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Arlington, Virginia, Management Sciences for Health, Technologies for Primary Health Care [PRITECH], 1992. , 49,  p. (USAID Contract No. DPE-5969-Z-00-7064-00)In Mexico, focus group discussions were conducted with low-middle- and working-class mothers in Mexico City and Villahermosa to study their knowledge, attitude, and practices regarding the use of oral rehydration salts (ORS) to treat childhood diarrhea and to evaluate the mothers' reactions to a bottle of Pedialyte and a sachet of Vida Suero Oral. Common methods of treating diarrhea were home remedies, rice water, flavored cornstarch custard, ORS, much liquid, and drugs (e.g., Pepto Bismol). Mothers sought medical assistance when these methods did not work. They knew that dehydration is a serious result of diarrhea and that it can cause death. Mothers knew that fluids must be replaced to prevent dehydration. All mothers knew about Pedialyte and that it replaces fluids. ORS brands with which mothers were familiar were Pedialyte and Vida Suero Oral. Some myths included: ORS contains more substances than just sugar and salts; ORS is not harmful, so one can give children any amount; and Pedialyte is a soda. All mothers accepted ORS. An unpleasant, salty taste was the main constraint to using ORS, especially Vida Suero Oral. Vida Suero Oral takes too much time to prepare and to cool. Its preparation can be unhygienic. Mothers did not trust government health services, an obstacle to use of Vida Suero Oral. Since it is given free of charge, mothers were uncertain about its quality. They preferred prepared, bottled ORS. Characteristics of a new ORS preparation that mothers would consider favorable were found to be: pleasant taste, a bottle attractive to children, easy-to-remove cap, and a bottle size of 250-500 ml. Mothers wanted to buy ORS near their homes and in retail outlets. They learned about home remedies from mothers-in-law, grandmothers, other mothers, and friends. They learned about drugs from physicians. They were willing to pay Mexican $4000-6000 (US$1.20-1.60) for a bottle of prepared ORS.
Seattle, Washington, PATH, 1988. 40 p.The issues of oral rehydration salts (ORS) packet volume and label design must be carefully considered by managers of diarrheal disease control programs. Primary considerations in selecting the volume size are the source of ORS supply and the availability of household containers to measure accurately a predetermined amount of water. The World Health Organization (WHO) stresses the importance of choosing 1 volume to avoid confusion. Although the liter size packet is traditional, few commonly used household containers can be used to measure this amount; another disadvantage is that, since the total volume is not consumed in 1 serving, there is potential for contamination. Some countries have addressed the packet volume problem by distributing standard containers for measuring the water required for a given packet size. ORS label information must cover 3 components: marketing or identification, regulatory information, and mixing and use instructions. The 1st 2 components are intended for physicians and pharmacists, while the 3rd--and most important--is aimed at consumers. Package materials use as part of an oral rehydration treatment program can reinforce campaign themes or complement nonprint channels of communication such as radio messages.
Washington, D.C., National Academy Press, 1981. 22 p. (Contract AID/ta-C-1428)2 essential direct interventions in management of acute diarrheal diseases, oral rehydration and continued feeding, are summarized. Recent estimates of the global problem are that more than 500 million episodes of diarrhea occur yearly in infants and children under 5 years of age in Asia, Africa, and Latin America. 5 million deaths from diarrhea have been reported each year. Dehydration is the major cause of the immediate morbidity and mortality of children with diarrhea. Oral rehydration techniques may assist and reverse progression to severe dehydration and thereby are highly efficient in managing diarrheal disease. Formula selection, preparation of ingredients, distribution of oral rehydration solution, economic considerations, and cost-effectiveness of therapy programs are the primary concerns for those using oral rehydration. Formula selection should take into account the quantity of sodium, potassium, bicarbonate, and glucose in the formula. Preparations should be made so they can be done in the household rather than in national agencies. Centralized national packaging is recommended to standardize the salt/sugar mix. Measuring spoons and containers are also important in the packaging. Distribution should be accomplished by government or private agencies. The home preparation is the most economical. The effectiveness of the program is an important consideration. It is recommended that 2 different formulas be introduced into the community: a simpler lower sodium formula for home preparation and the more complex World Health Organization solution for supervised use in the health center. Continuation of feeding is important during and after diarrheal illness. Anorexia, nausea, vomiting, and abdominal cramps, may accompany acute infection. Cow milk may help produce symptomatic fermentative diarrhea, however breastfeeding should be continued. Fruits, vegetables, and sources of protein should also be fed to patients with diarrhea. Deleterious effects may occur if a patient fails to continue eating. A community system of surveillance and education should be developed to control diarrheal disease.
Report of the WHO/UNICEF Consultation on the National Production, Packaging and Distribution of Oral Rehydration Salts (ORS), Bangkok, January 23-26, 1979.
Geneva, Switzerland, WHO, 1979. 33 p. (ATH/79.1)The conclusions and recommendations reached by the participants at a joint WHO and UNICEF sponsored consultation on the national production, packaging, and distribution of ORS (oral rehydration salts) were presented. Also provided were separate country reports on the status of ORS production and distribution in Bangladesh, Costa Rica, Egypt, India, Indonesia, Mozambique, Pakistan, Philippines, and Thailand. The purpose of the consultation was 1) to identify the problems involved in national efforts to produce and distribute ORS and 2) to develop guidelines for the production, packaging, and distribution of the ORS. Oral rehydration therapy provides an effective method for treating all but the most serious types of diarrhoeal diseases and the treatment can be administered at home without medical assistance. Many countries are engaged in the production of ORS and at the present time there is considerable variation in the formulation, packaging, cost, and quality of the products. Recommendations were 1) the product should be packaged and identified as a drug in order to inspire confidence in the product; 2) national standards for the quality control of pharmaceuticals should be applied to the production of ORS; 3) eventually international standards for the formulation and quality control of ORS should be established; 4) bulk packaging of separate ingredients for use in large facilities is preferred; 5) efforts should be made to make ORS widely available especially in rural and isolated areas; 6) efforts should be directed toward developing a product with a long shelf-life; 7) all levels of health personnel should be trained in oral rehdyration therapy; and 8) evaluation of production and distribution systems should be promoted.
[Control of diarrheal diseases in Mexico and Latin America] El control de las enfermedades diarreicas en Mexico y Latinoamerica.
BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO. 1989 May; 46(5):360-7.Gastrointestinal infections are the most frequent causes of illness and death in children under 5 in most Latin America countries and in other developing countries. The simple and effective techniques now available to prevent death from diarrhea offer promise therefore of lowering overall pediatric mortality rates. Oral rehydration therapy is the single most effective treatment for control of diarrheal disease in children because most diarrhea deaths are directly related to dehydration. The discovery during the 1960s that intestinal absorption of glucose, sodium, and salt by the small intestine continued during diarrheal episodes gave scientific support to oral rehydration therapy. The World Health Organization estimates that up to 67% of diarrheal deaths can be prevented with oral rehydration therapy. Oral rehydration therapy can help prevent harmful treatments such as fasting and requires no laboratory controls. By the late 1980s, diarrheal control programs were in effect in over 90 countries, including all of Latin America except Chile. 20% of children with diarrhea receive modern treatment, thus avoiding an estimated 600,000 deaths annually. The World Health Organization formula for oral rehydration has been proven effective and safe for treatment of dehydration caused by diarrhea at any patient age. Early experience with oral rehydration therapy in Mexico and elsewhere demonstrated that it resulted in shorter episodes of diarrhea with fewer effects on nutritional status. The reduced need for hospitalization is another significant benefit or oral rehydration therapy. An estimated 60% of the population of Latin America has access or oral rehydration therapy. In late 1985 the rate of use was estimated at 20% for Latin America as whole but only 9% in Mexico. Research in Mexico indicated that the product name and packaging of oral rehydration packets were unattractive and intimidating to mothers. The new packaging has pictures of a healthy baby and the tree of life, a statement of indications for use (avoid dehydration due to diarrhea), and logos of institutions in Mexico's health sector. The package also provides simple instructions for preparation and use. In 1986-87 greater emphasis was placed on clinical training in use of oral rehydration therapy, communication, and increasing access. Selected personnel from each of the 32 Mexican states and territories received training in oral rehydration therapy in a hospital in Mexico City and returned to act as multipliers in their home states. Over 1700 health professionals were trained in 6 priority states. In 1986, efforts were initiated to promote use of oral rehydration therapy directly in the home. A 2nd survey showed that by 1987 the rate of use of oral rehydration therapy in Mexico had increased from 9 to 24%, but that some harmful practices persisted.
Resolution no. 3068 of 15 April 1986 on the conditions for the sale of products for oral rehydration.
INTERNATIONAL DIGEST OF HEALTH LEGISLATION. 1988; 39(2):433.Secs. 1-3 of this Resolution, which has been issued by the Director of the Public Health Institute of Chile, read as follows: "1. The products known as oral rehydration salts shall be sold directly in Type A and Type B establishments, this condition for sale being indicated in the labels of authorized products or products registered in the future. 2. Authorized packages shall contain an insert providing the following particulars: composition, indications, mode of preparation, directions for use, precautions, and the name of the manufacturing laboratory. 3. Any advertising or publicity text in respect of such products shall be submitted for the approval of the Department of National Control of the Public Health Institute of Chile, and shall provide simple and clear information on the prevention and control of infantile diarrheas and rehydration." (full text)
[Unpublished] . , 89 p.The use of oral rehydration therapy is often affected by local beliefs and behaviors in relation to the causes and cures of diseases. Folk beliefs may include diarrhea with diseases of the land, not amenable to modern medicine. They may consider it as due to an imbalance of hot and cold elements, breathing of the wrong air, exposure of the fetus to lightning, agitation of benign intestinal worms, the evil eye, fright, fallen fontanelle or various supernatural causes. In many places diarrhea is so common that it is considered a normal part of growing up. Beliefs about cures are as varied as beliefs about causes. Purgatives and herbal teas are commonly administered, and breast milk as well as other food is commonly withheld. When oral rehydration therapy is administered, it is often discontinued because it does not immediately stop the diarrhea. The lack of sanitation itself is often supported by folk beliefs, such as the idea that using latrines is like defecating in a house or that latrines give witches a chance to collect urine or feces of their enemies. Often adults use latrines, but children may defecate anywhere. Human wastes are sometimes used for fertilizer; kitchens are often located near latrines; and farm animals may share the family living quarters. Water is often polluted or contaminated at the source, or in storage, or when poured into unclean vessels; so that even if the mother understands how to mix the oral rehydration solution, both the water and the container may be contaminated. Oral rehydration salts may be rejected as therapy because they do not stop the diarrhea or because they conflict with a traditional remedy, or they are regarded as inferior medicines because they are not expensive enough. They may be rejected on the basis of taste or the color of the package. Standard measures are rarely available among the rural poor, so oral rehydration salts are more likely to be used successfully if they come in premeasured packets and/or with standard measures. Such items may add to the cost, but the additional cost is offset by the reusability of the containers. Graphics and logos on the packets will increase correct use of oral rehydration salts among illiterate people by showing in pictures what they are for and how to mix them. If mothers are too poor to buy the premixed packets, they can be taught to use the pinch and scoop method for measuring salt and sugar as long as some commonly used container of a standard size is available. Oral rehydration solutions may be distributed by physicians or pharmacists, but these people are usually too busy to explain correct use to mothers, so, unless trained community health volunteers are available, traditional healers should be thoroughly trained in mixing the solutions, especially since the traditional healers are usually trusted and accepted by the community. Since mothers are the group that has most need to know about oral rehydration therapy, an integrated media approach that reaches the mothers directly is recommended. The messages must be clear, simple, given in the local language, and carefully worded so as to overcome, but not conflict with, cultural barriers and beliefs. As illustrative examples of the promotion of oral rehydration therapy, successful experiences in Ecuador, Honduras, and the Gambia are recounted.
Uses of formal and informal knowledge in the comprehension of instructions for oral rehydration therapy in Kenya.
Social Science and Medicine. 1987; 25(11):1225-34.Information for using pre-mixed oral rehydrations salts solutions which have been made widely available in rural Kenya is normally printed on the packets in English, along with illustrations, and is either read or explained to the purchaser. This report found that comprehension of these directions could be improved with simple changes in the printed text that would reinforce prior knowledge and increase the effectiveness of the illustrations. The larger issue at stake is the need to develop long term health care remedies such as education and literacy, as well as short term. Oral rehydration therapy (ORT) was adopted as a short term way of combatting infant mortality due to diarrhea with explanation of ORT becoming the responsibility of village level health workers. This study suggests, however, that education including literacy, knowledge of environmental and biological causes of disease, and the ability to comprehend treatments is essential to long term health care goals.
[Washington, D.C.], Academy for Educational Development, 1985 Apr.  p. (Mass Media and Health Practices Field Note No. 14)Many children who die each year from diarrheal dehydration could be saved if they were given the oral rehydration salts (ORS) promoted in many countries today. But a common problem for diarrheal disease control programs is how to be sure that the correct amount of water is used in preparing the ORS. In Ecuador a practical and original solution was found that is economically feasible: a plastic bag which could be used as the liter measure. The bag is made of durabe polyethylene plastic, measures 6 x 10.5 inches, and costs US $.02 apiece when ordered in lots of 60,000. 1 side of the bag contains instructions on how to mix and administer the solution: 1) filling the bag with water to a clearly printed line; 2) emptying the water into another container; 3) pouring in the contents of 1 packet; and 4) mixing the salts. The bag also teaches the mother to give the child as much of the solution as it wants throughout the day and to continue breastfeeding and feeding soft foods throughout the diarrhea episode. Logo and instructions were pretested with rural mothers to insure that they were understandable and attractive. Laboratory tests were performed to determine proper strength of the bag. Community distributors instruct mothers in its use, and radio spots adivse mothers to bring dehydrated children to a clinic as soon as any signs of dehydration appear. This response to the measurement dilemma has proven to be a highly effective communication tool, as well as providing an accurate standardized measuring device.
In: Infant and child survival technologies, annual technical update No. 1 by Technologies for Primary Health Care Projects [PRITECH]. Arlington, Virginia, Management Sciences for Health, PRITECH Project, 1984 Sep. 15-8.WHO and UNICEF have recommended a universal oral rehydration solution (ORS) for the treatment of dehydration caused by diarrhea. Several features of this formula have been debated. Some pediatricians in developed countries have expressed concern about the sodium content of the solution, arguing that this can potentially cause an excess of sodium in the blood. However, when used properly, significant adverse consequences of the high sodium concentration (90 mmol/liter pf the solution) have not been demonstrated, and formulas employing lower sodium concentrations have not proven uniformly adequate in correcting dehydration. The replacement of glucose with sucrose in ORS has also been investigated. In the past few years, futher studies have been undertaken to investigate possible improvements in the ORS formula. For instance, a formula employing sodium citrate in the same molarity as the sodium bicarbonate has been proven effective in field studies sponsored worldwide by WHO. The citrate is now recommended for all packets as it extends shelf life. Other alternatives and supplements to the simple sugar in the formula are also under investigation. Solutions using rice-based starches have been demonstrated to be as effective in correcting dehydration as those using glucose or sucrose. In addition, the caloric intake is twice as high with rice-fortified ORS as with regular ORS. Research is under way to identify a super ORS in which the formula is modified to increase further the absorption of water and sodium from the intestinal lumen. Controversy over the potable quality of water for preparation of ORS continues. There is no evidence that bacterial contamination in any way changes the physiologic effectiveness of the resulting ORS solution. Recent studies show that boiling ORS does not change its compostion. Thus, to ensure the quality of water ORS can be boiled. More attractive ORS market presentations, e.g., ORS in tablet form, the provision of pre-mixed solutions in cheap containers such as those for juices, are being introduced in the commercial sectors of many countries. Uses of oral rehydration are reviewed for neonates, for hypernatremia and hyponatremia and other dehydrating conditions such as respiratory illness and dengue hemorrhagic fever and shock syndrome.
Lancet. 1976 May 29; 1(7970):1195.The main problem in instructing Indian mothers on how to prepare an electrolyte solution for oral rehydration was to teach them to use the correct amount of water. Most mothers tended to make the solution too concentrated, thus preparing hyperosmolar solutions, and incurring into the danger of hypernatraemia. To correct the problem small packets of glucose-electrolyte powder could be prepared, thus encouraging a small volume of solution to be made up at one time, and reducing the amount of contamination of the solution.
WHO Chronicle. 1979 Apr; 33(4):132.Sn a field study carried out recently in a rural district near Ankara, Turkey, (ORT) oral rehydration therapy was shown to be an acceptable and effective method in the management of mild and moderate degrees of dehydration in children suffering from diarrhea. In addition, the children given ORT gained comparatively more weight than those treated by conventional methods. Auxiliary nurse midwives were assigned during the study to provide ORT at home and to teach mothers to prepare the fluid. The ingredients--salts (sodium chloride, sodium bicarbonate, and potassium chloride) and glucose--were provided prepackaged, mostly by UNICEF. Some packages were prepared in the pharmacy of the University hospital. The trial was preceeded by an information drive to educate the mothers on the need for early administration of the rehydration fluid and the importance of feeding a child suffering from diarrhea. After the study, mothers were asked whether they would give the fluid to a child with diarrhea and they replied affirmatively, since children who drank the fluid felt better and ate better, and stopped crying and bothering the mother. The improved appetite may explain the weight gain. It was observed that the consumption of the oral fluid increased when its taste was good. Some locally made mixtures were not found to be as palatable as the one supplied by UNICEF, and this was reflected in the acceptance of the fluid by the children. Another interesting observation was the clear preference for the readymade packages rather than the "pinch and scoop" method. This method of estimating the amounts of sugar and salt, recommended in some pediatric textbooks, was not so well accepted by the rural mothers and the directions of the healthworkers were not followed carefully or willingly. In the Turkish experience, the utilization of ORT can be increased by: 1) participation of the community in the program with a major role played by young girls and mothers in popularizing this simple form of treatment; 2) provision of the ingredients in packages carrying health education messages to the mothers; 3) distribution of the packages through stores as well as the health services, to ensure the availability of the product even in small villages; and 4) inclusion of ORT in the medical school curriculum and adoption of this method of treatment in hospitals. (Authors' modified)
Nature. 1979 Mar 29; 278:389-91.Oral rehydration therapy now allows mothers to treat their children suffering from diarrhea by themselves by making a solution of glucose and electrolyte salts. Now that mothers need not seek treatment at hospitals or health centers miles away, the large % of childhood deaths from diarrheal disease can be controlled. This available therapy has allowed treatment, if not prevention, to be at every doorstep in the 3rd world. Studies now show tht a child regularly treated with oral fluids should be able to maintain good health. WHO and UNICEF are now spearheading a campaign to persuade 3rd world governments to introduce oral rehydration work into their primary health care activities. Delivery of this therapy to the villages remains controversial. WHO maintains that standardized packets should be prepared and sold through commercial channels or distributed through rural health centers; UNICEF wants to help in the distribution and in the production. The advantage of the prepackaged solution is that each ingredient would be properly measured in order to reduce complications. Criticisms of either approach rest on the assumption that the extent of rural poverty has not been adequately taken into account nor have the logistical difficulties of distribution. The suggested alternatives would be make the mother the focus of this treatment--she would make and administer the solutions herself. The sugar-salt solution is simple and almost as effective as the WHO standard mixture. To solve the problem of accurate measure, a special plastic spoon has been developed in Indonesia which measures the sugar and salt. While some maintain that no 1 method can be applied globally, others maintain that attempts to simplify the oral rehydration therapy should not happen too quickly. Local doctors must be included and must be convinced of the efficacy of the therapy if it is to be widely promoted.
AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 1980 Mar; 29(2):285-90.Sucrose-electrolyte oral therapy packets (1 liter) were distributed to a rural Bangladesh population of 157,000 by community-based workers and this effort was evaluated. A similar population of 134,000 served as a comparison group. The locally-produced packets showed satisfactory chemical composition with a shelf-life of up to 3 months and a cost of U.S. $.05. After 4 months, the workers were distributing an average of 70 packets/1000 population/month. Most patients used 1 packet/diarrheal episode; 13% of children used 2 packets, and 15% and 8% of adults used, respectively, 2 and 3 packets. The electrolyte composition of the oral fluids prepared by fieldworkers and mothers showed substantial variation, but no hyperconcentrated solutions were noted. When comparing the hospitalization rate from the 2 study areas, it appears that there was a 29% reduction in hospital stays for diarrhea during the 4-month distribution period. (Authors' modified)
Acceptability and use of oral rehydration salts: the development of user pamphlets and improved packaging.
[Unpublished] 1982 Feb 23. 8 p.A major problem facing diarrhea disease control programs is to train mothers of children under 5 in the correct use of oral rehydration salts. The authors have approached this problem in 4 Asian countries: Bangladesh, Indonesia, Philippines, and Thailand. The work was performed by indigenous groups in each country: Social Marketing Project (Bangladesh), Yayasan Kusuma Buana (Indonesia), Kabalikat Ng Pamilyang Pilipino (Philippines), and Population and Community Development Association (Thailand). The authors methodology has been to use the technique of focus group discussions to develop instructional pamphlets and improved labeling for oral rehydration salts. The pamphlets and packages that have been developed are now in field testing and should be introduced into wide scale distribution in the near future. In addition to developing pamphlets and packages that have high levels of comprehension, the focus group discussions have also yielded important insights about the devliery of oral rehydration therapy. The authors have been able to identify widely available, uniform volume containers that mothers can use to prepare ORS. The authors have identified a simple 3 diagram illustration for ORS preparation that is highly effective. The authors have determined that dosage is the most difficult message to transmit. Materials for service providers should be developed next, since many providers are uniformed, apathetic or antagonistic to the use of ORS. (author's, modified)