Mothers’ treatment seeking behavior for

children with diarrhea: a cross-sectional

study in Zambia

Helena Dahl

Självständigt arbete – Folkhälsovetenskap GR (C)

Huvudområde: Folkhälsovetenskap
Högskolepoäng: 15p
Termin/år: HT-2020
Handledare: Koustuv Dalal
Examinator: Katja Gillander Gådin
Kurskod: FH038G
Abstract

Introduction: According to WHO, diarrhea disease is the second leading cause of

death worldwide for children under five. Around 525 000 children under five are
killed every year by diarrhea. Most deaths from diarrhea occur among children less
than 2 years of age living in South Asia and sub-Saharan Africa. With a
comprehensive strategy that ensures all children in need receive critical prevention
and treatment measures it is possible to save the lives of millions of children at risk of
death from diarrhea. The aim of this study was to identify what kind of treatment has
been given to under-five children with symptoms of diarrhea and what kind of care the
respondent sought in Zambia, a low-income country.
Method: A cross-sectional study with secondary data from Zambia Demographic and
Health Survey (ZDHS). The first-born child under five with diarrhea the last two
weeks was selected in this study, to analyze what kind of treatment was given when
showing symptoms of diarrhea. Out of the first-born children (n=7048) we found that
1 289 children had diarrhea during the last two weeks before the survey.
Result: Of children having diarrhea 80% received some kind of treatment. Thirty
eight percent of the children with diarrhea symptoms was given zinc and 67% was
given pre-packaged Oral Rehydration Solution (ORS). The first place to seek
treatment for the child’s diarrhea was at the Government Health Center (66%)
followed by 18% that sought treatment at the Government Health Post.
Conclusion: This study showed that the treatment and care seeking behavior for
caregivers to under-5 children with diarrhea is of public health concern. Less than half
of the children receives zinc as a treatment and 67% receives prepacked ORS. There is
a need for education and awareness on the efficacy of ORS and especially zinc in
preventing diarrhoea mortality and contribute to the UN Sustainable Development
Goals target 3.2.

Key words: care-seeking, diarrhea, child under five, diarrhea, treatment, rural/urban,
Zambia.

1
Abstrakt

Introduktion: Enligt WHO är diarré den näst största dödsorsaken för barn under fem
år. Cirka 525 000 barn under fem år dör varje år till följd av diarré. De flesta dödsfall
på grund av diarré inträffar bland barn under 2 år som bor i Sydasien och Afrika söder
om Sahara. Med en omfattande strategi som säkerställer att alla barn i nöd får
förebyggande åtgärder och rätt behandling är det möjligt att rädda miljontals barns liv
som riskerar att dö på grund av diarré. Syftet med denna studie var att identifiera
vilken typ av behandling som har givits till barn under fem år med diarré och vilken
typ av vård respondenten sökte i Zambia, ett låginkomstland.
Metod: En cross-sectional study med andrahandsdata från Zambia Demographic and
Health Survey (ZDHS). Det förstfödda barnet under fem, som haft diarré under de
senaste två veckorna, valdes ut för att analysera vilken behandling barnet fick. Utav de
förstfödda barnen (n=7048) hade 1 289 barn haft diarré de två senaste veckorna.
Resultat: Av barnen med diarré fick 80% någon form av behandling. Trettioåtta
procent av barnen med diarré fick zink och 67% fick förpackad Oral Rehydration Salt.
Det första stället att söka behandling för barnets diarré var på Government Health
Center (66%) följt av 18% som sökte behandling på Government Health Post.
Slutsats: Denna studie visade att behandling och sökande av behandling för barn
under fem år med diarré var ett folkhälsoproblem. Mindre än hälften av barnen får
zink som behandling och 67% behandlas med ORS. Det finns ett behov av utbildning
och information om effekten av ORS och speciellt zink för att förhindra barndödlighet
vid diarrésjukdomar och därmed bidra till Agenda 2030 mål 3.2.

Nyckelord: barn under fem, behandling, diarré, landsbygd/urban, söka behandling,

Zambia

2
Table of Contents

Abbreviations………………………………………………………………….4
Background……………………………………………………………………5
Definition of diarrhea………………………………………………………......6
Treatment of diarrhea………………………………………………………..…7
Zinc………………………………………………………………………...…...7
ORS……………………………………………………………………..……...8
Zambia……………………………………………………………………...….9
Heath care in Zambia…………………………………………...……………..10
Public health relevance …………………………………………...…………..12
Rationale……………...………………………………………………………13
Aims and objectives………………………………………………………….14
Method………………………………………………………………………..15
Sample for this study………………………………………………………….15
Ethical consideration……………………………………………………….....17
Result…………………………………………………………………………18
Care seeking ……………………………………………………………...…..21
Treatment ……………………………………………………………………..23
Discussion…………………………………………………………………….28
Result discussion……………………………………………………………...28
Method discussion…………………………………………………………….31
Conclusion……………………………………………………………………33
References……………………………………………………………………34

3
Abbreviations

EA Enumeration area

GH Government Hospital

GHC Government Health Center

GHP Government Health Post

MOH Ministry of Health

LMIC Low- and middle-income country

ORS Oral rehydration solution

ORT Oral rehydration therapy

RHF recommended home fluids

SSA Sub-Saharan Africa

SDG Sustainable Development Goal

U5MR Under Five Mortality Rate

UNICEF The United Nations Children's Fund

USAID United States Agency for International Development

WHO World Health Organization

ZamStats Zambia Statistics Agency

ZDHS Zambia Demographic and Health Survey

4
1. Background

For children under five, diarrhea disease is the second leading cause of death.
Around 525 000 000 children under five are killed every year by diarrhea
(WHO, 2017). Diarrhea kills more children than AIDS, malaria and measles
combined (Liu et al. 2013). Most deaths from diarrhea occur among children
less than 2 years of age living in South Asia and sub-Saharan Africa. Even
though the heavy toll, progress is being made. From 2000 to 2017, the total
annual number of deaths from diarrhea among children under 5 decreased by
60 per cent. Through basic interventions many more children could be saved
(UNICEF, 2006).

In low- and middle-income countries, diarrheal diseases are more prevalent,

largely as a result of lack of safe drinking water, sanitation and hygiene, as well
as poorer overall health and nutritional status (WHO/UNICEF, 2015).
Diarrhoea can last several days which can leave the body without the water and
salts that are necessary for survival. Children exposed to poor environment
conditions as well as poor nutritional status and overall health, are more
susceptible to severe diarrhea and dehydration than healthy children. Water
constitutes a greater proportion of children’s body- weight, which makes
children at greater risk than adults of life-threatening dehydration, also the
kidneys of young children are less able to conserve water compared to older
children and adults (WHO/UNICEF, 2009).

However, it is both preventable and treatable. Many children’s lives can be

saved with correct management of childhood diarrhea. With safe drinking-
water and adequate sanitation and hygiene together with right treatment
significant proportion of death due to diarrhea can be prevented (WHO, 2017).

5
Definition of diarrhea

According to WHO (2017) diarrhea is defined as the passage of three or more

loose or liquid stools per day (or more frequent passage than is normal for the
individual). Frequent passing of formed stools is not diarrhea, nor is the
passing of loose, "pasty" stools by breastfed babies. WHO has argued that there
could be four types of diarrhea:

Acute watery diarrhea (including cholera), which lasts several hours or days:
the main danger is dehydration; weight loss also occurs if feeding is not
continued;

Acute bloody diarrhea, which is also called dysentery: the main dangers are
damage of the intestinal mucosa, sepsis and malnutrition; other complications,
including dehydration, may also occur;

Persistent diarrhea, which lasts 14 days or longer: the main danger is

malnutrition and serious non-intestinal infection; dehydration may also occur;

Diarrhea with severe malnutrition (marasmus or kwashiorkor): the main

dangers are severe systemic infection, dehydration, heart failure and vitamin
and mineral deficiency.

Diarrhea is usually a symptom of an infection in the intestinal tract, which can

be caused by a variety of bacterial, viral and parasitic organisms. Infection is
spread through contaminated food or drinking-water, or from person-to-person
as a result of poor hygiene.

Treatment of diarrhea
There is an increased loss of water and electrolytes (sodium, chloride,

6
potassium, and bicarbonate) during diarrhea in the liquid stool. Water and
electrolytes are also lost through vomit, sweat, urine and breathing (WHO,
2005). When these losses are not replaced adequately, and a deficit of water
and electrolytes develops - dehydration occurs. Tough most episodes of
childhood diarrhea are mild, acute cases can lead to significant fluid loss and
dehydration. This dehydration can lead to death unless fluids are quickly
replaced (WHO/UNICEF, 2009). Many of the diarrheal deaths are caused by
dehydration.

In 2004, WHO and UNICEF issued a joint statement on clinical treatment of

acute diarrhea, recommending the use of low osmolarity oral rehydration salts
(ORS), zinc supplementation, increased amounts of appropriate fluids, and
continued feeding. The recommendations are

- Oral rehydration solution (ORS), a solution of clean water, sugar and salt.

- In addition, a 10-14-day supplemental treatment course of dispersible 20 mg

zinc tablets shortens diarrhea duration and improves outcomes.

However, other study shows that population coverage for this basic but
effective intervention is still very low, particularly in countries that are hardest
hit by diarrheal diseases. In SSA, only about one in three children experiencing
diarrhea episodes receives ORS, and the proportion receiving zinc is below 5%
(UNICEF, 2015).

Zinc
According to WHO (2005) several studies have now shown that zinc
supplementation (10-20 mg per day until cessation of diarrhoea) significantly
reduces the severity and duration of diarrhoea in children less than 5 years of
age. Other studies have shown that short course supplementation with zinc (10-

7
20 mg per day for 10 to 14 days) reduces the incidence of diarrhoea for 2 to 3
months.

Zinc is recommended (10-20 mg/day) be given for 10 to 14 days to all children

with diarrhea (WHO, 2005).

Oral Rehydration Solution

OSR contains salts and sugar, which help the child to absorb water to replace
what is lost during diarrheal episodes. WHO and UNICEF have for more than
25 years recommended a single formulation of glucose-based ORS to prevent
or treat dehydration from diarrhea. OSR has contributed substantially to the
dramatic global reduction in mortality from diarrheal disease during this period
(WHO 2005, Roth et al. 2018).

Treatment of diarrhea with ORS is a simple, proven, high-impact intervention

that can be provided in home settings by caretakers or by health care-providers
at community and facility levels to prevent dehydration due to diarrhea and
decrease related deaths. There is evidence that ORS may reduce diarrhea
specific mortality by up to 93% (Munos, Fischer, Christa & Black, 2010).

Important additional components are continued feeding, including

breastfeeding, during the diarrhea episode and use of appropriate fluids
available in the home if ORS are not available (UNICEF/WHO, 2009). In
response to low ORS coverage for children with diarrhea, in the 1980s, WHO
promoted the use of so-called recommended home fluids (RHF) in addition to
ORS. To refer to treatment with ORS or RHF the expression Oral rehydration
therapy (ORT) was used (Victora, Bryce, Fontaine & Monasch, 2000). ORS
can be prepared at home and it is a simple treatment used to prevent mortality
due to dehydration and undernutrition in children with diarrhea (Das, Salam &
Bhutta, 2014). In areas where intravenous fluids are scarce or unavailable it is
especially suitable and replaces indiscriminate and unnecessary use of
antibiotics to treat diarrhea (Das, Lassi, Salam, & Bhutta, 2013).

8
Zambia
Zambia is a former British colony situated in Sub-Saharan Africa. In 1964
Zambia gained independence and while it is today a democratic republic, the
country has, for most of its independence, been under one-party rule. Zambia
consists primarily of Bantu-speaking people representing nearly 70 different
ethnicities. Administratively Zambia is divided into nine provinces with
Copperbelt, Lusaka and Eastern being the most populous. The total population
of Zambia is 17 426 623 (CIA, 2020).

Zambia was for several years one of the most successful economies in Africa,
up until the economic crisis in 2015, and has for a long time been seen as a role
model in the region thanks to its peaceful and democratic development.
However, Zambia faces a major challenge since being one of the most unequal
countries in the world. The economic growth in the country did not benefit the
majority of the people, inequalities are particularly obvious in terms of urban
versus rural areas of the country and between the genders (CIA, 2020, Swedish
Government, 2018).

Approximately 55% of the country’s population are living in poverty, but in

rural areas the figure is over 75%. Almost 4% of the population live in extreme
poverty (Swedish Government, 2018). Some of the serious problems that
challenge the country is those of food insecurity, malnutrition and an
unbalanced diet, leading to an unusually high proportion of children with
stunted growth. However, some progress has been made in health and
education, and life expectancy has risen substantially. Population growth is
high. Areas such as economic empowerment, education, health, sexual and
reproductive health and rights (SRHR) and political participation are lacking
gender equality and are therefore serious barriers to development. The key to

9
achieving long-term sustainable and inclusive socioeconomic development is
buy reducing inequality (Swedish Government, 2018).
The political climate has worsened and polarization in the country has
increased since the election in 2016. In a way that is unusual for Zambia since
it has remained relatively stable as a country in the region from a conflict
perspective. The democratic space has shrunk and the respect for human rights
has worsened, particularly in terms of freedom of expression and freedom of
the media. With a growing burden of debt and a large state deficit, there is a
need for economic diversification, reforms and macroeconomic stability. Poor
people are particularly affected badly by corruption and shortcomings in terms
of accountability. Unemployment among the young part of the population is
high (Swedish Government, 2018).

A functioning agricultural sector and markets are key to development, but at

the same time climate change and unsustainable use of natural resources have a
serious effect on the agriculture-dependent poor population and weakens their
resilience. The economic development is hampered since the access to
renewable and sustainable energy for the poor rural population is very limited
(Swedish Government, 2018).

Health care in Zambia

According to Government of the Republic of Zambia et al. (2015) the major
causes of child mortality in Zambia are malaria, respiratory infections,
diarrhea, malnutrition and anemia. Diarrhea is the third largest killer of under
five children in Zambia and it is estimated that 15 000 die every year as a result
of the disease (CIDRZ, 2015).

UN IGME (2020) reports that Zambia has an under-five mortality rate of

57.8%. In Zambia 13% of all deaths of children between 1–59 months are
attributable to diarrhea (Chilengi, Simuyandi & Beres, 2017).

10
For both primary and secondary care, the health care in Zambia is facing major
challenges. Absence of trained health personnel, limited access to and
knowledge of sexual and reproductive rights and services, and high
malnutrition among pregnant women and children are some of the problem
areas (Zambian Government, 2011).

A report that presents the List of Health Facilities in the country (MoH, 2012)
shows 1 956 health facilities recorded in Zambia. Eighty-eight percent of the
health facilities in the country are Government owned, 13% are owned by
private health facilities and 6% are owned by faith-based health facilities.

5 levels of health care in Zambia according to List of Health

Facilities in the country (MoH 2012).

Health Centre
There are two types of health centers in the health care delivery system
in Zambia. These include urban health centers or clinics (UHC), which
serve a catchment population of between 30,000 to 50,000 people; and
Rural Health Centre (RHCs)s, which a population of 10,000 people. In
2012, there were 409 Urban Health Centres and 1 131 Rural Health
Centres in the country.
Health Posts
These are the lowest levels of health care and are built in communities
far away from health centers. They cater for a catchment population of
approximately 3,500 in rural areas and 1,000 to 7,000 in the urban
settings and are set up within a 5 km radius for sparsely populated
areas. The types of health services offered at this level are basic first
aid rather than curative. There are 307 Health Posts in the country
Third Level Hospitals
Third level hospitals also called Specialist or Tertially Hospitals are the
highest referral hospitals in Zambia. These hospitals cater for a
catchment population of approximately 800,000 and above, and have
sub- specializations in internal medicine, surgery, pediatrics, obstetrics,
gynecology, intensive care, psychiatry, training and research. All
complicated cases not attended to at second level hospitals are referred
to third level hospitals. In 2012, there were 6 Third Level Hospitals in
the country.
Second Level Hospitals

11
 Second level hospitals, also referred to as Provincial or General
Hospitals, are found at provincial level. They are intended to cater for a
catchment area of between 200,000 and 800,000 people, with services
in internal medicine, general surgery, pediatrics, obstetrics and
gynecology, dental, psychiatry and intensive care services. These
hospitals also act as referrals for the first level institutions, including
the provision of technical back up and training functions. In 2012, there
were 19 Second Level Hospitals in the country.
First Level Hospitals
First level hospitals, also referred to as District Hospitals are found at
district level. In 2012, there were 84 First Level Hospitals in the
country.

Public Health relevance

Since diarrhea disease is the second leading cause of death for children under
five around the world with approximately 525 000 children under five are
killed every year by diarrhoea, it is a public health concern.

Children living in poor or remote communities are most at risk and evidence
shows children are dying from these preventable diseases because effective
interventions are not provided equitably across all communities (WHO, 2013).

The Sustainable Development Goal (SDG) 3 target to “Ensure healthy lives

and promote well-being for all at all ages” and also promotes that SDG aims to
be significant to all countries – poor, rich and middle-income.

To achieve the SDG 3.2, which targets to end preventable deaths in newborn
and under-five children by 2030 there must be a decrease in child mortality due
to diarrheal diseases (SDG-report, 2015).

12
Rationale

Globally, around 525 000 children under five are killed every year by diarrhea.
Only 44% of children with diarrhea in low-income countries receive the
recommended treatment (WHO/UNICEF, 2013). With a comprehensive
strategy that ensures that all children in need will receive critical prevention
and treatment measures it is possible to save the lives of millions of children at
risk of death from diarrhea (UNICEF/WHO, 2009).

If children’s lives can be saved with correct management of childhood

diarrhea, it is high relevance to focus on what kind of treatment the child gets
and what kind of care seeking actions the caregivers are taking. Treatment of
diarrhea and care seeking behavior is important to understand to be able to
prevent and implement right treatment actions, to reduce the risk for children
under five of dying from diarrhea

13
Aims and objectives

The purpose of this study was to identify what kind of treatment has been given
to under-five children with symptoms of diarrhea and what kind of care the
mothers sought, in Zambia.

Study objectives:

1. What proportion of children showing symptoms of diarrhea get

treatment, and what are the given treatments?

2. Where do mothers seek treatment?

3. How many children with symptoms of diarrhea were given zinc and/or
ORS respectively?

4. Does the treatment for diarrhea differ regarding geographical and

socioeconomic factors?

14
Method
Secondary data from the 2018 Zambia Demographic and Health Survey
(ZDHS) was used. The survey was implemented by the Zambia Statistics
Agency (ZamStats) in collaboration with the Ministry of Health (MOH). Data
collection was conducted from 18 July 2018 to 24 January 2019.

The Zambian survey had a stratified two-stage sample design. The first stage
involved selecting sample points (clusters) consisting of enumeration areas
(EAs). EAs were selected with a probability proportional to their size within
each sampling stratum. A total of 545 clusters were selected. The respondents
lived in following regions; Central, Copperbelt, Eastern, Luapula, Lusaka,
Muchinga, Northern, North Western, Southern and Western.

The systematic sampling of households was conducted in the second stage. In

all of the selected clusters a household listing operation was undertaken. An
average of 133 households were found in each cluster during the listing, from
which a fixed number of 25 households were selected to obtain a total sample
size of 13,625 households which is representative at the national, urban and
rural and provincial levels.

Eligible to be interviewed were all women and men age 15-59 who were either
permanent residents of the selected households or visitors who stayed in the
households the night before the survey. Response rate for the survey was
96.4%.

Sample
The first-born child under five was selected for the purposes of the current
study, to analyze what kind of treatment was given when showing symptoms of
diarrhea. Out of the first-born children (n=7048) we found that 1 289 children
had diarrhea during the last two weeks before the survey. The mother of the

15
child has provided the information concerning the child’s health.

Internal missing was 28% (n = 357) due to missing responses in the following
two variables: “Place first sought treatment for diarrhea” and “How many
days after the diarrhea began did you first seek treatment or advice?”

Variables of interest

Diarrhea: Showing symptoms of diarrhea, the last two weeks before the survey.
Rural/ urban: Living residence.
Economic status: The economic status of the household was measured with the
Wealth Index. The Wealth Index is calculated using easy-to-collect data on a
household's ownership of selected assets, for example radio, television and
bicycle and also materials used for housing construction; and types of water-
access and use of sanitation facilities. The individual households are placed on
a continuous scale of relative wealth from which groups are created that define
wealth quintiles as; poorest, poorer, middle, richer and richest.
Number of days after diarrhea for respondent to seek treatment or advice
First health care facility the respondent sought treatment at (for example health
post or hospital)
If receiving treatments
What kind of treatments
If receiving ORS and/or zinc

Data analysis
The sample, consisting of quantitative data from the ZDHS, has been analyzed
in IBM SPSS Statistics version 25, looking at the different variables
concerning treatment and comparing those findings with recommended
treatment by WHO/UNICEF and earlier research.

16
In the data analysis, cross tabulations were used to analyze the relationship of
the treatment children received with the demographic factors such as
rural/urban living, economic status of the household. A chi-square test was
used, and the significant level has been presented in the same table. A chi-
square test is used when the study has two independent groups with data at a
nominal level. It is based on the expected value compared with what was
observed in a cross table (Björk, 2012).

Ethical Considerations

Secondary deidentified data was used for this study, hence obtaining ethical
approval was not necessary. However, the survey has received ethical
permission from the National ethical committee in Zambia. All ethical rules
were strictly adhered and followed.

17
Results

Eighteen percent (n=1 289 children) of the first-born child had diarrhea during
the last two weeks before the survey whereas 80.6% (n=5 759) did not.

7000

6000

5000

4000

3000

2000

1000

0
No Yes Do not know

Figure 1. Firstborn children from 13 595 households who had diarrhea the last
two weeks before the survey.

Figure 2 shows that of the total sample (n=13 595) 60% were living in rural
areas and 40% were living in urban areas.

18
 40%

60%

Urban Rural

Figure 2. Living residence (urban/rural) for the total sample (n=13 595)

Of the children that had had diarrhea the last two weeks, 30% were living in
urban areas compared to 70% of the children living in rural area (Figure 3).

30%

70%

Urban Rural

Figure 3. Living residence (urban/rural) for children having diarrhea.

Figure 4 shows the economic status from poorest (21%) to the riches (21%) of
the total sample population.

19
Figure 4. Economic status of the households for the total population.

Figure 5 shows the economic status of the household for the children showing
symptoms of diarrhea during the last two weeks. 32% of the children with
diarrhea was living in the poorest households, 20% in middle-income
household and 11% in the richest household.

20
Figure 5. Economic status of household for the children having diarrhea.

Care seeking

The same day that the child showed diarrhea symptoms 25% sought treatment
or advice. However, most of the respondents (39.4%) answered that they
sought treatment or advice the following day (figure 6).

At some point during the first three days, 88.2% had sought treatment or
advice.

21
 400
350
300
250
200
150
100
50
0
The 1 2 3 4 5 6 7 10
same
day

Figure 6. Number of days with diarrhea for respondent to seek treatment or

advice.

Figure 7 shows that the first place to seek treatment for the child’s diarrhea is
at the Government Health Center (GHC). 66% sought treatment at the GHC
followed by 18% that sought treatment at the Government Health Post (GHP).
Nearly 90% answer that their first choice to seek treatment is at some
Government institution: Government Health Center, Government Health Post
or Government Hospital (GH).

22
 700
607
600
500
400
300
200 168

100 62
5 26 3 6 24 9 1 9 5 4 1 2
0

Figure 7. First place the respondent sought treatment

Treatment

Eighty three percent of the respondents answered that the children with
diarrhea received any type of treatment (figure 8). 71% answered that the
treatment was medical treatment.

Of the ones seeking treatment or advice outside their home, almost everybody
98% responded that they had received medical treatment. 17% of children with
diarrhea received no treatment at all.

23
 17%

No treatment

Any treatment

83%

Figure 8. Chidren that recives treatment

Figure 9 is showing what type of treatment that was given. The respondents
gave the children with diarrhea symptoms different treatments. Some gave
their children not only one but several types of treatments. 67% was given pre-
packaged ORS liquid or/and oral rehydration, 38% was given zinc, 20% was
given recommended home solution, 17% was given antibiotic pills or syrup
and 6% was given antimotility.

Under 5% of the children was given antibiotic injection, intravenous, home

remedy, herbal medicine, non-antibiotic injection, unknown injection and/or
other (not antibiotic, antimotility, zinc).

24
 1000
900
800
700
600
500
400
300
200
100
0

Figure 9. Type of treatment

Zink and ORS

Of the children with diarrhea symptoms during the last two weeks 38% was
given zinc while 67% were given pre-packed ORS liquid.

There was no significant geographical difference in receiving ORS (Table 1).

Also shown in Table 1, there was no difference in economic status in ORS
treatment.

25
Table 1. Comparison of children given pre-packed ORS and demographics.
Given pre-packed ORS
Type of place of residence No Yes Don't know

Urban 30.1% (n=116) 69.9% (n=269) 0% (n=0)

Rural 34.3% (n=310) 65.6% (n=593) 0.1% (n=1)

P-value 0,275

Econimc status No Yes Don't know

Poorest 34.3% (n=140) 65.4% (n=267) 0.2% (n=1)

Poorer 32.2% (n=97) 67.8% (n=204) 0% (n=0)

Middle 35.3% (n=91) 64.7% (n=167) 0% (n=0)

Richer 29.3% (n=54) 70.7% (n=130) 0% (n=0)

Richest 31.9% (n=44) 68.1% (n=94) 0% (n=0)

P-value 0,821

The chi-square test from table 2 showing relationship between zinc and
residence shows that it is not significant at the 0,556 level, at the same
table showing relationship between zinc and economic status we found that it is
significant at the 0,035 level.

Of the respondents that took their child to the GHC 52% received zinc as a
treatment for their child and 86% had pre-packaged ORS liquid as treatment
for their child.

26
Table 2. Comparison of children given zinc and demographics.

27
Discussion

Result discussion

The prevalence (18%) of diarrhea exposed in this study is comparable with that
of earlier studies (Kanté, Gutierrez, Larsen, Jackson, Helleringer & Exavery,
2015, Benson, Sepiso & Hikabasa, 2020).

The results show 67% of the children that had had diarrhea during the last two
weeks were given pre-packaged ORS liquid. UNICEF’s survey shows that in
2000 only 34% of children younger than 5 years in low-income and middle-
income countries (LMICs) received ORS to treat diarrhea. In 2016, the
proportion increased to 44%, yet the majority remained untreated (UNICEF,
2016). In many low-income countries, ORS for treatment of diarrheal diseases
in children has been reported to remain below 50%, despite available evidence
meaning that scaling up the use of ORS is a cost-effective way to highly reduce
preventable child death (Andrus, Cohen, Carvajal-Aguirre, El Arifeen &
Weiss, 2020).

Children with diarrhea should be treated with ORS, if not available then with
other fluids to help prevent dehydration (even though they are not as effective
in treating children who are already dehydrated). Breastmilk is also an
excellent rehydration fluid, which should be given to children still
breastfeeding along with ORS. Children with diarrhoea should continue to be
fed, in addition to fluid replacement, during the episode (UNICEF, WHO
2009).

In this study we see that more than half of the children gets treated with ORS.
However, it is still 33% of the children with diarrhea that does not get ORS. Of
the children, in this study, taken to the GHC 86% received pre-packaged ORS

28
liquid as treatment. In high-burden SSA-countries too many children are not
receiving adequate care for diarrhea, even among those seen in health facilities.
According to one study (Carvajal-Vélez, Amouzou & Perin, 2016), redoubling
efforts to increase care seeking and improve quality of care for childhood
diarrhea in both health facilities and at community level is an urgent priority.

This study showed that urban/rural living is not significant regarding treatment
with zinc, however, did it show that the relationship between zinc and
economic status is significant. Other studies show that rural or urban areas and
also household wealth has been determinants of the treatment-seeking behavior
for childhood diarrhea, where children in rural areas were less likely to receive
ORS treatment and zinc supplementation than those in the urban areas (Lee,
Huy & Cho, 2016; Kawakatsu, Tanaka, Ogawa, Ogendo & Honda, 2017).

Also, in UNICEF’s report (2013) we can see that children in the richest 20% of
households may be up to four times more likely to receive ORS when they are
sick with diarrhea compared to children in the poorest 20% of households.
Furthermore, Sood and Wagners (2014) found that poor children, in SSA, were
less likely to receive ORT than wealthy children – this effect was much
stronger in the private sector.

According to WHO/UNICEF (2009), Walker & Black (2010) and Buttha et al

(2000) children should also simultaneously receive zinc treatment, because it
reduces the duration and severity of diarrhea episodes, stool volume and the
need for advanced medical care. The information about the prevalence of zinc
treatment for childhood diarrhea is limited (UNICEF, 2012), only recently
questions on zinc use were added to household surveys. The limited data
indicate low use of zinc to treat childhood diarrhea. Also, in this study we
found that only 38% of the children with diarrhea symptoms during the last
two weeks was given zinc. 40.3% of the children living in urban area compared
to 37.5% living in rural area was treated with zinc for diarrhea (table 2). 37.7%

29
of the children living in the poorest households was given zinc and 49.3% of
the children living in the richest households was given zinc. We found that of
the children taken to the GHC 52% received zinc as a treatment. Ibrahim et al.
study in Nigeria (2020) showed that difference for zinc was not statistically
significant between urban and rural caregivers. Acceptability of zinc tablet was
significantly associated with the utilization of zinc plus ORS, caregiver’s age,
and educational attainment of respondents in both urban and rural
communities. Study shows that children are dying from these preventable
diseases because effective interventions are not provided equitably across all
communities (WHO, 2013).

This study shows that nearly 90% answer that their first choice to seek
treatment is at some Government institution: Government Health Center,
Government Health Post or Government Hospital (GH). However, according to
MoH (2012) 88% of the health facilities in Zambia are Government owned.
Bradley, Rosapep and Shiras study (2020) showed that 63% for of the
caregivers sought care out of home when child had diarrhea. The findings in
Munos et al study (2010) shows clearly that there is an important missed
opportunity to prevent child deaths due to diarrhea by making sure that health
care providers are managing childhood diarrhea appropriately, including
advising caregivers effectively about providing ‘good’ diarrhea management at
home and the importance of seeking care outside the home.

66% sought treatment at the GHC followed by 18% that sought treatment at the
GHP. Sood and Wagners study (2014) found that there was little difference in
treatment between rural and urban children in SSA that received care in the
public sector.

The distance to a health facility can be a contributing factor to the health

seeking behavior, which is lacking in our study. A study in Ethiopia (Godana
& Mengistie, 2013) pointed out distance as a barrier to seeking treatment.

30
Kantés et al. study (2015) in Tanzania showed children living 1 km from health
facility were more likely to receive delayed treatment, home care and/or no
care at all. Another study (Bagchi, Das, Dawad, Suraya & Dalal, 2020) in India
showed that the majority of women said that their family members did not use
public healthcare facilities, the main reason were no nearby facilities.

Different studies have shown that there is a good proportion of childhood

diarrheal cases being managed at home (Omore, O'Reilly Williamson, Moke,
Were, Farag & van Eijk, 2013), home management of diarrhea is preferable by
most people living in rural areas (Löfgren, Tao, Elin, Kyakulaga & Forsberg,
2012; Other, Orago, Groenewegen, Kaseje, & Otengah, 2008). Diarrhea and
treatment seeking behaviors in most rural communities still remain a major
challenge (Diaz, George, Rao, Bangura, Baimba, McMahon, & Kabano, 2013).
Also, UNICEF (2012) argues that it is the sickest children that lives in the
poorest communities, often has caregivers that provide medicines at home or
seek care outside the formal health sector, which could result in inappropriate
treatment and delayed care seeking.

Method discussion

The data being used is secondary data which made it possible to study the
treatment of diarrhea for children under five living in Zambia. Without
secondary data, this kind of study would not been possible. However,
secondary data can lack specific information for the particular study, since the
data was not collected to answer our questions.

The data showed us what kind of treatment children received and what kind of
action respondent took when child had symptoms of diarrhea. The data did not
show us if the action was depending on other symptoms, for example fever.
Which could be a care seeking trigger. Neither did the data tell us if the child
was breastfed. If the child got breastfed during the diarrhea symptoms it would

31
be interesting to see if the treatment differs. The study also lacked information
about the distance to different health facilities, which can be a contributor to
care seeking behavior.

Since both quantitative and secondary data is being used, we won’t get answers
about why the respondent seeks help and what trigger them to seek.

32
Conclusion

This study showed that the treatment and care seeking behavior for caregivers
to under-5 children is of public health concern. Less than half of the children
receives zinc as a treatment and 67% receives prepacked ORS. Availability and
accessibility of ORS and zinc to all children with diarrhea could save numerous
lives of children each year.

Increased efforts are needed, particularly since diarrhea still is the third largest
killer of under five children in Zambia. There is a need for education and
awareness campaign on the efficacy of ORS and especially zinc in preventing
diarrhea mortality.

Further independent study is recommended to identify where the gaps in

treatment and care seeking behavior is, to contribute to the UN Sustainable
Development Goals target 3.2.

33
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