Control of deaths from diarrheal disease in rural communities. I. Design of an intervention study and effects on child mortality

Abstract

From May through October 1980, the "Strengthening Rural Health Delivery" project (SRHD) under the Rural Health Department of the Ministry of Health of Egypt had conducted an investigation into prevention of child mortality from diarrheal disease through testing various modules of Oral Rehydration Therapy delivery mechanisms. In a six-cell design counting a total of almost 29,000 children, ORT was provided both as hypotonic sucrose/salt solution prepared and administered by mothers and normotonic, balanced electrolyte solution in the hands of both mothers and health care providers and the effects on child mortality during the peak season of diarrheal incidence were measured. In addition, utilization and effects of ORT when made readily available through commercial channels was similarly examined. A cost-benefit analysis was performed on the cost of the services as well as on the outcome for each of five study cells using the sixth, the control, as reference. Results showed that early rehydration with a sucrose/salt solution in the hands of mothers, backed by balanced oral rehydration solution in the hands of health care providers proved the most cost-effective means of reducing diarrhea-specific mortality as well as being as safe as prepackaged commercial preparations.

PIP: A study design consisting of 2 control and 4 treatment cells was used to compare the effectiveness of different compositions of oral rehydration fluids and preventing dehydration and ultimately child deaths from diarrheal disease. Specifically, the extent of reduction in child mortality among 3 groups was compared: 1 group used a combination of oral rehdration therapy (ORT) prepared from the home ingredients of sugar and salt and administered by the mother and ("Oralyte") placed in the hands of the health care providers only; and 1 group used "Oralyte" only administered by both mothers and health care providers. Several data collection processes were employed to collect data on both baseline, intermediate (process), and impact (outcome) variables, including household surveys on demographic composition, sources of (drinking) water, incidence of diarrheal disease, knowledge and practice (KP) of mothers on diarrheal disease (DD) recognition and treatment regimen, availability of utensils and supplies necessary for the preparation of rehydration fluid, sodium concentration of randomly selected samples of home prepared rehydration fluids. In all study villages, the clerk in each health station maintained a regular count of the number of preschool children who had died within the preceding week. Age, sex, house number, and father's name were reported for each death. 2760 children (12.1%) of the total population under care in egypt's "Strengthening Rural Health Delivery" project were seen in the course of outpatient clinics during the 6 months of the program, May through October 1980. Overall, the rate of referral to secondary levels of care was almost 11 times higher in the control than treatment villages. From an initial level of about 22/1000 children per 6 months (May through October) in 1976-77, mortality dropped sigififcantly to a mean of 17.5/1000 in 1978-79 and to a mean of a mean of 10.5 by 1980 in the 3 treatment cells. A most important finding was the demonstration that ordinary household sugar and salt together with potassium containing fruits and vegetables or, intheir absence, tea, may serve as the basic ingredients of an alternative to, and temporary replacement of, the more costly and less readily available prepackaged ORS. This is not to suggest that a simple oral rehydration solution made from sugar and salt is as effective as the balanced "Oralyte", yet this simple solution when backed with adeqate supplies of "Oralyte" in the hands of the health care provider becomes a more cost effective means of reducing high child mortality from diarrheal disease than the "Oralyte" alone.