 1991).
Loevinsohn (1990), Oakley (1989), Rifkin (1990), and the
World Health Organization (1991) have highlighted a low
level community participation at macro level as a
potential factor contributing to the lack of success in
interventions designed to reduce diarrhea episodes.
However, currently community participation at the macro
6
level can only be measured qualitatively (Rifkln, 1993).
Therefore it is not possible to determine precisely the
level of community participation required to indicate
success in diarrhea control interventions. This study
proposed to measure community participation
quantitatively, and at the micro level to determine its

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Hygiene Care Knowledge
Hygiene care knowledge of the prim ar y caregiver is
defined as cognitive development regarding awareness of
health promoting activities to prevent diar rh ea in
children. Hygiene care knowledge as an a spect of health
promotion is learned through active participation.
Alam, Wojtyniak, Henry and Rahaman (1989), Huttly
(1990), Loevinsohn (1990), Patel, Eisemon, Arocha (1988),
Stanton and Clemens (1987), and Yoosuf (1993) reported
that the nature of health education as an intervention
was a potential factor for failure to reduce diarrhea
episodes. It is not possible to ascertain precisely the
nature of education required to reduce diarr he a due to
failure to document or fully describe hygiene education.
In addition none of the studies cited me a s u r e d the level
of hygiene care knowledge to determine its impact on
diarrhea episodes. This study proposes to measure hygiene
care knowledge to determine its impact on diarrhea
7
episodes.
Hygiene Practice
Hygiene practice is defined as primary c a r e g i v e r s ’
pattern of goal directed activities related to pr ev e n t i o n
of diarrhea in children (Boot & Cairncross, 1993).
Hygiene practice is regarded as a constellation of
ielcxLed hygiene activities (Boot & Cairncross, 1993)
w hi ch develop as a learned process through community
participation and hygiene care knowledge.
The m ajor weakness of the m a j o r i t y of studies
addressing diarrhea episodes is that only one hyg ie n e
activity is used to measure hygiene practice namely
mother's house appearance (Bertrand & Walmus, 1983);
method of disposal of children's feces (Baltazar & Solon,
1989; M e r t e n s , Jaffer, Fernando, Cousens & Feachem,
1992); or non-removal of animal feces from the yard
surrounding the house (Bukenya & Nwokolo, 1991). T h e r e is
a need to examine the primary caregiver's hygiene
practice as a constellation of hygiene activities to
determine the influence on diarrhea episodes.
A theoretical model determining the influence of
primary caregivers' community participation, h ygiene care
children under five years has not been examined. T h e
McGill model of nursing (Gottlieb & Rowat, 1987) p r o p o s e d
8
by Allen (1977) provides the basis for the study.
McGill Model of Nursing
The McGill model of nursing (Gottlieb & Rowat, 1987)
derived from social learning theory suggests that the
social environment, characteristics of the individual,
and the individual's behavior are important factors in
ptumuLiny health. There is a need to examine the
influence of social environment c reated by community
participation, characteristics of the individual
pertaining to hygiene care knowledge, and the
individual's behavior constituting hygiene practice on
diarrhea e p i s o d e s .
Nurses need a better understanding of the influence
of community participation, hygiene care knowledge and
hygiene practice on diarrhea episodes in children u nd er
five years in order to facilitate the primary caregiver's
dependent care capabilities regarding maintenance of
elimination. The proposed theoretical model has the
potential to provide the basis for health promotion
interventions to prevent diarrhea in children under five
years.
Significance to Nursing
The goal of nursing is to facilitate individuals,
families and communities in dealing effectively with life
events and to find healthy ways of developing (Allen,
9
1983). Health and healthy ways of living are learned
within the respective social context of the environment
(Gottlieb & Rowat, 1987). This goal of nursing is in
accordance with Donaldson and Crowley's (1978) statement
that "nursing studies the wholeness or health of humans,
recognizing that humans are in continuous interaction
with their environments" (p. 119).
Allen (1977) states that nursing focuses upon the
individual, family or community in c op in g with the events
of daily living. Wi th i n the context of pr im a r y health
care, nursing is also viewed as facilitating self-help
and beneficiary-environment interaction (Stewart, 1990).
The premise of social learning theory is that people,
their behavior and their environments are reciprocal
determinants of each other. Further it is p roposed that
individuals serve as the principal agents of their own
change through self regulatory capacities (Bandura,
1977). The McGill model of nursing assumes that
individuals, families and communities have the potential
within to aspire to and are motivated toward learning
positive health behaviors through active participation
and personal discovery (Gottlieb & Rowat, 1987).
Henderson and Nite (1978) explain that the primary
responsibility of the nurse is to help people with daily
patterns of living such as elimination, that individuals
10
ordinarily perform without assistance. In addition,
nurses provide help through social intercourse and
learning so that people can develop or maintain health
behaviors for their own well-being (Henderson & Nite,
1978). Primary caregivers as responsible adults, carry
out activities or dependent care (Orem, 1991) for
socially dependent individuals in the study children
under five years of age.
Maintenance of normative elimination patterns in
children leading to prevention of diarrhea depends on the
primary c a r e g i v e r s ’ knowledge of and skills to regulate
factors that affect their own development and functioning
in the interests of life, health or well-being (Orem,
1991). In this respect children under five years are
recipients of the dependent care provided. Nursing
activities focus on enhancing primary caregivers'
dependent care abilities in order to maintain normative
elimination patterns in children leading to prevention of
diarrhea. Elimination is a fundamental need for health
and well-being (Henderson & Nite, 1978). Therefore
primary caregivers' dependent care when effectively
performed contributes to human integrity, functioning and
development (Orem, 1991). Primary caregivers' dependent
care (Orem, 1991) is executed through purposeful and
meaningful learned behaviors within a given social
11
environment as stipulated by the M cG i l l model of nur si ng
(Gottlieb & Rowat, 1987). Therefore the modified McGill
model of nursing incorporates the concepts of dependent
care (Orem, 1991) and elimination (Henderson, 1966).
Social learning theory, the M cGill model of nursing,
O r e m and Henderson suggest the importance of social
environment, the characteristics of the individual, and
the individual's behavior as important factors in
promoting health. The social environment in McGill's
model of nursing refers to the c om m u n i t y as a dynamic
system in w h i c h individuals or families as subsystems
interact and learn. According to the McGill model of
nursing (Gottlieb & Rowat, 1987), c o m m u n i t y participation
at macro level creates a social e nvironment which
influences the primary caregivers' cognitive development
and behavioral outcomes. Community participation as a
social environment is viewed as the context within w h i c h
hygiene care knowledge and hygiene p ractice are learned.
Community participation at micro level is the extent
of involvement by individuals in c om m u n i t y affairs
(Rifkin, 1990). In the McGill model of nursing (Gottlieb
& Rowat, 1987), it is postulated that community members
active participation is increased w h e n the health goals
are those of the community. Community participation
facilitates learning through active involvement. The
12
primary caregiver's ability to maintain normative
elimination patterns in children under five years is
influenced by community participation, characteristics of
the individual pertaining to hygiene care knowledge, and
the individual's behavior constituting h ygiene practice
on diarrhea episodes.
Nursing research to examine the influence of primary
caregivers' community participation, hygiene care
knowledge and hygiene practice on diarrhea episodes in
children under five years is required for p r o m o t i n g
health in the community. An understanding of the level of
contribution of these factors will provide nurses w ith a
scientific basis for clinical practice. F u r t h e r research
to maintain normative elimination patterns in children
under five years in rural areas in less d e v e l o p e d
countries will provide the foundation for nu rs i ng
interventions to promote health and well-being. The
significance of the study is that it is ant ic ip at e d
knowledge will be developed that has the potent i al to
guide nursing practice.
Theoretical Rationale
Schwab (1962) suggests that a discipline is a way of
knowing, comprising a body of imposed conceptions which
guide and control scientific inquiry. The d i s c i p l i n e of
nursing as a science and a profession has i dentified its
13
unique domain of inquiry by focusing upon the
m e t a p ar a di gm concepts of person, health, environment and
nursing (Fawcett, 1984). Walker (1971) reiterates that
persons providing care, persons with health problems
receiving care, the environment in which care is given,
and the end state of w ell-being are the central focus of
trie discipline of nursing.
Conceptual models of nursing reflect particular
philosophical perspectives of person, health environment,
and nursing and ultimately provide a frame of reference
for members of the discipline (Fawcett, 1992). The
discipline of nursing utilizes conceptual models to
portray the essence and nature of nursing whilst
providing direction for nursing knowledge development
through research. Subsequent utilization of knowledge for
nursing education, and practice is necessary to enhance
the quality of care in health promotion activities.
This study is concerned with the health and w e l l
being of children with regards to prevention of diarrhea
by maintaining normative elimination patterns. The
primary caregiver as the individual providing dependent
care to the child (Orem 1991), is the person whose
hygiene care knowledge and hygiene practices need to be
enhanced. Nurses also promote primary caregivers'
commu n it y participation in order for caregivers to obtain
14
hygiene care knowledge and hygiene practice.
The McGill model of nursing derived from social
learning theory (Allen, 1982) and modified w i th concepts
from Orem (1991) and Henderson (1966), provides the
explanation and direction underlying the conceptual
perspective for the study. Social learning theory
identifies the concepts of person, behavior and
environment as having a reciprocal relationship (Bandura,
1977). The McGill model of nursing regards social
learning as the central foundation for health promotion.
In this study, primary caregivers' level of community
participation, providing a social environment in which
learning takes place, hygiene care knowledge reflecting
characteristics of a person and hygiene practice denoting
behavior are expected to promote health through reduction
of diarrhea episodes in children under five years.
There has been no systematic research using the
McGill model of nursing with regards to the concepts of
elimination, and dependent care which are of interest in
this study. The concept of elimination as a basic
physiologic need (Henderson 1966), and the concept of
dependent care (Orem 1991) as an activity provided by
primary caregivers' are used to enhance this study's
conceptual perspective.
The McGill model of nursing refers to the community
15
as a dynamic system consisting of individuals. Henderson
an d Orem models of nursing refer to individuals who make
u p the community. The McGill, O r e m and Hende rs on models
of nursing are based on the premiss of person-environment
interaction as well as the individual ha vi n g potential
capabilities for positive health behaviors thereby
portraying philosophical congruence. This s tu dy focuses
on individual caregivers as members of a larger
community. The individual caregivers interact with and
are influenced by the community as a social environment.
T herefore the inclusion of H enderson (1966), and Orem
(1991) concepts of elimination and d ep en d en t care
respectively complement, and enhance the McGill model of
nursing.
Organizing Framework
The McGill model of nursing (Gottlieb & Rowat,
1987), derived from social learning theory (Bandura,
1977) and modified with concepts from O r em (1991) and
Henderson (1966), form the basis of the conceptual
framework for the proposed study that includes the
importance of social environment, person and the person's
behavior. The proposed conceptual framework suggests that
social environment, person and the person's behavior are
important factors in promoting hea l th (Bandura, 1977;
G o t t li eb & Rowat, 1987).
16
The primary caregivers' community participation
creating a social environment, hygiene care knowledge
reflecting the individual p r i m ar y caregiver's
characteristics, and hygiene practice denoting the
individual primary caregiver's behavior, are important
factors in reducing diarrhea episodes in children under
five years. Thus community participation, hygiene care
knowledge and hygiene practice are influential factors in
diarrhea episodes in children under five years of age.
This study proposed that the pr i ma ry caregivers'
community participation, hygiene care knowledge, and
hygiene practice would explain the occurrence and
frequency of diarrhea episodes.
Conceptual Definitions of Terms
Community participation is defined at micro level as
the number of times that the primary caregiver attends
community meetings or activities on diarrhea within a
defined community. Community participation facilitates
learning through active involvement. Community
participation at macro level creates a social environment
which influences the primary caregivers' cognitive
development and behavioral outcomes. Community
participation as a social environment is viewed as the
context within which hygiene care knowledge, and hygiene
17
practice are learned
Hygiene care knowledge is defined as the primary
ca re g i v e r s ' cognitive development regarding awareness of
health promoting behaviors to prevent diarrhea in
children. Hygiene care knowledge as an aspect of health
promotion is learned through active participation.
Hygiene Practice
Hygiene practice is defined as primary caregivers'
pattern of goal directed activities related to prevention
of diarrhea in children. Hygiene practice is regarded as
a constellation of related hygiene activities performed
by people to m aintain a clean personal, domestic and
environmental state. Hygiene practice activities develop
as a learned process through community participation and
hygiene care knowledge.
Diarrhea Episode
Diarrhea episode is defined as the occurrence of
three or more liquid stools with or without blood during
a twenty-four hour period in children under five years.
Diarrhea episode is a dysfunction of the basic
physiologic process of elimination necessary for health
and well-being. Maintenance of normative elimination
patterns in c hildren under five years is an aspect of
dependent care provided by primary c aregivers'. The
18
primary caregivers' capabilities for dependent care
leading to prevention of diarrhea in children under five
years is influenced by community participation/ hygiene
care knowledge and hygiene practice.
Summary
If nursing is to provide the basis for interventions
to maintain normative elimination patterns by reducing
diarrhea in children under five years in less developed
countries, it is essential to determine the influence of
community participation, hygiene care knowledge and
hygiene practice on diarrhea episodes. The proposed
theoretical model (Figure 1), based on McGill's model of
nursing and modified by Orem and Henderson concepts, is
intended to determine the influence of primary
children under five years.
Questions and Hypotheses
The study will test the following questions and
hypotheses:
Question 1 . Is community participation of primary
caregivers' associated with children's diarrhea episodes?
Hypothesis 1 . Community participation has a negative
effect on diarrhea episodes.
Question 2 . Is hygiene care knowledge of primary
19
Commumt
articipation
Hygiene
Care
Knowledg
CONTROLS
Primary caregiver's age
Formal Education
Study child's age
Number of children ^ 5 yr
Time of diarrhea occurrence (wks)
Community (ward)
Figure 1. Organizing Framework
20
caregivers' associated w i th c h i l d r e n ’s diarrhea episodes?
Hypothesis 2 . Hygiene care knowledge has a negative
Question 3 . Is hygiene practice of primary c a r e g i v e r s ’
associated with children's diarrhea episodes?
Hypothesis 3 . Hygiene practice has a negative effect on
diarrhea episodes.
Question 4 . Is the primary caregivers' community
practice associated with children's diarrhea episodes?
Hypothesis 4 . Community participation, hygiene care
knowledge, and hygiene practices have a negative effect
on diarrhea episodes.
practice associated with children's diarrhea episodes
when controlling for primary caregivers' age, primary
caregivers' formal education, primary caregivers' number
of children five years and under, primary caregivers' age
of youngest child, time of diarrhea occurrence and
community?
knowledge, and hygiene practice have a negative effect on
diarrhea episodes controlling for primary caregivers'
age, primary caregivers' formal education, primary
21
caregivers' number of children five years and under,
primary caregivers' age of youngest child time of
diarrhea occurrence and community.
CHAP T ER 2
L ITERATURE REVIEW
The purpose of this study was to determine the
influence of primary caregivers' community participation,
hygiene care knowledge, and hygiene practice on diarrhea
episodes. The following literature review addressed
research pertaining to diarrhea episodes in children
under five yesrs in less developed countries. A esse is
made for the need to focus on prevention rather than
management approaches during diarrhea, and the provision
of clean water, and sanitation facilities.
Research regarding primary caregivers' cognitive and
social factors; community participation, hygiene care
knowledge, and hygiene practice will be discussed. A
theoretical model derived from the McGill model of
nursing based on social learning theory and modified w i t h
Orem and Henderson concepts will be used to examine the
potential influence of primary caregivers' community
practice on diarrhea episodes in children under five
years in less developed countries.
Diarrhea Episodes
Diarrhea episodes as a health problem of elimination
(Henderson, 1966) are regarded as a major cause of
morbidity and mortality in children under five years in
22
23
less de ve l o p e d countries (Zimbabwe Ministry of Health,
1986). A gover n me nt survey (Zimbabwe Ministry of Health,
1987) found that each child under five years had four
episodes of diarrhea per year. Basing on these findings
the Zimbabwe Ministry of Health and Child Welfare (1992)
stated that diarrhea was the second most notifiable
condition w i t h an incidence rate of 1,7 37 per 100,000
population for the year 1986. The number of diarrheal
associated deaths resulting that same year was 135 per
100,000. Diarr he a is the major cause of child deaths
(Republic of Zimbabwe Report, 1997) and is also ranked as
the second most freguently man a ge d condition by nurses at
health centers (Zimbabwe Mini st ry of Health and Child
Welfare, Statistics Department, 1992).
Due to under-reporting, the diarrhea rates prese n te d
only account for reported diarrhea episodes and m ay well
be an un de re s ti ma te of the true nature of the pro bl em
(Zimbabwe M i n i s t r y of Health, 1987). Despite commun it y
based nurs in g practice to control diarrhea, and the
provision of clean water and sanitation facilities, the
number of diarrh ea episodes in children remains high
leading to morbi di ty and mortal it y in rural areas of
Zimbabwe (Zimbabwe Ministry of Health and Child Welfare,
1992) .
The W o r l d Health Organization (1990) following 7,350
24
cross sectional surveys in seventy less developed
countries projected a global mean of 3.4 diarrhea
episodes per child per year. Huttly (1990) specifies that
diarrheal diseases are common throughout the developing
world, and are a leading cause of morbidity and mortality
in children under five years with 1,500 million diarrhea
episodes per year and 4 million diarrhea associated
deaths.
Snyder and Merson (1982) established that diarrhea
morbi di ty tends to peak in children aged six to twenty-
four months due to the development of m o bi l it y skills,
and tactile skills through the mouth. Diarrhea episodes
are primarily caused by pathogenic organisms which are
t ransmitted exclusively by the fecal-oral route (Feachem,
1984). The two studies highlight the importance of
pr im ar y caregivers' dependent care (Orem, 1991) abilities
to prevent diarrhea episodes in children under five years
through hygiene care.
Diarrhea is a health problem because of excessive
loss of fluids and electrolytes, incomplete absorption of
nutrients leading to dehydration, electrolyte imbalance,
and loss of weight and strength (Roper, Logan & Tierney,
1980). Children with diarrhea are irritable, inactive,
weak, and anorexic (Bentley, 1992). Diarrhea exacerbates
conditions such as malnutrition, lowered resistance to
25
infection, and is a leading cause of illness and dea th
among young children in less developed countries (Snyder
& Merson, 1982). One diarrhea episode has been found to
be a risk factor for repeated diarrhea (Tatley & Yach,
1988).
In particular, frequent diarrhea episodes in
children under five years in less developed countries
leads to weight loss, malnutrition, and failure to thrive
(Morley & Woodland, 1979). A relationship has been
established between the frequency of a child's diarrhea
episodes and nutritional status thereby affecting the
child's development, and health (Morley, 1973). Frequency
of diarrhea reduces absorption of nutrients necessary for
growth and maintenance.
There are two major approaches used to control
diarrhea in children under five years in less developed
countries namely; the provision of clean water and
sanitation facilities (Isley, 1984; Lindskog, Linds ko g &
Wall, 1987; Narayon-Parker, 1988; Nichter, 1985; Weidner,
Nossier & Hughs, 1985), and the management of diarrhea
through c ontinued feeding, and the use of oral
rehydration fluid, salt, sugar and wa t e r solution, and
other fluids (Bentley, 1988; Eisemon, Patel & Sena, 1987;
Nyatoti, Nyate & Mtero, 1993; Walsh & Warren, 1979; World
Health Organization, 1995a; WHO, UNICEF & Zimbabwe
26
Ministry of Health & Child Welfare 1992).
Provision of clean water and good sanitat i on
facilities does not automatically reduce diarrhea
episodes (Bassett, Sanders & Todd, 1992; Huttly, 1990).
The use of food and fluids during diarrhea indicates a
focus on secondary management (World He a l t h Organization,
1993, 1995b), rather than prevention.
A theoretical model determining the influence of
primary caregivers' community participation, hygiene care
knowledge, and hygiene practice on episodes of diarrhea
in children under five years has not been examined. The
proposed theoretical model could provide the basis for
health promotion interventions to prevent diarrhea in
children under five years.
Community participation as a component of primary
health care has been suggested as an important factor in
diarrhea control programs in the community (World Health
Organization 1991). Community participation is the
process whereby people are involved with, and share in, a
variety of activities with a communal goal
(Katzenellenbogen, Pick, Hoffman & Weir, 1988). Rifkin
(1988) defines community participation as "a social
process whereby specific groups with shared needs living
in a defined geographic area pursue identification of
27
their needs, make decisions and establish mechanisms to
meet these needs" (p. 933).
Community participation defined at the group level
denotes a social process and assumes that every
respective membe r is equally involved, and contributes to
the goals of the community at macro level. In this study
community participation is viewed as creating a social
environment in wh i c h individual co m m u n i t y members are
exposed to and interact in their respective communities.
However the extent of each member's community
participation at micro level depends upon the degree of
involvement in community activities. Primary caregivers
as members of their designated communities are exposed to
community participation as a social environment at the
micro level. Therefore the individual primary caregivers'
c ommun it y participation at micro level is regarded as the
degree of involvement in community activities.
Independent evaluation of numerous health
interventions carried out in developing countries towards
reduction of diarrhea episodes concludes that a low level
of community participation was a potential factor
contributing to the lack of success (Loevinsohn, 1990;
Oakley, 1989; Rifkin, 1990 & World Health Organization,
1991). Reasons highlighted for failure of diarrhea
control strategies result from health planners engaging
28
local m a n p o w e r and resources but not involving the
community in the planning, implementation and evaluation
of interventions.
Stanton, Clemens, Khair, Khatun and Jahan (1987)
study of community participation in delivery of hygiene
education intervention to alter hygiene practice and
reduce childhood diarrhea in rural communities of
Bangladesh attributed failure of the intervention to low
level c om m u n i t y participation. In another study (Isley,
Sanwogou & Martin 1979) designed to establish the
effectiveness of community participation as an approach
for health education to control diarrhea in rural
communities of Cameroon, reported that failure to reduce
diarrhea episodes was attributed to low level community
participation.
Ahmed, Zeitlin, Beiser, Super, Gershoff and Ahmed
(1992), using community participation as an approach,
involved two out of three selected groups from different
sections of the community to identify local hygiene
practices. The groups in collaboration with the
investigators reached consensus on hygiene education
topics and low cost products for their personal use. The
groups w e r e collectively reported to have achieved a 96%
acceptance of interventions. However, achievement of
group consensus does not indicate the degree of
29
individual community m e m b e r s ' active involvement in the
interventions which constitute community participation.
The study's failure to report the impact of community
participation at an individual level and hygiene practice
on diarrhea incidence makes the level of success
difficult to ascertain.
Katzenellenbogen, Pick/ Hoffman and Weir's (1988)
carried out a preliminary survey to initiate community
participation for a diarrhea control program in a
municipal community of South Africa. A steering committee
of local community members was established to liaise with
researchers and to involve the whole community in the
study activities. The authors report that community
participation was not achieved due to community members'
poor attendance at local meetings. However, individual
member attendance at meetings was not measured to
determine level of community participation. A 98.8%
response rate in the survey indicated that community
consent and passive participation were achieved as the
majority were in favor of the diarrhea control program.
However only 40% of community members were actually
willing to become actively involved. The authors report
suggests the need to measure community participation as a
social environment at the micro level as the amount of
each primary c a r e g i v e r s ' involvement in community
30
activities with regards to programs addressing diarrhea
in children under five years. Therefore, this study
focused on measuring community participation at the
individual level rather than community participation at
the aggregate level.
Currently community participation has on ly been
e valuated guaiitativeiy at the macro level (Rifkin,
1993). Therefore, the level of community participation
required to indicate success in diarrhea control
interventions has not yet been established. This study
p ropo se d to measure community participation at the micro
level. Involving primary caregiver's as members of a
c o mm u n i t y may provide a precise indicator in a diarrhea
control program. It is the individual primary caregivers'
amount of involvement which constitutes the level of
c o mm un it y participation.
Hygiene care knowledge of the primary caregiver is
d e f in ed as cognitive development regarding awareness of
health promoting behaviors to prevent diarrhea in
children. Hygiene care knowledge as an aspect of health
p r om ot io n is learned through active participation.
Hygiene care knowledge considered necessary for
diar rh ea prevention has not been made explicit in health
e d uc at io n interventions (World Health Organization 1983).
31
Feachem (1984), Huttly (1990), and Loevinsohn (1990)
comment that most intervention studies related to
diarrhea control interventions fail to document or fully
describe the hygiene education component, making
replication difficult and intervention effectiveness
uncertain. In addition, hygiene education approaches were
viewed as being paternalistic, comprising unconnected
facts, lacking coherence, pre-packaged and not integrated
into the community's social environment. Alth ou gh the
need for community participation, referred to as
community social environment, is proposed to be
necessary for hygiene education, the studies place
emphasis on the nature, and the delivery of hygiene
e ducation rather than measurement of hygiene care
knowledge and its influence on diarrhea episodes.
Stanton and Clemens (1987) in Bangladesh, selected
hygiene education for the target behavior of maternal
handwashing of mothers with children under six years. A
26% reduction rate of diarrhea was achieved at o n ly seven
of the 25 intervention sites. The researchers reported
that the low reduction rate of diarrhea was due to the
method of delivery of hygiene education as well as an
inability to establish community participation. However,
the study did not measure the mother's hygiene care
knowledge and community participation to examine the
32
effects on the incidence of diarrhea episodes.
Alam, Wojtyniak, Henry and Rahaman (1989) focused
hygiene education on the danger of diarrheal diseases and
the role of clean water and hygiene. Interventions
consisted of maternal handwashing before food preparation
and following defecation, removal of child faeces from
Liiti ydxrci, ana nandpump water systems in rural areas of
Bangladesh. The reported results of 3.4 episodes of
diarrhea per child for the intervention area compared to
4.1 episodes of diarrhea per child for the control area
are difficult to judge based on the omittance of p r e
intervention diarrhea rates. In addition, the authors did
not include community participation as an aspect of the
hygiene education intervention to reduce diarrhea.
Patel, Eisemon and Arocha (1988) investigated rural
mothers' conception of diarrhea in Kenya. A comparative
analysis was carried out between schooled and unschooled
mothers to elicit cognitive processes of the causality,
recognition and treatment procedures of diarrhea. The
study demonstrated that despite schooled mothers being
aware of practices required to prevent diarrhea, the
ability of transferring knowledge to practice was
lacking. However the researchers did not examine the
relationship of hygiene care knowledge to diarrhea
e p i s o d e s . Hygiene care knowledge in the intervention
33
studies has not been studied to determine its association
with diarrhea episodes.
Yoosuf's (1993) study of group learning by Maldivian
rural mothers about primary health care including
diarrhea, focused on hygiene care knowledge. Mother's
hygiene care knowledge regarding safe water and
sanitation was examined. The hygiene care knowledge was
intended to enable the mothers' to take action in their
homes and diminish the risk of diarrhea occurring. The
social environment created by the group learning approach
was intended to promote community participation in the
hygiene education intervention. Th e experimental and
control groups demonstrated the same level of hygiene
care knowledge at pre-test. Following post-test, the
experimental group's scores doubled on hygiene care
knowledge. Therefore community participation through the
group learning approach had an influence on hygiene care
knowledge. However the impact of the intervention on
diarrhea episodes was not examined.
Hygiene Practice
Hygiene practice is defined as primary caregivers'
pattern of goal directed activities related to the
prevention of diarrhea in children. Hygiene practice is
regarded as a constellation of related hygiene activities
which develop as a learned process through community
34
participation and hygiene care knowledge.
Negative hygiene practice as a pattern of activities
assumed to be linked to the increased diarrheal episodes
have been reported in descriptive studies utilizing
observation technigues. Ahmed, Zeitlin, Beiser, Super,
Gershoff and Ahmed (1992); Alam, Wojtyniak, Henry and
Rahaman (i989); Dabbagh, Green and Walker (1992); De
Zoysa, Carson, Feachem, Smith and Loewenson (1984);
Stanton and Clemens (1987) describe three negative
hygiene activities in relation to the incidence of
diarrhea: open defecation in the living area by children,
reduced maternal handwashing before preparing food and
following defecation, and inattention to disposal of
garbage and feces. These studies collectively describe
hygiene practice in accordance with the nature of
personal hygiene, domestic hygiene and environmental
hygiene in rural settings.
The occurrence of childhood diarrhea is generally
assumed to be linked wi t h negative hygiene-related
activities at the household level (Bartlett, Hurtado,
Schroeder & Mendez, 1992). Mertens, Jaffer, Fernando,
Cousens and Feachem (1992) suggest that more studies
needed to focus upon specific hygiene activities to
confirm the association with diarrhea episodes prior to
implementing intervention activities. In contrast, Alam,
35
Wojtyniak, Henry, and Rahaman (1989) and Tatley and Yach
(1988) suggested that multiple hygiene activities
constituting hygiene practice need to be examined
simultaneously to determine the influence on diarrhea
episodes.
Alam, Wojtyniak, Henry, and Rahaman's (1989) who
otuuicu mt/uucra ^ c ia u iia i auu uumcaux^ iijftjicuc xu i.ui.ax
Bangladesh found that when the use of handpump w a te r was
the only hygiene activity adopted, diarrhea episodes
remained unchanged. The study showed that mothers who
carried out one hygiene activ i ty were more likely to
carry out other activities as well. Therefore improved
hygiene practice cannot be attributed to the effect of
only one particular hygiene activity.
The major weakness of the majority of studies
addressing diarrhea episodes is that only one hygiene
activity is used to measure hygiene practice namely the
mother's house appearance (Bertrand & Walmus, 1983);
method of disposal of children's feces (Baltazar & Solon,
1989; Mertens, Jaffer, Fernando, Cousens & Feachem,
1992); on non-removal of animal feces from the yard
surrounding the house (Bukenya & Nwokolo, 1991). There is
a need to examine the primary caregiver's hygiene
practice as a constellation of hygiene activities to
determine the influence on diarrhea episodes.
36
Summary
Diarrhea in children under five years remains a
major health problem in rural areas of less developed
countries and specifically in Zimbabwe. The negative
physical effects of diarrhea to children are well
documented. There is a need to focus on preventative
measures. The cognitive and social variables of the
primary caregiver's community participation, hygiene care
knowledge and hygiene practice in relation to their
potential influence on diarrhea episodes in children
under five years are inadequately addressed in the
research literature. The most noted weakness is the lack
of instruments with established psychometric properties
to measure the variables: community participation,
hygiene care knowledge and hygiene practice. In addition
the studies cited were not based on a theoretical model
that included the importance of community participation,
hygiene care knowledge, and hygiene practice, and their
potential influence on diarrhea episodes. The McGill
model of nursing derived from social learning theory
provides the theoretical framework for this study.
Theoretical Model
The McGill model of nursing derived from social
learning theory suggests the social environment,
characteristics of the individual, and the individual's
37
behavior are important factors in promoting health. The
literature presents several uses of the model. The World
Health Organization has adopted the McGill model of
nursing to describe and evaluate primary health care
(Kavitz & Frey, 1989). Gottlieb and Rowat (1987) report
that implementation of the model for nursing practice in
communities resulted in improved problem solving, and
increased involvement in health learning among community
members. The McGill model of nursing presents a unique
theoretical perspective of the central concepts: person,
health, environment, and nursing (Allen, 1977; 1981; &
1983). In addition, the model also reflects a community
aggregate and primary health care focus. However, there
is a lack of empirical evidence regarding the linkages of
the model concepts of person, behavior, and environment
with health outcomes. In this study, primary caregivers'
community participation, creating a social environment in
which learning takes place, hygiene care knowledge
reflecting the individual primary caregiver's
characteristics, and hygiene practice d enoting the
individual primary caregiver's behavior were expected to
promote health through reduction of diarrhea episodes in
children under five years. It is proposed that primary
caregivers' level of community participation, hygiene
care knowledge, and hygiene practice would explain
38
episodes of diarrhea in children under five years.
The study was based on the McGill model of nur si ng
(Gottlieb & Rowat, 1987) d e r iv ed from social learning
theory. Based on the theory, the social environment,
characteristics of the individual, and the individual's
behavior are important factors in promoting health.
In the current study, community participation was
viewed as the social environment, hygiene care k nowledge
as characteristics of the individual, and hygiene
practice as an aspect of the individual's behavior.
Reduction of diarrhea episodes was regarded as an asp ec t
of promoting health through the maintenance of n ormative
elimination patterns as a basic physiologic need. T h e
influence of primary caregivers' community participation,
hygiene care knowledge and hygiene practice on episodes
of diarrhea in children under five years was examined.
The McGill model of nursing was applied as a h ea l th
promotion model for reduction of diarrhea episodes. The
social environment, person and the person's behavior were
regarded as important factors in promoting health.
Potential negative effects of community participation,
hygiene care knowledge, and hygiene practice on d i a r r h e a
episodes have been implied in previous research studies
(Ahmed, Zeitlin, Beiser, Super, Gershoff, & Ahmed 1992;
Alam, Wojtyniak, Henry & Rahaman, 1989; Stanton &
39
Clemens, 1987; Stanton, Clemens, Khair, Khatun, & Jahan,
1987; Yoosuf 1993). Studies using the McGill model of
nursing as an approach to nursing care have reported an
increased nurse client contact, improved problem solving
skills and increased involvement in health learning among
community members ( Allen, 1983; Gottlieb & Rowat, 1987).
There has been no systematic research reported using the
McGill model of nursing to examine potential linkages of
hygiene practice on episodes of diarrhea.
CHAPTER 3
RESEARCH DESIGN/METHODS
A cross-sectional survey, design was used for the
study. The design is particularly appropriate for
describing the strength and direction of the
relationships of the independent variables: community
participation, hygiene care knowledge and hygiene
practice with the dependent variable, diarrhea episodes.
According to Brink and Wood (1989), in this type of study
design variables are not manipulated but measured
numerically and studied as they exist naturally at one
point in time. A conceptual framework was proposed to
support the possibility of the influence of community
practice on episodes of diarrhea. Essential features of
the design included a large random sample of the
population of interest, multiple measurements on each
subject, and statistical analysis appropriate to the
study questions and interpretation of the findings.
The strength of the design lies in its ability to
examine the interaction among several variables at the
same time and to determine which of them vary together.
In addition external validity is maximized when a
representative sample is used.
40
41
Sampling Plan
The Zimbabwe Ministry of Health and Child W e lf ar e in
accordance with the World Health Organization standards,
recommend rural w a t e r and sanitation facilities of at
least one water point per ten families and one latrine
per household. The investigator contacted the M i n i s t r y of
Urban and Rural Development to identify the province with
the highest coverage of community-based clean w a t e r and
sanitation facilities. One province was selected whic h
met the study site inclusion criteria.
It is the cultural norm in rural Zimbabwe that
prim ar y caregivers are exclusively female, in p ar ti cu la r
mothers and g r a n d m o t h e r s , who provide dependent care for
their children and grandchildren, respectively. The
sample was selected from female primary c a r e g i v e r s ' in
one province of Zimbabwe. The inclusion criteria for
pri ma ry caregivers was that they lived in communities
w i t h at least one wat er point per ten families and one
latrine per household. The primary caregiver also had to
be totally responsible for at least one child unde r five
years of age.
Sample Size
The sample size for the study was based on Cohen's
(1988) technique of power analysis for multiple
regression. The effect size for prediction of d ia rr he a
42
episodes using the variables c ommunity participation,
hygiene care knowledge, and hygiene practice is not
known. Cohen recommends a medium effect size of R2 = .13
as adequate for correlational research. However, a
c on se rv at iv e approach with a small effect size of R2 =
.02 (Cohen 1988), was used in order to be able to detect
the smallest effect of community participation, hygiene
care knowledge, and hygiene practice on diarrhea
episodes. A significance level .05 and p o w e r . 80, resulted
in lambda 11.1 on C o h e n ’s tables for three independent
variables. The formula, {N = lambda 11.1 ( 1 - R2) / R2}
in Cohen's tables resulted in a sample size of 544. In
order to compensate for a potential 10% attrition rate
due to migration or refusal to participate, a random
sample of 600 primary caregivers was obtained. A total of
600 primary caregivers were approached and agreed to
pa rt ic ip at e in the study with no refusals. The reason for
no refusals may have been due to the primary caregivers'
p er ce pt io n of the study as being non threatening and
their interest to contribute to the preve nt io n of
diarrhea in children.
Sampling Procedure
A multistage random sampling proc ed ur e was used. A
random sample of 600 primary caregivers who met the
inclusion criteria was selected from ten wards within the
43
identified province. One province comprising nine
districts was used as the study site. Each district was
made up of ten wards. Each ward had a pproximately two
hundred households providing a frame of eigh te en thousand
households from which to sample. The M i ni st ry of Health
and Child Welfare Provincial headguarters was contacted
to identify districts and wards that met the criteria of
w ater and sanitation facilities. Ten wards from the five
districts meeting the criteria were selected using
successive simple random sampling technigues without
r e p l a ce m en t.
In order to ensure even distribution of subjects
across the ten wards, sixty primary caregivers from each
ward were selected making a total of 600. Systematic
random sampling was used to identify the sample in each
ward. The Kth interval of every third household was
obtained by dividing the total number of w a r d households
(200) by the desired number of primary caregivers for
each ward (60). Four local data collectors w e r e trained
in the systematic random sampling procedure and were
assigned to the respective wards.
Sample Characteristics
Six hundred primary caregivers were a pp ro a ch ed and
fully participated in the study with no refusals or
withdrawals. The sample comprised 600 p rimary caregivers
44
who were responsible for most of the dependent care for
at least one child under five years of age. The primary
caregivers' ages ranged from 12 (.2%) to 79 years of age
(.2) with a mean age of 32, median age of 30 years and
standard deviation of 12. Sixty eight percent of the
primary caregivers' (n = 406) were in the age groups 20
to 29, and 30 to 39 respectively (see Table 1.). The
primary caregivers resided in ten randomly selected rural
wards in five randomly selected districts of Mashonaland
East province which met the study inclusion criteria. The
number of primary caregivers in each wa r d ranged from 58
to 61.
The primary c a r e g i v e r s ' educational level ranged
from no education (12%) (n = 73) while 21% (n = 127) had
received primary education (grade 1 to grade 6), with 23%
(n = 138) completing grade 7, and 43% (n = 258) having
acquired an education above grade 7 (see Table 1.). Out
of the total sample, 87% (n = 523) had attended school.
The majority of primary caregivers' looked after at
least one child under five (74%) (n = 444) while less
than 1% cared for four children. The primary caregivers'
children's ages ranged from 1 (.8%) to 60 (1.2) months
old with a mean age of 27, median age of 25 months and
standard deviation of 16. The majority of the children
were 7 to 12 months (13%) (n = 83), 13 to 18 months (13%)
45
Table 1.
C a r e g i v e r ’s Age and Education (N=600)
n %
Age
10 - 19 55 9.2
20 - 29 243 40.5
30 - 39 163 27.2
40 - 49 70 11.7
50 - 59 37 6.2
60 - 69 22 3.6
70-79 6 1-0
(missing) 4 .6
Education
None 73 12.2
Grade 1 7 1.2
Grade 2 15 2.5
Grade 3 21 3.5
Grade 4 11 1-8
Grade 5 28 4.7
Grade 6 45 7.5
Grade 7 138 23.0
Above 7 258_____________ 43.0
46
(n = 79), 19 to 24 months (11%) (n = 66), and 25 to 30
months old (14%) (n = 83) (see Table 2.).
The relationship of the primary caregiver to the
youngest child being c a r e d for included mother (77%) (n =
462), grandmother (15%) (n = 87), family relative (5%) (n
= 32), and child min d er (3%) (n = 19) (see Table 2).
Sixty one percent of the primary caregivers (n = 366)
cared for the youngest child 24 hours a day while 39% (n
= 234) provided care from 3 to 23 hours per day.
Variables
The independent variables in the study included
community participation, hygiene care knowledge, and
hygiene practice. The depen de nt variable was the number
of diarrhea episodes. The demographic variables comprised
of primary caregiver characteristics. The control
variables identified w e r e time of diarrhea, community,
number of children five years and under, primary
caregiver's age, study child's age and primary
caregiver's formal education.
Independent Variables
Community participation
Community p ar ti cipation was defined as the number of
times that the primary c aregiver attended community
meetings or activities on diarrhea in the self defined
community. Community pa r ti cipation was measured by the
47
Table 2.
Careqlver*s Childrens Age and Relationship (N=600)
n
Children's Age in Months
1 - 6 57 9. 5
7-12 83 13. 2
13 - 18 79 13. 2
19 - 24 66 11. 0
25 - 30 83 13. 8
31 - 36 52 8. 7
37 - 42 54 9. 0
43 - 48 55 9. 2
49 - 54 36 6. 0
55 - 60 28 4. 6
(missing) 7 1. 2
Primary Caregiver Relationship to Child

M other 462 77. 0
G randmother 87 15. 0
Family Relative 32 5. 0
Child Minder____________________ 19_______________ 3_;_0
48
community participation index designed by the
investigator.
The community participation index (see Appendix E)
was created from item one and two of a four item scale.
Item one, indicated the number of local community formal
meetings or activities on diarrhea held in the last
twelve months. Item two indicated the number of local
formal community meetings or activities on diarrhea
attended in the last twelve months. Community
participation index as a percentage was created using the
number of meetings attended by each subject divided by
the highest reported number of community meetings held in
each of the respective wards. Community meetings or
activities are regarded as major social events in rural
areas. Therefore primary caregivers reported attendances
at community meetings or activities are not likely to be
affected by recall validity. Item three asked if the
content of the meetings or activities included personal
hygiene, domestic hygiene, and environmental hygiene.
Item four was an open ended question used to elicit
subjects perception of community participation.
Hygiene care knowledge
Hygiene care knowledge was defined as the degree of
cognitive awareness that an individual possessed in
relation to hygiene. Hygiene care knowledge was
49
operationalized using the Knowledge, Attitude, Practice
questionnaire (KAP), (Green 1982).
Hygiene care knowledge was measured by the n u m b e r of
correct responses to an eight item subscale of the
Knowledge, Attitude, Practice questionnaire (KAP)
(Fukumoto, & Aguila, 1989; Green 1982) (see Appendix C ) .
The Knowledge, Attitudes, Practice questionnaire was
pretested four times (Green 1982).
Content validity for the Hygiene Care Knowledge
scale was established by consulting local Provincial
health officers considered to be experts in health
promotion. In addition, the Hygiene Care Knowledge scale
was pretested on 40 primary caregivers' in four war ds
excluded by the multistage random sampling procedure of
the study site and necessary amendments made.
The total score for the scale ranged from 1 to 33.
Items 1, 2, 3, 5, and 6 had a maximum score of 1 each.
Subsections of items 1, 2, 3, and 5 had a maximum score
of 4 categorized as follows: don't know 0; social
dirtiness 1; perceived dirtiness 2; contaminated
dirtiness 3; and germ theory 4.
Social dirtiness referred to aesthetic or social
values. Perceived dirtiness was regarded as anything
which looked or felt dirty and/or uncomfortable.
Contaminated dirtiness meant contact with anything which
50
was considered to be a vehi cl e of illness. Ger m theory
constituted the faecal-oral transmission cycl e in
diarrheal diseases.
Subsection of item 6 had a score of 1; for latrine.
Item 4 was categorized and scored as follows: fresh water
1; soap and fresh wate r 2. Item 7 was c a tegorized and
scored as follows: ei th e r bad food, or po or environment
or dirty baby dishes or d i r t y water, I; d i r t y hands 2 and
flies 3. Item 8 referring to met ho d of w a t e r storage was
categorized and scored as follows: container 1; always
covered 2; covered c on t a i n e r 3; covered clea n container
4; clean container with lid 5; and clean container, place
and lid 6.
Hygiene practice
Hygiene practice was d e fi ne d as activities performed
by people to maintain a clea n personal, domes t ic and
environmental state. H y g i e n e practice was operationalized
using a Hygiene Behavior C h ec kl is t scale (Curtis,
Cousens, Mertens, Traore, Kanki & Diallo 1993).
The Hygiene Behavior Chec kl is t scale was derived
from the Knowledge, Attitude, Practice questi o nn ai re
(KAP) (Green 1982). The scale is comprised of six
questions, items 1 to 6, d i r e c t e d to the prima ry
caregiver and four sele ct ed observations, items 7 to 10,
carried out by the i nt er v ie we r (see Appendix D ) .
51
S e l ec te d observations are a particular type of
structured observation, w h e re by the observer records the
presence o r absence of a behavior of interest at the time
of the inter vi e w (Boot & Cairncross, 1993). Items 7 and 8
of the s e l e c t e d observations were intended to validate
the primary caregivers' responses to items 1 and 2.
uuwsver, items 9 and 10 are simply direct observations of
cleanliness of the yard and child.
The instrument total score ranged from 1 to 16.
Items 1, 2, 3, 4, 7, 8, 9, and 10 had a score of 1 for
each correct response. The correct responses are as
follows: item 1, 'pot/to il et /n a pk in /p an ts ', item 2 'in
the latrine', items 3, 4, 7, 8, and 9, 'no', and item 10
'yes'. Item 5 was categorized and scored as follows:
container 1; always covered 2; covered container 3;
covered c l e a n container 4; clean container with lid 5 and
clean container, place and lid 6. Item 6 was categorized
and scored as follows: fresh water 1 and soap and fresh
water 2.
The instrument was derived from the Knowledge,
Attitudes, Practice guestionnaire which had reliability
tested u s i n g the kappa statistic (Green,1982). The kappa
statistic determines the percentage of agreement between
the direct observation and the reported response. Green
(1982) r e po rt e d good agreement (k = 0.76) between the
52
direct observation and the reported response.
In this study, interrater reliability was determined
b y dividing the number of agreements by the total number
of agreements and disagreements (Burns & Grove 1997).
Interrater reliability of 90% agreement was achieved
d ur in g the field training session of interviewers and was
m aintained during the data collection phase.
Dependent Variable
Diarrhea episodes
Diarrhea episodes as the dependent variable was
d efined as the occurrence of three or more liquid stools
w i t h or without blood during a twenty-four hour period
(World Health Organization/Control of Diarrheal Diseases,
1990). Two or three days without symptoms was considered
as a new episode of diarrheal illness (Morris, Cousens,
Lanata & Kirkwood 1994). Diarrhea episodes was
operationalized using the Diarrhea Episodes questionnaire
(World Health Organization, 1989).
The Diarrhea Episodes Questionnaire (see Appendix B)
consisted of eight items pertaining to diarrhea episodes.
Scoring was based on the youngest child's number of
diarrhea episodes reported by the primary caregiver with
more than one child, five years or under. The youngest
c hild was considered to be most at risk of contracting
diarrheal illness (Alam, Wojtyniak, Henry & Rahaman,
53
1989). The questionnaire was based on a standard measure
(Morris, C o u s e n s , Lanta & Kirkwood 1994; World Health
Organization/Control of Diarrheal Diseases, 1990).
Reported diarrheal illness was validated by the data
collector at the time of interview using the child's
'Road to Health Card'. The Road to Health Card, kept by
the primary caregiver, is a primary health care growth
monitoring and illness record of the child who is five
years or younger (Ministry of Health and Child Welfare
1992 ) .
Item 1 indicated whether the child ever had diarrhea
or not. Item 2 indicated when the diarrhea occurred and
was recorded in weeks. Item 3 determined how long the
diarrhea lasted in days. Item 4 elicited the number of
loose stools per day. Item 5 was used to find out if the
child ever had periods of two days or more without loose
stools during the diarrheal illness. Item 6 was used to
determine the number of diarrhea episodes based on
periods of two days or more without loose stools during
the diarrheal illness. Items 7, and 8 were used to elicit
the number of diarrhea episodes within the last two weeks
of the time of data collection.
Demographic Variables
Participant demographic sheet
The Participant Demographic Sheet (see Appendix A)
54
consisted of 7 items w hi ch sought to identify attributes
of the p r i m a r y caregiver. The items referred to the
primary caregiver's age, residential community, level of
education attained, total number of children five years
and under being cared for by the pr im ar y caregiver, age
of the youngest child receiving care, relationship of the
primary caregiver to the youngest child, and the number
of hours per day that the child was looked after by the
primary caregiver. Demographic information was used to
describe the sample.
Control Variables
The control variables in the study included: time of
diarrhea, community, number of children five years and
under, p r i m ar y caregiver's age, study child's age and
primary caregiver's formal education.
Time of diarrhea
T ime of diarrhea was defined as the period between
the time of data collection and when the diarrhea
occurred. Time of diarrhea was measured in weeks as
reported by the primary caregiver and validated with the
child's 'Road to Health card'.
Community
C o m m u n i t y was d efined as the w ar d in which the
primary careg iv er resided. Community was measured as the
number assig n ed to each of the ten wards.
55
Number of children five years and under
N u m b e r of children five years and under was defined
as the total number of children cared for by the primary
caregiver. Number of children five years and under was
m easured as the reported number given by the primary
caregiver.
P IT iiu a ry C a rc C jlv 6 t ' 5 aQ6
P r i m ar y c a r e g i v e r ’s age was defined as the number of
chronological years at the time of data collection.
Primary caregiver's age was measured by the reported date
of birth and validated with the primary caregiver's
national registration identity card.
Study child's age
S t u d y child's age was defined as the number of
chronological months at the time of data collection.
Study child's age was measured by the reported date of
birth and validated with the child's 'Road to Health
card'.
Primary caregiver's formal education
P r i m a r y caregiver's formal education was defined as
the level of schooling acquired. Primary caregiver's
formal education was measured by the reported school
grade of none to seven and above.
Instruments
F our instruments were used in this study. The
56
independent variables were measured by the; Community
Participation Index, Hygiene Care knowledge scale, and
the Hygiene Behavior Checklist scale respectively. The
dependent variable was measured by the Diarrhea Episodes
Questionnaire. The University of Zimbabwe Department of
African Languages carried out linguistic translation of
the instruments trom English to Shona ianguage used by
the subjects. The instruments underwent back translation
by the study site provincial Ministry of Health and Child
Welfare health officials. Colloquial discrepancies were
identified and appropriate corrections made.
Data Collection
Consent for the study was sought from the Institutional
Review Board at Case Western Reserve University, the
Zimbabwe Medical Research Council and the study site
Provincial Medical Directorate.
Instruments were adapted to the local language by
the University of Zimbabwe Department of African
Languages. The instruments underwent double back
translation ensuring that regional colloquialisms were
accurate. To ensure instrument reliability and validity,
pretesting of the translation was carried out.
Experienced field interviewers fluent in the Shona
language were recruited from the study site. Five
separate days of training sessions for interviewers
57
regarding the study were conducted and focused on issues
of sampling, interviewing and observation techniques. In
particular, interrater reliability was established to
ensure consistency and repeatability of the measures
between the raters. Each interviewer was assigned to
interview 150 primary caregivers. Interviews were
conducted during the month of March in the rainy season
(November to April, 1997).
Interviewers approached every third household
primary caregiver with a child under five years to seek
informed consent to participate in the study (see
Appendix F ) . Face to face interviews took place in the
participants homes following signing or marking of the
consent form. The interview method and manner for m a r ki n g
the consent form accommodated differing levels of
literacy. Interviews of the primary caregivers lasted
approximately forty-five minutes. U po n completion of the
interview, participants received ten Zimbabwe dollars
(USD $1.00) in a ppreciation of their time. The data
collection coordinator visited each interviewer on a
weekly basis to main ta in contact and discuss concerns
regarding the interview process and questionnaire items.
Human Rights Considerations
Participants w ere assured of anonymity and
confidentiality as identification numbers were used
58
d u r i n g the data c ollection procedures. Each ward was
a s s i g n e d a number w hich only was known to the
investigator.
Participants were also reassured by the interviewer
that the study procedures were not harmful and did not
p re di sp os e them to any physical, emotional, social or
e conomical r i s k s . The study did not interfere with
current health services or facilities available to the
participants at that point in time. Interviewers informed
the participants that participation was voluntary and
that refusal or withdrawal from participation at any time
w o u l d not affect access to existing community services.
Interviewers were not required to disclose any
i nforma ti on to parties other than the investigator.
The participants may have benefited educationally
a nd socially from increased awareness of community
practice. The only social cost to the subjects was their
time. A token of m o n et ar y reimbursement was given to each
s ub je ct upon completion of the interview in appreciation
of their time. Zimbabwe Ministry of Health and Child
W e l f a r e may have benefited from the study in terms of
e v a l u a t i n g current health care approaches in preventing
d i a r r h e a in children under five years.
U pon completion of the interviews, the interviewers
59
stored the questionnaires in locked bags in a safe place
until c ollected by the investigator. Completed
questionnaires were stored in a locked filing cabinet by
the investigator. Data was stored on a floppy disk and in
a locked cabinet which was only accessible to the
investigator.
Data Analysis
Data were analyzed using the SPSS-PC statistical
package (Norusis, 1990). Descriptive statistics including
measures of central tendency were used to describe the
sample in terms of age, geographical location, and formal
education. Descriptive statistics were used to describe
the child under five years on which reported diarrhea
episodes were based, and the total number of children
under five years in the family household. Descriptive
statistics also described, personal hygiene, domestic
hygiene, and environmental hygiene, and community
meetings or activities.
Preliminary Analyses
The purpose of preliminary analyses using analysis
of variance and Pearson product moment correlations was
intended to check for possible differences among the
wards, and multicollinearity respectively. Differences
among the wards would suggest that ward samples were not
drawn from the same population and did not have the same
60
mean. Multicollinearity if present decreases the p ower of
significance tests whereby the regression coefficient may
not be significant when in actual fact significance does
exist (Burns & Grove, 1997). Analysis of variance of the
independent variables was carried out. Pearson p roduct
moment correlations of the independent variables were
per f o r m e d .
Analysis of Variance
Analysis of variance was used to determine a n y
differences between the ten wards with regards to the
independent variables; community participation, hygiene
care knowledge and hygiene practice prior to multiple
regression analysis. The oneway analysis of variance
(ANOVA) procedure was used to test the null hypothesis
that the ward group means of the independent variables
were not different. The F ratios for community
participation (F=5.89), hygiene care knowledge (F=3.28)
and hygiene practice (F=3.93) were significant (p > .05)
implying that two or more of the ward groups were
different in each of the independent variables.
The Tukey-b multiple comparison test was used to
identify ward groups which were different at a
significance level of .05. Community participation in
ward groups 3, 4, and 9 was found to be different from
w ar d groups 1, 2 5, 8, and 10. Hygiene care knowledge in
61
ward gr ou p 8 was found to differ from w a rd groups 1,
3, 4, and 10. Hygiene practice in ward group 1 differed
from w a r d group 4 and 7 while ward group 5 was different
from w a r d group 7, and ward group 10 was d i ff er en t from
ward groups 2, 4, 6, 7 and 9. Out of the ten wards there
were three wards identified in community participation,
one w ar d in hygiene care knowledge and three wards in
hygiene practice which were different from the rest.
Pearson product moment correlation analysis
Th e Pearson r correlation test was car ri ed out to
examine the independent variables for multic ol li ne ar i ty
and linear relationship with the dependent variable.
Table 3 shows the correlation matrix of the dependent
variable, diarrhea episodes and independent variables,
community participation, hygiene care knowl ed g e and
hygiene practice. The correlation coefficients of the
independent variables were community parti c ip at io n and
hygiene care knowledge (r= .06; p> .05), c om mu ni t y
participation and hygiene practice (r= -.01; p > .05),
and hygiene care knowledge and hygiene pra ct ic e (r= .13;
p = < .01). In accordance with Burns and G ro ve (1997)
mu lticollinearity exists if the correlation coefficient
of the independent variables is greater than (r= .65)
which suggests that in this study there was no evidence
of multicollinearity. Therefore the r egression analysis
62
Table 3.
Correlation Matrix of Independent and Dependent Variables
Y1 x2 x3
Y1 1.0000 .0249 -.0022 -.1296
X! .0249 1.0000 -.0645 -.0121
X2 -.0022 -.0645 1.0000 .1329*
X3 - .1296* -.0121 .1329 1.0000
* p <.01 ** <.001
N=600
Y1 (Diarrhea Episodes)
X3 (Community Participation)
X2 (Hygiene Care Knowledge)
X3 (Hygiene Practice)
63
assumption of absence of multicollinearity was not
violated -
The correlation coefficients of the independent
variables; with the dependent variable, diarrhea episodes
were community participation (r= .02; p> .05), hygiene
care knowledge (r= -.002; p> .05), and hygiene practice
{r= -.12; p< .01). Apart from community participation and
hygiene care knowledge, hygiene practice has a linear
relationship with the dependent variable. The linear
relationship of hygiene practice with diarrhea episodes
is both negative and significant. As hygiene practice
increases, diarrhea episodes decreases.
The control variables: time of diarrhea, community,
c a r e g i v e r ’s age, study c h i l d ’s age and primary
caregiver's formal education were considered potential
extraneous variables. Identification of extraneous
variables increases the sensitivity of the analysis by
separating systematic variance in the dependent variable
(Pedhauzer & Schmelkin, 1991). The identified extraneous
variables were controlled statistically (Burns & Grove,
1997). Time of diarrhea, number of children five years
and under, study child's age (Alam, Wojtyniak, Henry &
Rahaman, 1989; Moy, Booth, Choto & McNeish, 1991),
primary caregiver's education (Boot & Cairncross, 1993;
64
Manunebo, Haggerty, Kalengaie, Ashworth & Kirkwood, 1994)
primary caregiver's age (Patel, Eisemon & Arocha, 1988;
Yoosuf, 1993) were considered as potential extraneous
variables. Community was included as a control variable
because of the differences found among the wards. Pearson
product mo me nt correlation analysis was carried out to
examine cne independent variable with control variables
for multicollinearity with the dependent variable. Table
4 shows the correlation matrix of the dependent variable,
diarrhea episodes with the independent variables:
hygiene practice and control variables time of diarrhea,
community, number of children five years and under,
primary caregiver's age, study child's age and primary
caregiver's formal education. There was no correlation
greater than (r = .65), (Burns & Grove, 1997) which
suggested no evidence of multicollinearity.
Residual analysis
Residual analysis was carried out to check for
violation of multiple regression assumptions (Norusis
1991) as well as to identify outliers which may influence
the results. Residuals of estimated values of regression
provide the basis for assessing adeguacy of the model
(Cohen & C o he n 1983). Norusis (1991) describes a residual
as the part that is left after the model is fit and
65
Table 4.
Correlation Matrix of Independent/ Dependent and Control

Variables
Y1 x3 x2 x3 x4 x5 x6 x7 x„ x9
Y 1 1.00 .02 .00 -. 13* .28 - .03 .01 .00 .05 .04
.02 1.00 -.02 -.02 -.00 -.00 -.01 .15* .08- . 12*
x2 .00 -.02 1.00 .13* -.05 .06 -.02 - .07 -.09* .16*
x 3 -.13* -.02 . 13* 1.00 .02 .01 -.07 .04 -.02 . 12*
x 4 .28* -.04 -.05 .02 1.00 .03 -.07 .08* .22* .04
A 5 '.U J - .uu .U o .U X . UJ x .uu - .uo .U X — •U /
x6 .01 -.01 -.02 -.07 -.07 -.06 1.00 .04 -.22*- .02
X7 .00 .15* -.07 .03 .09* .02 .04 1 .00 .29*- .60*
X8 .05 .08 -.09* -.02 .22* .01 -.22* .29* 1.00 - .22*
x9 .04 -.12* .16* .12* .04 -.07 -.02 - .60* -.22*1 .00
* p <.05
N=600
Y1 (Diarrhea Episodes)
x3 (Community Participation)
x2 (Hygiene care Knowledge)
x3 (Hygiene Practice)
x4 (Time of Diarrhea)
X5 (Community)
X6 (Number of Children < 5 y r s )
X7 (Primary Caregiver's Age)
X8 (Study Child's Age)
x9 (Formal Education)
66
represents the difference between the observed value and
the value predicted by the model.
The residual statistics of the standardized
residuals show that there are ten outliers on the
dependent measure using the criteria of 2.56 or 3
standard deviations as a cut value (Weissfeld & Butler
1588). The residuai s ummary statistics show the
assumption of zero mean has not been violated (Verran &
Ferketich 1984). The histogram of the standardized
residuals showed that the distribution was slightly
positively skewed. The probability plot of observed
residuals versus expected residuals showed slight
deviation from normality as there were a few negative
values below the line with the majority of positive
values around and above the line.
The standardized scatterplot of residuals against
predicted values of the dependent measure showed a random
distribution suggesting that homoscedasticity was not
violated. The scatterplots of independent variables
versus the residuals assessed the assumption of fixed X
and linearity. A random pattern distributed around the
mean suggested that no important variable had been
omitted.
A further test of fixed X and linearity assumption
using Pearson correlation coefficient of the standardized
67
residuals showed that the independent variables,
hygiene practice were not correlated with the residuals.
Cook D identifies cases greater than .2 as outliers
(Weissfeld & Butler 1988). No cases were identified as
outliers. Lever was used to determine the cut value with
the formula 2(K + 1)/N {2(3 + i)/600 = .013} and
identified forty outliers which might have affected the
results. Following deletion of the outliers from the
analysis there was no change in the regression
coefficient values.
Analysis for Hypotheses Testing
Multiple regression analysis was used to test the
proposed theoretical model. The analysis was used to
explain diarrhea episodes with community participation,
hygiene care knowledge, and hygiene practice as
independent variables (Figure 2). Residual analysis was
carried out to ensure that the regression assumptions
were not violated. Using a criteria of .05 level of
significance for rejecting the null hypotheses, the
following research questions and hypotheses were tested;
Question 1 . Is community participation of primary
caregivers' associated with children's diarrhea episodes?
Hypothesis 1 . Community participation has a negative
68
I N D E P EN D EN T V A R I A B L E S
Community
Participation
DEPENDENT
VARIABLE
Knowledge Episodes
Hygiene
CONTROLS
Primary caregiver's age

Formal Education
Study child's age
Number of children ^ 5 yrs
Time of diarrhea occcurrence (wks)
Community (ward)
Figure 2. Regression diagram for the hypothesized model
69
Question 2 . Is hygiene care knowledge of primary
caregivers' associated w i t h children's diarrhea episodes?
Hypothesis 2 . Hygiene care knowledge has a negative
Question 3 . Is hygiene practice of primary caregivers'
associated with children's diarrhea episodes?
Hypothesis 3 . Hygiene practice has a negative effect on
diarrhea episodes.
Question 4 . Is the pri m ar y caregivers' community
practice associated w i t h children's diarrhea episodes?
knowledge, and hygiene practices have a negative effect
on diarrhea e p i s o d e s .
practice associated w i t h children's diarrhea episodes
when controlling for prim ar y caregivers' age, primary
community?
knowledge, and hygiene practice have a negative effect on
diarrhea episodes controlling for primary caregivers'
70
age, primary caregivers' formal education, primary
caregivers' number of children five years and under,
primary caregivers' age of youngest child, time of
diarrhea occur re nc e and community.
Multiple r e gr es si on analysis
Multiple regression analysis as a multivariate
sLdtisticai technique was used to understand the
relationship between community participation, hygiene
care knowledge and hygiene practice on diarrhea episodes.
The questions and hypotheses 1, 2, 3, 4, and 5 were
tested and d e s cr ib ed the extent, direction, and strength
of the relationship between the independent variables and
the dependent variable. The results also indicated the
effects of one independent variable on the dependent
variable w hi l s t holding the effects of the other
independent variables constant.
The mult ip le regression models tested were linear
and additive; Y = b 0 + b 1X 1 + b2X 2 + b 3X 3 + e, without
controls and Y = b0 + b 3 X 3 + b2X 2 + b 3X 3 + b 4X 4 + b5X 5 + b6X 6
+ b7X 7 + b8X 8 + bgXg + e, with controls. The support for
each hypothesis was based initially on the significant R2
statistic and the significant negative regression
coefficient of the respective independent variable. The
independent variables; community participation (X3),
hygiene care knowledge (X2), and hygiene practice (X3) are
71
at the same causal level, and were entered in the
regression equation simultaneously. The independent
variables were regressed on the dependent variable,
diarrhea episodes (Y) . The significant R 2 statistic
indicates the combined effects of the independent
variables with significant regression coefficients on the
dependent variable and is expressed as the percen ta g e of
explained variance. Significant regression coefficients
indicate the unstandardized coefficients representing the
change in the dependent variable for every unit change in
the respective independent variables. This suggests that
the respective independent variables predict the
dependent variable. The direction of the association is
based on the sign of the significant regression
coefficients. The negative significant b indicated that
the independent variables have a negative effect on
diarrhea e p i s o d e s . The assumptions for multiple
regression include; 1) the variables are measured wi t ho ut
error; 2) the variables are measured at interval level;
3) the residuals are not correlated; 4) scores are
homoscedastic or have equal variance and thus there is a
normal distribution of Y scores at each value of X, 5)
the independent variables are linearly related to the
dependent variable, 6) the m e a n of errors for each
observation of the dependent variable is zero, and 7) the
72
errors are not correlated with the independent variables
(Pedhazur, 1982).
CHAPTER 4
RESULTS AND DISCUSSION
This chapter presents the results of the study data
analysis and includes a description of the independent
variables; community participation, hyg ie ne care
knowledge and hygiene practice and the dependent
variable; episodes of diarrhea. Results of correlation
and multiple regression analysis are a lso presented.
Comm u ni ty Participation Index
Primary caregivers (n=600) were a s k e d 'how many
local formal community meetings or a ctivities addressing
diarrhea had taken place in their respective areas within
the last twelve months. The number of m e e ti n gs held
ranged from none to ten. Fifty-eight p e r ce nt (n = 345) of
the sample stated that no meetings had ta ke n place. Of
the 255 subjects (42%) who reported that meetings had
been held, the reported number of meetings ranged from
one to ten (see Table 5.).
Primary caregivers responses were reviewed in terms
of the actual number of reported community meetings held
in each of the ten wards. The number of meetings for each
of the ten wards ranged from five to ten. Forty percent
of the sample (n = 239) resided in wards w i t h ten
meetings while 40% (n = 240) lived in w a r d s with seven
and six meetings respectively (see Table 5.)
73
74
Table 5.
Community Participation Index (N=600)
n %
Reported Number of Meetings in Ward
None 345 57.5
One 50 8.3
Tw o 52 8.7
Three 48 8.0
Four 24 4.8
Five 43 7.2
Six i3 2.2
Seven 8 1.3
Eight 6 1.0
Nine 1 .2
Ten 5 .8
Actual Number of Meetings in Ward

Five 60 10.0
Six 120 20.0
Seven 120 20.0
Eight 61 10.2
Ten 239 39.8
Number of Meetings in Ward Attended

None 385 64.2
One 68 11.3
Two 64 10.7
Three 32 5.3
Four 19 3.2
Five 19 3.2
Six 6 1.0
Seven 4 .7
Eight 2 .3
Nine 1 .2
75
Further review of primary caregivers' responses
regarding the nature of community meetings held in the
respective wards, revealed that only 156 (26%) viewed the
meetings solely as community participation activities.
One hundred and twenty primary caregivers (20%) indicated
that community meetings took the form of attending the
under five clinic when the child was eicuer w e n or i n .
Seventeen percent (n = 102) of the primary caregivers
differentiated the nature of meetings as either clinic
focused or community participation. Twenty-seven percent
(n = 162) of primary caregivers stated that no meetings
had occurred while 10% (n = 60) did not know whether or
not meetings had taken place.
Primary caregivers were asked 'how many times they
had attended local formal community meetings or
activities on diarrhea in the last twelve months'. Sixty-
four percent (n = 385) responded that they had never
attended while 36% (n = 215) indicated a range of
attendance of one to nine times (see Table 5.).
A community participation index for each primary
caregiver was calculated by dividing the actual number of
meetings held in each respective ward by the number of
meetings attended. Sixty-four percent (n = 385) of the
primary caregivers had no attendance and therefore
received a zero percent index. Thirty-six percent of the
76
primary caregivers (n = 215) attended community meetings
and the community participation indexes ranged from six
to 100 percent.
Primary caregivers were asked to identify components
of hygiene education included in the community
meetings/activities. Forty-two percent (n = 250) of the
study sample indicated that no meetings or activities of
any kind had been attended and therefore hygiene
education components were 'not applicable'. Of the
remaining primary caregivers (58%) (n = 350) who had
either attended w a r d community participation meetings and
or under five health care clinics, 34% (n = 202) stated
that they had received a combination of personal,
domestic and environmental hygiene education. Thirteen
percent (n = 76) stated that hygiene education
combinations either personal and domestic, personal and
environmental or domestic and environmental had been
discussed. The remaining 11% (n = 72) stated that single
hygiene education components had been included namely;
domestic (5%) (n = 31), environmental (4%) (n = 25), and
personal (2%) (n = 16) (see Table 6).
The primary caregivers' were asked to express their
perception of community participation as a means to
validate the community participation index. The maj or
themes which emerged from the primary caregivers
77
Table 6.
Hygiene Education in C o mm un it y Meetings (N=600)
n %
Hygiene Components
Personal 16 2.7
Domestic 31 5.2
Environmental 25 4.2
Two Combinations 76 12 .7
Three Combinations 202 33.7
None 250 41.7
78
perceptions described community participation as 'sharing
ideas' (20%) (n = 119), 'working together' (15%) (n =
91), 'learning or teaching each other' (12%) (n = 69),
and 'promoting health and cleanliness' (10%) (n = 62)
(see Tab le 7.).
Hygiene Care Knowledge Scale
H ygiene care knowledge scores ranged from 12 to 28
out of a total maximum score of 33 wit h a mean score of
20 and standard deviation of 2.5. Three groups emerged
from the score ranges. Eighteen perce nt of the primary
caregivers' (n = 107) had a total hygiene care knowledge
score of 20 points with 48% (n = 286) above the m e a n and
34 % (n = 206) below the mean (see Table 8.).
Ninety-nine percent of the p r i m a r y caregivers' (n =
594) knew that it was necessary to wash hands after
defecation. Out of the 99% (n = 594) who knew to wash
hands after defecation 33% (n = 196) indicated perc ei ve d
dirtiness as the reason for wash in g hands while 32% (n =
190) suggested germ theory. The need to wash hands before
eating was identified by 99% (n = 594) of the prima ry
caregivers. Out of the 99% (n = 594) who knew to was h
hands before eating 60% (n = 356) gave perceived
dirtiness as the reason for washing hands. Thirty percent
(n = 178) out of the 99% (n = 594) stated contaminated
dirtiness, 15% (n = 87) and germ theory, 15% (n = 91)
79
Table 7.
Caregivers' Perception of Community Participation (N=600)
n %
Themes
Working Together 91 15.2
Sharing Ideas 119 19 .8
Togetherness 15 2.5
Planning and Development 23 3.8
Learning or Teaching 69 11.5
Working Together for Development 17 2.8
Helping Each Other/Those Without 21 3.4
Promote Health/Cleanliness 62 10.3
Planning Together 38 6.3
Knowledge 34 5.7
Promotes Laziness and Hatred 7 1.2
Better Lifestyle 16 2.7
Monetary Beni fit 3 .5
Learning Family Care 43 7.2
Make Work Easier and Quicker 12 2.0
Solving Difficulties 5 .8
Causes Stealing 2 .3
Learn Water and Sanitation 11 1.8
Don't Know 7 1.2
(missing) 5 .8
80
Table 8.
C a r e q i v e r s ' Hyqiene Care Knowledqe (N=600)
n %
Total Score
Twelve 1 .2
Thirteen 1 .2
Fourteen 7 1-2
Fifteen 7 1.2
Sixteen 18 3.0
Seventeen 32 5.3
4 A ft
Eighteen DU 1U.U
Nineteen 80 13.3
Twenty 107 17.8
Twenty One 92 15. 3
Twenty Two 88 14.7
Twenty Three 42 7.0
Twenty Four 32 5.3
Twenty Five 15 2.5
Twenty Six 11 1.8
Twenty Seven 4 .7
Twenty Eiqht 2 .3
81
respectively for w a s hi ng hands before eating. O n e hundred
percent of the primary caregivers said it was necess ar y
to wash hands after eating. F i f t y percent gave the reason
as perceived dirtiness followed by 46% (n = 276)
indicating social dirtiness as a need to look
presentable. Only 4% (n = 24) of the primary caregivers
reported contaminated dirtiness and germ theory as a
reason for washing hands after eating.
Fifty-five percent (n = 330) of the primary
caregivers indicated that soap and fresh water w e re
needed to wash hands followed by 23% (n = 138) w h o stated
that only fresh water was required. The remaining 22% (n
= 132) indicated combinations of soap and/or fresh water
with other alternatives such as cloths, paper, vaseline,
paraffin, and ashes for washing hands.
Ninety-nine percent (n = 594) of the primary
caregivers said it was necessary to cover food dishes.
The majority (79%) (n =474) identified social dirtiness
as the main reason while only 11% (n = 66) indicated germ
theory.
Primary caregivers (n=600) responded that childrens'
stools should be disposed of if left in the yard. The
majority (83%) (n = 498) specified the latrine w h i l e 102
(17%) indicated the bush, covered hole or left alone as
their understanding of stool disposal.
82
The majority of the primary caregivers (72%) (n =
432) gave multiple and varied responses to the question
’what causes diarrhea?' Eight percent (n = 48) of the
multiple responses referred to bad food and flies. Bad
food and dirty water accounted for 6% (n = 36) of the
multiple responses. Of the primary caregivers who gave
multiple responses, less than half of the sample 46% (n =
274) included flies as a cause of diarrhea and o nly 151
subjects (25%) included d ir ty hands as a cause of
diarrhea. Primary caregivers (13%) (n = 78) wh o specified
'others' in their responses included mosquitoes, aphids,
and walking barefoot as a cause of diarrhea. Of the
primary caregivers (28%) (n = 168) who provided single
responses, diarrhea was mostly related to: bad food (10%)
(n = 60), flies (8%) (n = 48), dirty water (4%) (n = 24),
and d ir t y hands (.8%) (n = 5). Five percent (n = 30) of
the primary caregivers d i d not know any causes of
diarrhea.
In response to 'how drinking water should be stored
in the home', the majority of primary caregivers (49%) (n
= 294) indicated a covered container while only 38% (n =
228) specified that the w a t e r should be covered. Less
than 1% of the primary caregivers reported that water
should be stored in a c lean container with a lid and off
the ground in a clean area.
83
Hygiene Behavior Checklist Scale
Hygiene practice is presented as the primary
caregivers' hygiene behavior check list scores (see Table
9). Total scores ranged from 3 to 13 out of a maximum
score of 16 with a mean of 9 and standard deviation of
1.8. Three groups emerged from the score ranges. Nineteen
percent (n =113) of the primary caregivers obtained a
m ean score of 9 while 42% (n = 253) scored above the mean
and 30% (n = 182) below the mean. Nine percent (52) of
the total scores were not computed due to incomplete data
on some of the items. The primary caregivers with missing
data were not assumed to be different as their
descriptors were similar to the rest of the population.
Fifty-five percent (n = 330) of the primary
caregivers reported that the children defecated either in
a pot, toilet, napkin or pants while 45% (n = 270) stated
that the child defecated either on the ground or outside
the yard. Primary caregivers (89%) (n = 534) responded
that child's stools were disposed of in the latrine.
Eleven percent (n = 66) of the primary caregivers'
reported that the stools were either buried in the yard,
thrown away in the yard or disposed of outside the yard.
Primary caregivers were asked if they ever purged
the child. Sixty-three percent (n = 378) indicated 'no'
w hile 37% (n =222) responded 'yes'. Of the 37% (n = 222)
84
Table 9.
C a r e g i v e r s ’ Hygiene Practice Scores (N=600)
n %
Total Score
Three 1 .2
Four 5 .8
Five 10 1.7
Six 21 3.5
Seven 56 9 .3
Eight 89 14 .8
1 A A
tT
11XUC
•
113 10.0
Ten 109 18.2

Eleven 80 13.3
Twelve 50 8 .3
Thirteen 14 2 .3
(missing) 52 8.7
85
who stated that the c hild was purged, 10% (n = 60)
specified oral rehydration therapy/sugar, salt s o lu ti o n
(ORT/SSS). Eight percent (n = 48) of the primary
caregivers gave over the counter medications such as
'gripe w a t e r ’ or 'milk of magnesia', 7% (n = 42) used
traditional medicines and 6% (n = 36) administered
various combinations of co ok i n g oil, traditional herbs
and spiritual water. Five percent (n = 30) of the p rimary
caregivers' stated that the clinic provided various
purgatives and 1% (n = 6) indicated that such medicines
were given to the child b y ambuya (grandmother). The
primary caregivers (67%) (n = 402) reported that the
child did not eat earth w h i l e 33% (n = 198) stated that
earth was eaten.
In response to the g u es ti on 'how do you store
drinking water in the h o m e ? ', 240 primary caregivers
(40%) answered either 'covered container' or c o n ta in er
(32%) (n = 192) or 'always covered' (19%) (n = 114) with
only 2% (n = 12) specifying clean container with a lid.
Fifty four percent (n = 324) of the primary caregivers'
stated that soap and fresh water were used to w as h hands
while 34% (n = 204) indica te d fresh water alone. The
remaining 12% (n = 72) p r o v i d e d various combinations of
cloths, paper, vaseline, paraffin and ashes for w a s h i n g
hands.
86
Interviewers made four specified observations for
each primary caregiver du ri ng the interview. These
selected observations were: 1) presence or absence of
feces on the latrine slab; 2) presence or absence of
feces in the yard; 3) presence or absence of stagnant
water in the yard, and 4) whether the child was clean or
unclean. It was observed that the majority of primary
caregivers (75%) (n = 449) had no feces on the latrine
slab while 25% (n = 151) did have feces present on the
latrine slab. Feces in the yard was evident in half of
the study sample settings (50%) (n = 302) comprising
mainly animal with 1% (n = 7) human. Stagnant water was
observed in 21% (n = 127) of the primary caregivers'
yards while the majority (79%) (n = 471) had none.
Children who were considered clean were those who
appeared to have been bathed and wearing clothes that had
been washed and were free from dirt. The opposite applied
for those who were considered unclean. Approximately two-
thirds of the children (71%) (n = 427) looked after by
primary caregivers were observed to be clean with one
third (29%) (n = 171) u nclean (see Table 10.). Five
single observations were missed by the interviewers.
Diarrhea Episodes
Of the sample (n=600) almost half of the primary
caregivers' (n = 267) (44%) reported that the youngest
87
Table 10.
Interviewer Latrine, Yard and Child Observations (N=600)
n
Feces on Latrine Slab
None 449 74.8
Presence 151 25.2
Feces Present in Yard

None 302 50.3
Animal 290 48.3
Human 7 1.2
(missing) 1 -2
Stagnant Water in Yard

None 471 7 8.5
Presence 127 21.2
(missing) 2 .3
Clean Child
Clean 427 71.2
Unclean 171 28.5
(missing)________________________________ 2________________ *_3
88
child had experienced diarrhea while 56% (n = 333) stated
that the child never had diarrhea. Of the 267 primary
caregivers, 76% (n = 203) reported diarrhea o ccurring 2
to 36 weeks prior to the week of data collection w hich
was validated with the child's 'Road to Health card*. Of
the 267 primary caregivers 97% (n = 195) stated that the
diarrhea iiiness iasted from 1 to 14 days. With regards
to the number of loose stools that the child experi en ce d
per day, 91% (n = 244) of the subjects reported 1 to 5.
When further asked if the child had periods of two days
or more without loose stools during the diarrhea illness,
102 (38%) of the 267 primary caregivers responded
"yes". Of the 102 primary caregivers who reported the
youngest child having experienced diarrhea with two days
or more without loose stools, the diarrhea episodes
ranged from 1 to 7. Children experiencing one episode of
diarrhea constituted the greatest number with 64% (n =
170) while 36% (n = 97) had 2 to 7 diarrhea episodes
during a diarrheal illness (see Table 11.). Of the 267
primary caregivers who reported that the youngest child
had experienced diarrheal illness, 15 % (n = 40) occu rr ed
within the last 2 weeks before data collection wi t h the
number of diarrhea episodes ranging between 1 and 4.
Among the ten wards, ward two had the highest number
of children with diarrhea episodes (63%) (n = 38)
89
Table 11.
Children's N umber of Diarrhea Episodes (N=600)
n %
Diarrhea Episodes
aJU1
Never 333 55.!
One 170 28 .
M N ) U U M O (
Two 54 9.1
Three 31 5.:
Four 8 1 ..
Five 2
Six i
Seven 1 .:
90
followed by 31 children with diarrhea episodes in wards
three and six respectively. Ward five had the least
number of children with diarrhea episodes (n = 17) (see
Table 12.).
Multiple Regression Analysis
A multiple regression analysis model was used to
w3st thG rsistionship of fchs indopondsnt v s ri sb is s*
hygiene practice with the dependent variable diarrhea
episodes. The independent variables: community
practice were regressed on the dependent variable
diarrhea episodes. The variables were entered into the
regression equation simultaneously. Table 13 shows the
results of the multiple regression analysis. The combined
effect of the independent variables is shown by the
significant R2 (p < .05). The significant F test implies
a linear relationship and R2 represents the amount of
variance in the dependent variable diarrhea episodes,
explained by the independent variables: community
practice. Therefore the independent variables in the
regression equation explain 2% of the variance in the
dependent variable. Unstandardized regression
coefficients b of community participation (.001296) and
91xy
Table 12.
Children with Diarrhea Episodes in Each W ard
n %
Ward
One 19 31.7 (n = 6 0 )
Two 38 63.3 (n = 6 0 )
Three 31 50.8 (n = 6 1)
Four 28 45.9 (n = 6 1)
Five 17 28.8 (n = 5 9 )
o :—
UXA 31 52.5 (n = 5 9 )
Seven 24 39.3 (n = 6 1)
Eight 25 41.0 (n = 6 1)
Nine 32 55.2 (n = 5 8 )
Ten 22 36.7 (n = 6 0 )
Table 13.
Multiple Regression Analysis of Diarrhea Episodes
Variable_________ B_______________SE B__________________ Beta
X3 .001296 .002261 .024403

X2 .006743 .017152 .016889
X3 -.071373** .023259 -.131565*
Constant 1.229520
R2 = .02* F = 3.25319
* p <.05 ** p <.01 *** p <.001
N=600
X x (Community Partcipation)
X 2 (Hyiene Care Knowledge)
X 3 (Hygiene Practice)
93
hygiene care knowledge (.006743) are not significant. The
unstandardized coefficient b of hygiene practice (-.07; p
< .01) was significant. The significant unstandardized
coefficient b represents a change in diarrhea episodes
for a unit change in hygiene practice. Therefore hygiene
practice explains diarrhea episodes. The sign for the
unstandardized regression coefficient for hygiene
practice is negative. Therefore hygiene practice has a
negative relationship on diarrhea episodes.
Multiple regression of the independent variables
while controlling for primary caregivers age; formal
education; study child's age; number of children u nder
five and time of diarrhea occurrence and ward were
entered into the regression equation simultaneously. Both
community participation (.002134; p >.05), and hygiene
care knowledge (.012575; p > .05) were not significant.
Hygiene practice (-.076927; p = .001) was significant.
The control variables: community, number of children five
years and under, primary caregiver's age, study child's
age and primary c a r e g i v e r ’s formal education were not
significant. Thus hygiene practice explains diarrhea
episodes controlling for: primary caregivers age, formal
education, study child's age, number of children un de r
five, time of diarrhea and community. The control
variable of time of diarrhea was significant (p = .001)
94
reflecting m onthly variations in diarrhea prevalence from
the point of data collection in March to July
retrospectively (see Table 1 4 .)*
Hypotheses Results
1. The hypothesis that community participation has a
negative effect on diarrhea episodes was not supported.
2. The hypothesis that hygiene care knowledge has a
negative effect on diarrhea episodes was not supported.
3. The hypothesis that hygiene practice has a negative
effect on diarrhea episodes was only partially and weakly
s u p po rt ed .
4. The hypothesis that community participation, hygiene
care knowledge and hygiene practice have a negative
effect on diarrhea episodes was partially and weakly
s u p po rt ed .
5. The hypothesis that community participation, hygiene
care knowledge and hygiene practice have a negative
effect on diarrhea episodes controlling for; primary
caregivers' age, primary caregivers' formal education,
primary caregivers' age of y oungest child, primary
caregivers number of children five years and under, time
of diarrhea occurrence and comm u ni ty was not supported.
The hypothesis that hygiene practice has a negative
effect on diarrhea episodes was only partially and weakly
supported w i t h the control v a r i a b l e s .
95
Table 14 •
Multiple Regression Analysis of Diarrhea

with the Controls
Variable B SE B Beta
xi .002129 .002233 .040100

X2 .013480 .016918 .033861
X3 -.076772** .023331 139890**
X 4 .006454** 9 .57121 289648**
X 5 -.011568 .0014091 032822
V .044517 .085337 022406
“6
X7 3.789851 .004507 004565
X8 -1.57099 .002939 002443
Xg .933481 .019982 041884
Constant .933481
R2 = .10*** F = 6.68706
* p <.01 * * p = .001 *** p <.001
N=600
X3 (Community Participation)
X2 (Hygiene Care Knowledge)
X3 (Hygiene Practice)
X4 (Time of Diarrhea)
X5 (Community)
X6 (Number of Children <5 yrs)
X7 (Primary Caregiver's Age)
X8 (Study Child's Age)
Xg (Formal Education)
96
Post Hoc Analysis
Post hoc analysis was carried out due to the
unanticipated low incidence of diarrhea. Less than half
of the primary caregivers reported that their children
had experienced a diarrheal illness. The independent
groups t test was used to compare the means of two
s amp le s.
A comparison of community participation, hygiene
care knowledge and hygiene practice between no d iarrhea
episodes and one to seven diarrhea episodes showed that
only hygiene practice had a significant difference (p =
.01). This means that there is a difference in hygiene
practice between the groups with and without diarrhea.
The results supported the regression analysis in w hi ch
the hygiene practice was significant suggesting that as
hygiene practice improves, diarrhea episodes reduce.
Community participation and hygiene care knowledge did
not show a significant difference.
care knowledge and hygiene practice between zero to one
and two to seven diarrhea episodes showed that only
hygiene practice had a significant difference (p < .01).
This suggests that there was a difference in hygiene
practice between the groups with 0 to 1 and 2 to 7
diarrhea episodes.
97
care knowledge and hygiene practice between zero to one
and five to seven diarrhea episodes showed no significant
difference between the groups. The results suggested that
the two extremes of 0 to 1 and 5 to 7 diarrhea episodes
were not influenced by community participation, hygiene
care knowledge and hygiene practice.
Discussion
This study examined the influence of primary
knowledge and hygiene practice on episodes of diarrhea in
children five years and under. The sample comprised 600
female primary caregivers' who were responsible for most
of the dependent care of at least one child five years
and under. The youngest child (Alam, Wojtyniak, Henry &
Rahaman, 1989) was selected for the study if the primary
caregiver had more than one child in her care. The
primary caregivers' age distribution with a mean of 32
years was comparable to other diarrheal studies carried
out in Zimbabwe (De Zoysa, Carson, Feachem, Smith &
Loewenson, 1984) and Kenya (Patel, Eisemon & Arocha,
1988). The majority of primary caregivers' were mothers
as reported in previous studies (De Zoysa, Carson,
Feachem, Smith & Loewenson, 1984; Moy, Booth, Choto &
McNeish, 1991a) which confirms that child minders, other
98
family relatives and grandmothers still play a minimal
child caring role in the rural setting in Zimbabwe. The
educational level of the majority of primary caregivers'
was above grade 7 unlike Moy, Booth, Choto and McNeish's
(1991b) study where the majority of primary caregivers'
were illiterate and had never attended school. The
in c r e a s e d level of education of the primary c aregivers'
was an unexpected but positive finding.
Primary caregivers' resided in ten wards of one
province considered to have similar water and sanitation
facilities and amount of health promotion activities in
diarrheal prevention (Morgan, 1990). Although the ten
wards were randomly selected there was an unexpected
difference in three wards in community participation, one
ward in hygiene care knowledge and three wards in hygiene
practice. The difference may be due to other factors such
as non usage of or malfunctioning water and sanitation
facilities and/or reduced amount of health promotion
activities. Variations in physical geographical features
and local social norms of the wards may also have
contributed to the differences.
Comm u ni ty participation was based on the number of
meetings attended by each primary caregiver and expressed
as a percentage of the actual meetings held in each of
99
the respective wards. The findings demonstrated that
there was an unexpected non attendance which accounted
for 64% (n = 385) as the study site was considered to
have a high level of community participation activities
(Morgan, 1990). However low community participation has
also been reported in other studies (Katzellenbogen,
Pick, Hoffman & weir, i988; Loevinsohn, 1990; Oakley,
1989; Rifkin, 1990; Stanton, Clemens, Khair, Khatun &
Jahan, 1987; World Health Organization, 1991) intended
for health promotion activities to reduce diarrhea
episodes in children. Therefore in this study most of the
knowledge on diarrheal illness may have been obtained
from other sources such as the rural health centers
rather than community participation activities.
A secondary finding of this study showed that 58% (n
= 348) primary caregivers' perceived community
participation either as sharing ideas or working together
or learning or teaching each other or promoting health
and cleanliness. The perceptions reflected R i f k i n 's
(1988) definition of community participation as "a social
process whereby specific groups with shared needs living
in a defined geographic area pursue identification of
their needs, make decisions and establish mechanisms to
meet these needs" (p. 933).
Katzellenbogen, Pick, Hoffman and Weir (1988), found
100
that a response rate of 98% indicated community consent
considered as passive participation but that active
participation in community activities was minimal. In
this study 58% indicated positive perceptions of
community participation considered as passive
participation but only 36% (n = 215) engaged in active
pai in uuuuuunxLy a ttiv iL ic a • me atiiuy
demonstrated that having positive perceptions of
community participation considered as passive
participation does not necessarily guarantee active
participation in community activities.
The primary caregivers' hygiene care knowledge
scores were higher than expected. Out of a total m a x i mu m
score of 33, the mean score was 20. Fifty two percent (n
= 313) had a score of 20 and above with only 6% (n = 36)
achieving a score less than half of the total score. The
majority knew that it was necessary to wash hands after
defecation, before eating, after eating, use of soap and
fresh water for handwashing and covering of food dishes.
However, only 4% (n = 24) reported contaminated dirtiness
and germ theory as reasons given for hygiene care
behaviors to prevent diarrhea. The understanding of g erm
theory was also found to be minimal in previous studies
(Ahmed, Zeitlin, Beiser, Super, Gershoff & Ahmed, 1992;
101
De Zoysa, Carson, Feachem, Smith & Loewenson, 1984).
Reasons given were main l y perceived and social dirtiness
(Fukumoto, & Aguila, 1989). Less than half of the
subjects included flies as a main cause of diarrhea which
was also found by De Zoysa, Carson, Feachem, Smith and
Loewenson, (1984). Th e high level of hygiene care
knowledge ma y be attributed to the increased health
promotion activities in the study site (Morgan, 1990) and
the higher level of basic education observed as compared
to Moy, Booth, Choto and McNeish, (1991b) study. A
comparative study of schooled and unscho ol e d mothers
(Patel, Eisemon, Arocha, 1988) supported the finding that
schooled mothers had higher hygiene education knowledge.
However, the researchers reported that although the
schooled mothers could state causal agents of diarrhea
they were unable to demonstrate understanding of the
relational process in their explanations. In this study
despite the hygiene care knowledge scores being high, the
understanding of contaminated dirtiness and germ theory
was minimal. This finding may be a ttributed to hygiene
practice being weak ly supported in explaining diarrhea
episodes.
Hygiene Practice
The primary caregivers' hygiene practice measured as
hygiene behavior chec k list scores and based on both self
102
reports and interviewer observations showed that 17% (n =
93) were below half of the total score while 83% (n =
455) achieved half of the total score and above. The
level of hygiene practice attained by the primary
caregivers reflected positive behaviors. In particular,
the disposal of children's stools in the latrine
accounted for 89% (n = 534). In contrast V anderslice and
Briscoe (1995) reported that 61% of the mothers disposed
of the children's stools elsewhere other than the
latrine. In addition it was observed in this study that
75% (n = 450) of the primary caregivers' latrines did not
have feces present on the latrine slab. Only 1% of the
primary caregivers in this study had human feces observed
in the yard as compared to one third of the households
observed in Vanderslice and Briscoe (1995), study. Eighty
eight percent (n = 528) of the primary caregivers
reported the hygiene practice of handwashing using either
soap and fresh water or fresh water alone which was
supported by Tatley and Yach (1988) and regarded as the
most important personal hygiene behavior in the
prevention of diarrhea (Boot & Cairncross, 1993).
Positive personal hygiene as denoted by child cleanliness
was also observed in 71% (n = 427) of the primary
caregivers' children. Personal hygiene in particular,
w ashing of hands, face and body, cleaning of nails and
103
regular washing of clothes is regarded as an essential
component of positive hygiene practice (Boot &
Cairncross, 1993). The high scores in hygiene practice
for the majority of the primary caregivers may have lead
to reduced variance and subsequently hygiene practice
being weakly supported in explaining diarrheal episodes.
Diarrhea Episodes
The diarrhea episodes of children five years and
under was much less than expected. Fifty-six percent of
the study children had not experienced diarrhea and 28%
(n = 170) had only experienced one diarrhea episode.
These findings are in contrast to an earlier report
(Zimbabwe Ministry of Health 1987) of four episodes of
diarrhea per year for children in the same age group. In
addition, diarrhea is still a major cause of child deaths
(Republic of Zimbabwe Report, 1997) and is ranked as the
second most frequently managed condition by nurses at
health centers (Zimbabwe Ministry of Health and Child
Welfare Statistics Department, 1992). The contrast may be
due to the study site's improved water and sanitation
facilities and increased health promotion activities
towards the prevention of diarrhea used as the sample
inclusion criteria. Provision of clean w a t e r and good
sanitation facilities does not automatically reduce
diarrhea episodes (Bassett, Sanders & Todd, 1992; Huttly,
104
1990). It may be that the water anci sanitation facilities
accompanied by health promotion activities (Boot &
Cairncross, 1993) towards the prevention of diarrhea
reduced the incidence.
There were also variations among the ten wards with
regards to children w i t h diarrhea episodes with four
wards having fifty percent and above while the remaining
six wards had less than fifty percent. Variations in
physical geographical features and local social norms of
the wards may also have contributed to the differences.
In addition previous d i ar rh ea was found to be a risk
factor for repeated diarrheal illness (Tatley & Yach,
1988). Therefore children residing in the wards with
increased incidence of diarrhea episodes are at a higher
risk of contracting diarrheal illness. The results also
showed that the age group more prone to diarrhea episodes
was between 19 and 36 months as compared to the standard
indicator of 6 to 24 months initially reported by Snyder
and Merson (1982). The shift of the diarrhea morbidity
peak to an older age group ma y be attributed to the
promotion of continued breast feeding and proper weaning
practices from the ages of 6 to 24 months (Republic of
Zimbabwe Report, 1997). Following the 24 month age
period, children rely e n ti re ly on other foods which may
be contaminated thereby predisposing them to the
105
increased risk of diarrhea. In addition, the activity
level of children increases with age thereby further
predisposing them to the risk of diarrheal illness.
Community Participation, Hygiene Care Knowledge and
Hygiene Practice relationship to Diarrhea Episodes
Question 1 asked 'Is community participation of
primary ca r eg i v e r s ’ associated w i t h children's diar r he a
e p i s o d e s ? ’ and the hypothesis tested by regression
analysis was 'community participation has a negative
effect on diarrhea episodes'. C o mm un it y participation had
a non significant relationship w i t h diarrhea episodes.
C ommunity participation was therefore neither related nor
contributed to the explanation of diarrhea episodes. The
effect of community participation on diarrhea episodes
may have been affected by a low level of participation as
only 36% (n = 215) engaged in c ommunity participation
activities. This finding is supported by Stanton,
Clemens, Khair, Khatun & Jahan, (1987) who attributed
failure of the intervention in the reduction of childhood
diarrhea to low level community participation. C om m u n i t y
participation was regarded as the social environment.
Tumwine (1989) and Woelk (1994) emphasize the need
of community participation as a vehicle for effective
health promotion in Zimbabwe. Basset, Sanders and T odd
(1992), attribute lack of effective communication m ethods
106
at community level to the ineffectiveness of community
participation hygiene education in the reduction of
diarrheal disease. Katzellenbogen, Pick, Hoffman and Weir
(1988), in a study to initiate community participation
for a diarrheal control program, report poor attendance
despite the fact that the majority were in favor of the
diarrheal pro gr am activities.
This study also showed that despite positive
perceptions of community participation, 58% (n = 348),
the primary caregivers' active participation was low.
This study has demonstrated that having positive
perceptions of community participation considered as
passive participation, does not necessarily guarantee
active participation in community activities in reduction
of diarrhea episodes. In this study the low level of
community participation towards the prevention of
diarrhea may also have been attributed to health planners
not involving the community in the planning,
implementation and evaluation phases of community
participation activities (Loevinsohn, 1990; Oakley, 1989;
Rifkin, 1990 & World Health Organization, 1991).
Question 2 asked 'Is hygiene care knowledge of
primary caregivers' associated with children's diarrhea
episodes?' and the hypothesis tested by regression
analysis was 'hygiene care knowledge has a negative
107
effect on diarrhea episodes'. Hygiene care knowledge had
a non significant relationship with diarrhea episodes.
Hygiene care knowledge was therefore neither related nor
contributed to the explanation of diarrhea episodes. The
affect of hygiene care knowledge on diarrhea episodes may
have been affected by little variation in the scores
achieved by the primary caregivers' with very few (6% n =
36) below half of the total score. The high scores
achieved may have been attributed in part to increased
health promotion activities in the area (Morgan, 1990)
and the high level of primary caregivers' basic
education. In addition, the expected effect of hygiene
care knowledge on diarrhea episodes may have been
affected by the primary caregivers' poor understanding of
the causal relations of agents and diarrhea (Patel,
Eisemon & Arocha, 1988). Furthermore, the primary
caregivers' poor understanding of causal relations of
agents and diarrhea may have been due to prior learning
activities regarding the prevention of diarrhea. Prior
learning activities may not have been presented within
the context of traditional cultural values (Ahmed,
Zeitlin, Beiser, Super, Gershoff & Ahmed, 1992; Fukumoto,
& Aguila, 1989) so as to enhance meaningful
understanding.
Question 3 asked 'Is hygiene practice of primary
108
caregivers' associated with children's diarrhea
episodes?' and the hypothesis tested by regression
analysis was 'hygiene practice has a negative effect on
diarrhea e p i s o d e s '. Hygiene practice had a negative
significant relationship with diarrhea episodes (p < .01)
but w ea k beta (-.071373). The relationship was wea kl y
supported indicctting a change of .071373 in dxarrheo
episodes for every unit change in hygiene practice. This
means that as hygiene practice improves, diarrhea
episodes slightly decrease. The study finding is
supported by Alam, Wojtyniak, Henry and Rahaman (1989)
study in which hygiene practice was related to diarrhea
episodes. The occurrence of childhood diarrhea is
g enerally assumed to be linked with negative hygiene
related activities at the household level (Bartlett,
Hurtado, Schroeder & Mendez, 1992). In this study several
hygiene behaviors were used to constitute hygiene
practice. Similar approaches were u s e d in (Alam,
Wojtyniak, Henry & Rahaman, 1989; T a t l e y & Yach, 1988)
studies in which hygiene practice was found to be related
to diarrhea episodes. This means that hygiene behaviors
pertaining to personal, domestic and environmental
hygiene should be considered c ollectively to constitute
hygiene practice in the prevention of diarrhea. T he r e f o r e
positive hygiene related activities at the household
109
level slightly reduces diarrhea episodes. In this study,
the hypothesis that hygiene practice has a negative
effect on diarrhea episodes was weakly supported.
Question 4 asked 'Is the primary c a r e g i v e r s '
co mm u n i t y participation, hygiene care knowl e dg e and
hygiene practice associated with children's diarrhea
e p i s o d e s ? 5 and the hypothesis tested by regression
analysis was 'community participation, hygi en e care
knowledge and hygiene practice have a negative effect on
diarrhea episodes'. The combined effects of community
practice accounted for 2% of the explained variance in
diarrhea episodes. The hypothesis was p ar t i a l l y
supported. Only hygiene practice regression coefficient
was significant (p < .01). Therefore only hygiene
practice weakly contributed to the explanation of
diarr he a episodes. Stanton and Clemens (1987) also found
that hygiene practice comprising hand w a s h i n g and proper
disposal of feces slightly reduced diarrhea episodes.
In this study, the significant effect of hygiene
prac ti ce on diarrhea episodes may have been w e ak en ed by
the unexpected reduced incidence of diarrhea among
p r i ma ry caregivers' children. Moy, Booth, Choto, and
McNeish, (1991b) attributed non significant findings of
hygiene behaviors as a risk factor in d i ar rh ea due to
110
individual differences in personal and environmental
hygiene. In this study potential variations in hygiene
practice such as handwashing techniques and methods of
storing water in the home may also have contributed in
part to the hypothesis o nl y being weakly supported.
Furthermore, despite the provision of infrastructure at
household level such as clean water and sanitation being
similar there may have been differences among the primary
caregivers' with regards to the availability of material
resources necessary for the implementation and
maintenance of positive hygiene practices.
Community participation and hygiene care knowledge
did not contribute to the explanation of diarrhea
episodes. The study demonstrated that primary caregivers'
community participation m a y not be actively practiced and
hygiene care knowledge m a y have lacked the understanding
of causal relations of agents and diarrhea. Lack of
active community participation and lack of understanding
of causal relations of agents and diarrhea may have
contributed to the non significant result.
Question 5 asked 'Is the primary caregivers'
hygiene practice associated with children's diarrhea
episodes when controlling for primary caregivers' age,
primary caregivers' formal education, primary caregivers'
Ill
caregivers' age of youngest child, time of diarrhea
occurrence and primary caregivers' community?' The
hypothesis tested by regression analysis was 'community
practice have a negative effect on diarrhea episodes w h e n
controlling for primary caregivers' age, primary
primary caregivers' community'.
The combined effects of hygiene practice and one
control variable, time of diarrhea occurrence, accounted
for 10% of the explained variance in diarrhea episodes.
The hypothesis was partially and weakly supported. Only
hygiene practice regression coefficient was significant
(p = .001). Therefore hygiene practice with only one
control entered, time of diarrhea occurrence, partially
and weakly contributed to the explanation of diarrhea
episodes. The control variables of primary caregivers'
age (Katzellenbogen, Pick, Hoffman & Weir, 1988; Yoosuf,
1993), primary caregivers' formal education (Boot &
Cairncross, 1993), primary caregivers' number of children
five years and under, primary caregivers' age of youngest
child and primary caregivers' community did not
112
contribute to the explanation of diarrhea episodes.
Following control of potential extraneous variables,
hygiene practice remained significant suggesting that
hygiene practice has some influence in reducing diarrhea
episodes. However, community participation and hygiene
care knowledge remained non significant. The non
significant resuits may have been due to the measurements
not a dequately discriminating individual differences in
community participation and hygiene care knowledge among
the prim ar y c a r e g i v e r s .
Post hoc analysis using the independent t - test was
used to determine the amount of difference in community
practice between high and low episodes of diarrhea. Only
hygiene practice showed a significant difference. There
was a significant difference in primary caregivers'
hygiene practice between the groups with high and low
episodes of diarrhea. Therefore, the post hoc analysis
further supported the potential importance of hygiene
practice in reducing diarrhea episodes.
T h e study was based on the McGill model of nursing
(Gottlieb & Rowat, 1987). The derived conceptual
framework of the study stated that the social
environment, characteristics of the individual and the
individual's behavior are important factors in promoting
113
health- In this study community participation was v ie w e d
as the social environment, and hygiene care knowledge as
characteristics of the individual, and hygiene practice
c onstituted an aspect of the individual's behavior.
R eduction of diarrhea episodes was regarded as an o utcome
of promot in g health. The findings o n l y partially
s upported the model. Hygiene practice constituting the
individual's behavior was found to be an important factor
in reducing diarrhea episodes as an outcome of promoting
health. Community participation and hygiene care
knowledge as the social environment and characteristics
of the individual respectively were not supported by the
study findings as important factors in reducing diarrhea
episodes as an outcome of health promotion.
Primary caregivers' individual differences in
c o m mu ni ty participation and hygiene care knowledge m ay be
other important factors not addressed in this study. T h e
me as urement of community participation and hygiene care
knowledge may not have adequately discriminated the
individual differences among the primary caregivers.
Co mm u n i t y participation differences m a y have existed due
to pos si b le variations in leadership and cohesion wit hi n
the communities. Hygiene care knowledge differences ma y
have existed due to variations in the understanding of
causal relations of agents and diarrhea.
114
The low level of diarrhea episodes among primary
caregivers children may have been attributed to the
promotion of exclusive and continued breast feeding from
birth to two years. In addition, improved water and
sanitation facilities and health promotion activities may
have contributed to the low level of diarrhea episodes.
The differences in diarrhea episodes among the
communities may have been due to variations in facilities
and geographical physical features. Communities in which
the primary caregivers resided may have differed in safe
water supply due to malfunctioning water sources such as
bore holes' hand pump systems. Communities may also have
differed in geographical physical features such as
terrain and natural water sources.
CHAPTER 5
S U M M A R Y , LIMITATIONS, IMPLICATIONS AND RECOMMENDATIONS
This chapter presents a summary of the pertinent
findings of this study. The findings are discussed in
relation to limitations and implications. Relevant
recommendations are addressed in nursing knowledge
development, research and community health nursing
prsctics-
Summary
A cross-sectional survey design was used to examine
a health promotion model for prevention of diarrhea
episodes. A random sample of 600 primary caregivers' with
children under five was used for the study. The average
age of the primary caregivers' was 32 with the majority
(68%) (n = 406) in the age range of 20 to 39 years. The
mean age of the children was 27 months with a range of 1
to 60 months.
The majority of caregivers (88%) (n = 528) had
attended school and the remainder (12%) (n = 72) had no
education. Seventy-seven percent (n = 462) were mothers,
15% (n = 87) grandmothers, family relative (5%) (n = 32)
and 3% (n = 19) child minders. Sixty-one percent (n =
366) of the primary caregivers' cared for the youngest
child 24 hours a day while the remainder (39%) (n = 234)
provided care from 3 to 2 3 hours per day.
115
116
F orty-four percent (n = 267) of the primary
caregivers' reported that the youngest child had
experienced diarrhea. Diarrhea episodes ranged from 1 to
7. Thirty -s ix percent (n = 215) of the primary
c a r e g i v e r s ' had engaged in community p articipation and
the community part ic ip a ti on index ranged from 6 to 100
percent. Hygiene education received, c om pr i se d of either
one or two or three of the following; personal, domestic,
and environmental. Hygiene care knowledge total scores
ranged from 12 to 28 out of a total m a x i m u m score of 33.
Hygiene practice total scores ranged from 3 to 13 out of
a total m a x i m u m score of 16.
The McGill model of nursing, d erived from social
learning theory provided the basis for the health
promotion m o d e l . The theory states that the social
environment, characteristics of the individual, and the
individual's beha vi or are important factors in promoting
health. In this study reduction of d iarrhea episodes was
regarded as an outcome of promoting health. Community
p articipation was viewed as the social environment, and
hygiene care knowledge as characteristics of the
individual, and hygiene practice constituting an aspect
of the individual's behavior.
The study examined the influence of primary
caregivers' commu ni ty participation, hygiene care
117
knowledge and hygiene practice on episodes of diarrhea in
children under five years. Five hypotheses were generated
to examine the influence of community participation,
hygiene care knowledge and hygiene practice on diarrhea
episodes. Multiple regression analysis was used to test
the hypotheses. The hypotheses form the linkages for a
health promotion model in the reduction of diarrhea
ep i s o d e s .
Multiple regression analysis supported a weak
negative relationship between hygiene practice and
diarrhea episodes. The effects of community participation
and hygiene care knowledge on diarrhea episodes were not
supported. The health promotion model for prevention of
diarrhea was only partially supported. A large number of
the sample with no diarrhea episodes and community
differences may have attributed to the model only being
partially supported.
Limitations
A limitation of this study was the cross sectional
correlational design as it only allows data to be
collected at one point in time therefore causal
relationships cannot be determined. A longitudinal
intervention study may determine causality and changes
over time.
A second limitation of the study may have been
118
response bias due to the self reporting nature of the
instruments leading to social desirability. Interviewer
training as well as the interviewer selected observations
of one of the instruments were designed to reduce
response bias. The nature of self reports as compared to
observation techniques limits the degree of accuracy to
Lilts measure. Increased utilization of observation
techniques may minimize potential subject response bias.
The third limitation of the study was the limited
availability of comprehensive instruments with
established psychometrics. Experienced data collectors
familiar with the language, research methods and rural
communities were used to enhance measurement. Refinement
of the instruments may improve measurement of the
variables. Potential threats to internal validity namely
maturation, testing and history were minimized by the
cross sectional design and the relatively short duration
of the interview. The limitation of recall retrospective
data regarding diarrheal illness was reduced by
validating the primary caregivers' responses with the
c h i l d r e n ’s 'Road to Health ' cards.
Apart from the multistage random sampling procedure
utilized, generalizability of the findings can only be
limited to the population as per the study's sample
inclusion criteria as not all rural areas have water and
119
sanitation facilities. Generalizability of the findings
can only be made to the population in this study as
differences were found between the community wards w h i c h
was controlled for statistically to minimize threats to
external validity. The inclusion of data on community
differences may enhance generalizability.

I I
xuatiuua
The implications for the study relate to nursing
knowledge development, education and practice. Nursing
knowledge development was based on a health promotion
model intended to reduce diarrhea episodes in children
five years and under as an outcome of health promotion.
The health promotion model proposed that primary
knowledge and hygiene practice were important factors in
reducing diarrhea episodes. The model was partially
supported in terms of hygiene practice and it is possible
that community participation and hygiene care knowledge
m ay still be important factors in reducing diarrhea
episodes as an outcome of health promotion. Therefore the
health promotion model still needs to be developed using
c ommunity participation, hygiene care knowledge and
hygiene practice in reducing diarrhea episodes. Emphasis
also needs to be placed on refinement of the measurements
of the variables.
120
The findings of the study have implications for
community health nursing education. Both the amount and
understanding of primary caregivers' community
participation have been found to be problem areas.
Therefore commu ni t y health nursing education needs to
clearly delineate the concept of community participation
in its curriculum. Findings of the study on hygiene care
knowledge suggest the p ossibility of the link between
germ theory and diarrhea not being fully understood by
primary caregivers. In order to facilitate the transfer
of knowledge regarding germ theory to clients, community
health nursing e ducation needs to review the nature of
health education strategies. Hygiene practice in this
study was found to have a weak influence on diarrhea
episodes in terms of health promotion. Several hygiene
practice behaviors including observations at the
household level were found to be linked with reduction of
diarrhea episodes. Therefore community health nursing
education needs to include several hygiene practice
behaviors and o bs er vation techniques in the prevention of
diarrhea. The study findings also identified children
aged 19 to 36 months as being most at risk of contracting
diarrheal illness. Commu ni ty health nursing education
needs to highlight the importance of diarrheal prevention
for this age group.
121
In this study hygiene practice was found to have a
weak influence on diarrhea episodes in terms of health
promotion. However, it is possible that community
participation and hygiene care knowledge may still be
important factors in reducing diarrhea episodes as an
outcome of health promotion. The findings provide some
guidance for community health nursing practice. In
particular, the primary caregivers' low level of
community participation and understanding may have been
attributed to health planners not involving the community
in the planning, implementation and evaluation of
community participation activities. It is postulated that
community members active participation is increased when
the health goals are those of the community. Therefore
community health nurses need to consider active
involvement of the community in their practice. It may
also be helpful to consider the way in which hygiene care
knowledge is presented to the community by community
health nurses. Hygiene care knowledge may be facilitated
if the process of understanding of the causal relations
of agents and diarrhea are presented within the context
of traditional cultural values and in a home based
situation. Therefore, the implications for knowledge
development and education provide some guidance for
community health nursing practice.
122
Recommendations
A health promotion model, derived from McGill's
model of nursing was used to examine the influence of
hygiene practice on episodes of diarrhea in children
under five years of age in rural Zimbabwe. The health
promotion model for the prevention of diarrhea has
created the foundation for further research. The
recommended areas for future investigation are as
follows:
1. The study should be replicated with refined measures
of variables including potential ward differences.
2. The understanding and low level of community
participation among primary caregivers needs to be
explored to facilitate further research.
3. The understanding of the link between germ theory and
diarrhea among primary caregivers needs to be explored to
validate their hygiene care knowledge.
4. Observation technigues to measure hygiene practice
should be further utilized in subsequent studies.
5. Community participation, hygiene care knowledge and
hygiene practice instruments need to be refined in o rd er
to maximize the measurement of the variables.
6. Future studies should focus on household primary
caregivers' material resources for the implementation and
123
maintenance of hygiene practice.
7. An exploration is required to d etermine primary
c a r e g i v e r s ’ variations of hygiene practice behaviors in
relation to personal, domestic and environmental hygiene.
8. A comparative study of primary c a r e g i v e r s ' community
^LctuLice should be carried out to determine differences
between communities in diarrhea episodes.
9. An exploration is needed to determine if active
par ti ci pa ti on is increased when the health goals are
those of the community as postulated by McGill's model of
nursing.
124
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132
APPEN D I X A
PARTICIPANT DEMOGRAPHIC SHEET.
1. What is your date of birth?
2. Name of community? ...................
3. What level of schooling have you received?
a) None
K
k//\ —
\sx. a u c
1
X
c) Grade 2
d) Grade 3
e) Grade 4
f) Grade 5
g) Grade 6
h) Grade 7
i) Above Grade 7
4. How many children under five years do you look after?
5. What is the youngest child's date of birth?

••./ / ----
6. What relationship are you to the youngest child you

are taking care of?
a) mother
b) grandmother
c) family relative
d) childminder
e) other
7. How many hours per day do you take care of the

youngest child under five years? .................
133
APPENDIX B
DIARRHEA EPISODE QUESTIONNAIRE.
1. Has your child ever had diarrhea?
a) yes .............
b) no .............
IF YOUR ANSWER IS "NO" GO TO "C"
2. When did your child have diarrhea?
3. Ho w many days did the diarrhea last?
4. H o w many times of loose stools did your child have per

day?
5. D id your child ever have periods of two days or more

w ithout loose stools during that diarrhea?
a) yes ...........
b) no ...........
6. H o w many periods of two days or more without loose

stools did your child have during that diarrhea?
7. Did your child ever have diarrhea in the last two

weeks including today?
a) yes ...............
b) no ...............
8. IF YES, how many periods of two days or more without

loose stools did your child have during the last two
weeks including today? ................
134
APPENDIX C
HYGIENE CARE KNOWLEDGE SCALE
1. According to y our knowledge Is it necessary to wash

hands after defecation?
a) Yes ...............
b) No ...............
c) Don't Know ...............
If YES - why is it necessary to wash hands after

defecation?
2. According to your knowledge is it necessary to wash

hands wash hands before eating?
a) Yes ...............
b) No ...............
c) Don't Know ...............
If YES - why is it necessary to wash hands before

eating?
3. According to your knowledge is it necessary to wash

hands after eating?
a) Yes......... .............
b) No .............
c) D o n ’t Know .............
If YES - why is it necessary to wash hands after

eating?
4. According to your knowledge what should be used to

wash hands?
135
a) fresh water
b) soap and fresh wate r
c) re-used water
d) cloth or paper
e) other
5. A cc or di ng to your knowledge is it necessary to cover

all food dishes?
a) Yes ................
b) No ................
c) D o n ’t Know ................
If YES - why is it necessary to cover all food dishes?
6. According to your knowledge is it necessary to dispose

of children's stools if left in the yard?
a) Yes ..............
b) No.......... ..............
c) Don' t Know ..............
If YES - where should children's stool be disposed of

if left in the yard?
a) Bush ...............
b) Lat ri ne ...............
c) Hole ...............
d) C o v er ed Hole ...............
e) Left alone ...............
f) O t h e r ......... ...............
7. According to your knowledge what causes diarrhea?
a) d o n 't know
b) bad food
c) flies
d) d ir t y baby dishes
e) d i r ty water
f) evil spirits
136
g) bad environment
h) heat
i) dirty hands
j) bad breast milk
k) others
8. According to your knowledge how should water be stored

in the home?
137
APPENDIX D
HYGIENE BEHAVIOR CHECK LIST SCALE
1. Where does the child defecate?
a) pot............................
b) on the ground......... .......
c) in a napkin or pants .......
d) outside the yard.............
e) other.................. .......
2. Where do you dispose of the child's stools?
a) in the latrine
b) buried in the yard
c) thrown away in the yard ,
d) thrown outside yard
e) not disposed of
f) other
3. Do you purge the child?
a) yes ..............
b) no ..............
c) sometimes ..............
d) If you say yes or sometimes, what medicine do you
use?
4. Does your child eat earth?
a) yes ..............
b) no ..............
c) sometimes ..............
5. How do you store your water?
138
6. What do you use to w ash hands?
a) fresh water
b) soap and fresh w ater
c) re-used water
d) cloth or paper
e) other
INTERVIEWER SELECTED OBSERVATION
7. Were feces present on the latrine slab?
b) no .............
8. Were feces present in the yard?
a) no ................
b) yes, animal only ................
c) yes, human only ................
d) yes, animal and human ................
9. Was stagnant water visible in the yard?
a) yes .............
b) no .............
10. Was the child clean?
a) yes ............
b) no ............
139
APPENDIX E
C O MM U N I T Y PARTICIPATION INDEX
1. How many local formal community meetings or activities

on diarrhea w e r e held in the last twelve months in your
a r e a ? .....................
2. How many times have you attended local formal

community meetings or activities on diarrhea in the last
twelve months in your a r e a ? .................
3. Whioh of the following items were included in either

the community meetings or activities?
a) personal hygiene .............

b) domestic hygiene .............
c) environmental hygiene .............
4. What does community participation mean to

y o u ? .............................................
140
A PPENDIX F
INFORMED CONSENT
Hello, Ms.____________________, my name Is,________________ .
I work in the Department of Health of Mashonaland
East Province. We are learning about diarrhea in children
especially the youngest of the under five years of age.
The knowledge we obtain may help us to plan ways to
prevent this illness to your child and other children in
your area.
I am therefore kindly requesting to ask you some
questions which will take about 45 minutes of your time.
Please answer these questions to the best of your
ability. Your participation is voluntary and you should
feel free to answer or not to answer the questions. I
wish to assure you that answering all of the questions
will help us and nothing detrimental will happen to you
or your child. Nobody will know your name or your
answers.
If you answer all questions you will receive 10
Dollars as a token of appreciation for your time.
I fully understand the explanation given with regards to
this interview and I willi ng ly give my consent to
participate in answering the required questions.
Participant s i g n a t u r e ....... Interviewer Signature......
IMAGE EVALUATION
TEST TARGET ( Q A - 3 )
1.0 M
2.2
2.0
l.l
1.8
1.25 1.4 1.6
15 0 m m
APPLIED A IIW4GE . Inc

.as: 1653 EastMain Street
Rochester. NY 14609 USA
Phone: 716/482-0300
■= = = '-= = Fax: 716/288-5989
O 1993. Applied Image. Inc.. All Rights Reserved

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COMMUNITY PARTICIPATION, HYGIENE CARE KNOWLEDGE, AND

HYGIENE PRACTICE ON EPISODES OF DIARRHEA IN CHILDREN

UNDER FIVE YEARS OF AGE IN RURAL ZIMBABWE.

Submitted in partial fulfillment of the requirements

for the degree of Doctor of Philosophy

Dissertation Advisor: Dr. Diana L. Morris

CASE WESTERN RESERVE UNIVERSITY

UMI Microform 99II4I4

This microform edition is protected against unauthorized

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

candidate for th e PhD______________________ degree.*

COMMUNITY PARTICIPATION, HYGIENE CARE KNOWLEDGE, AND

HYGIENE PRACTICE O N EPISODES OF DIARRHEA IN CHILDREN

UNDER FIVE YEARS OF AGE IN RURAL ZIMBABWE.

Diarrhea in children five years and under is

potentially preventable but remains a major cause of

death and is ranked second out of ten conditions most

frequently managed by community health nurses at rural

health centers in Zimbabwe. Research and secondary health

programs in less developed countries have focused on

diarrhea management through feeding practices during

diarrhea, and the use of oral rehydration fluid, salt,

sugar and water solution and other fluids rather than

prevention. A health promotion model for the prevention

of diarrhea episodes, determining the influence of

primary caregivers' community participation, hygiene care

knowledge, and hygiene practice on diarrhea episodes in

children under five years has not been examined.

A health promotion model derived from the McGill

model of nursing proposed that primary caregivers'

community participation, as a social environment, hygiene

care knowledge as an aspect of a person's characteristics

important factors to promote health through r ed uc ti o n of

diarrhea episodes in children under five years. This

study proposed that primary caregivers* community

participation, hygiene care knowledge, and hygiene

practice would e xplain diarrhea episodes in children

under five years.

A cross"Ssctiop.sl survsy dssi^n usln^ 3. inultists^s

random sample of six hundred primary caregivers' in rural

areas was used to examine the factors which may influence

diarrhea episodes in children under five years. The

instruments administered were: Community Participation

Index, Hygiene Care Knowledge Scale, Hygiene Behavior

Checklist Scale, and Diarrhea Episodes Questionnaire.

Multiple regression analysis was used to dete rm in e

the influence of c ommunity participation, hygiene care

knowledge, and hygiene practice on diarrhea episodes.

Multiple regression analysis supported the negative

relationship of hygiene practice on diarrhea episodes.

The effects of c ommunity participation and hygiene care

knowledge on d iarrhea episodes were not supported. The

health promotion model for prevention of diarrhea was

The study suggests that community health nurses

should strengthen the promotion of primary c a r e g i v e r s '

children under five years. Community health nurses should

also acknowledge that community participation and hygiene

care knowledge m a y still be important factors in reducing

I wish to express my sincere thanks to my