Survey findings revealed information about knowledge, attitudes and practices relating to rotavirus and diarrheal disease. Table provides illustrative and representative comments with explanations below.
Representative quotes from focus-groups and interviews
A. Perceptions and knowledge of diarrheal disease
In all of the countries surveyed it was widely understood that serious diarrheal disease morbidity and mortality is a direct result of dehydration. Differences between the countries emerged in the level of concern about diarrhea and the priority of diarrheal disease as a public health problem.
In India, Indonesia, and Nicaragua, countries with relatively high under-five mortality and high diarrhea-related mortality (Table ), nearly all participants in interviews and FGD indicated that diarrheal disease was a serious and significant problem in their country, but that as a priority, diarrhea disease control has slipped.
Under-5 mortality rates and percentage of under-5 mortality due to diarrhea in survey countries
In these three countries the problem of diarrheal disease was often described as a reflection of larger cultural or socio-economic conditions. Poor hygiene and environmental conditions were seen as the major contributing factors to diarrheal disease, often exacerbated by under-educated or illiterate young mothers. Further understanding of the disease was greatly hindered in all of the countries by a lack of diagnostic capacity to identify the causal pathogens, and a lack of disease surveillance to determine the disease burden.
Despite this concern and the high level of importance placed on diarrheal disease, many expressed a perception that diarrheal disease was no longer receiving the attention it once had, and that previous diarrheal disease control education programs had languished or the focus had shifted to other health issues. In Nicaragua, India, and Indonesia there was a strong interest in renewed emphasis on preventing diarrheal disease through health education.
In Thailand, a middle-income country with lower levels of under-five mortality, diarrheal disease was seen as a relatively insignificant problem due to the wide availability of treatment and a high degree of community awareness of prevention and management methods. This view seems to contradict the data suggesting a relatively high percentage of under-five deaths caused by diarrhea (Table ). Hospital based physicians in Thailand considered severe cases to be problematic but infrequent. And most community-level health care workers perceived diarrhea as common and manageable, with most respondents at all levels indicating that severe dehydration and death from diarrhea were rare.
In Ukraine, opinions varied significantly as to the seriousness of diarrheal disease as a problem in that country, leading the research team to conclude that there was no consensus about the priority of diarrheal disease in Ukraine. Many of the Ukrainian respondents believed that diarrheal disease was not a major problem, and in instances of outbreaks, was thought to be well managed in in-patient and out-patient settings. However, certain medical and child survival specialists, and public health professionals at the national and regional levels (oblasts), voiced a contrary viewpoint, that diarrhea and dehydration were a serious problem for young children in Ukraine, despite low mortality from diarrhea.
In India, Indonesia, and Nicaragua, while rehydration therapies exist, several respondents indicated that many parents and caregivers wait too long to seek care, or are unable, or unwilling to do so and was an indicator of inadequate education about the disease and its potential severity. Some expressed a view that the delay often stems from parental beliefs that diarrhea is a common aspect of early child development, and was a sign of development and growth, which can lead to delays in care-seeking until severe symptoms occur.
B. Knowledge of rotavirus and rotavirus vaccines
In all of the countries, except for Nicaragua, awareness about rotavirus was extremely low. In fact, outside of university- or hospital-based pediatric and virology settings, rotavirus was an illness few in the broader public health community had heard of or knew anything about.
Those few with any familiarity with rotavirus did not differentiate it from other causes of diarrheal disease in terms of its transmission, prevention and treatment. They often expressed inaccurate information about the disease, and indicated, incorrectly, that improved hygiene and access to clean water would adequately prevent rotavirus. Many also indicated that ORT was a viable treatment option, however, in the face of severe disease, ORT is very difficult to administer outside of clinical settings due to the profuse vomiting that occurs.
In 2004 and 2005, Nicaragua and several other Central American countries faced an exceptionally severe rotavirus season. Several hundred deaths in the region led to declarations of public health emergencies, and significant public warnings and information campaigns to reduce the number of sick children[12
]. This helped sensitize the country to rotavirus, and certainly contributed to increased awareness among providers. Despite this high visibility, a number of participants expressed a lack of awareness about the disease. Not surprisingly, while few had heard of the disease, even fewer were aware of a vaccine or its potential.
Knowledge of rotavirus was so low in all countries that facilitators and interviewers were not able to test potential messages about rotavirus and the vaccine that might be used in building awareness about the disease. The respondents could not effectively respond without further information about the disease and the vaccine.
Regardless of their knowledge of the disease, discussions about rotavirus vaccines revealed some skepticism about whether or not the disease burden sufficiently warranted a vaccine. Even among knowledgeable pediatric specialists, lack of information about disease burden prevented them from making a judgment about the priority of the disease and the vaccine. In addition, in Indonesia and India several participants assumed that the vaccine would be expensive and likely out of reach financially for the poorest populations.
C. Other causes of diarrheal disease
In almost all instances, discussions about the cause of diarrheal disease centered around the transmission of diarrheal disease, such as poor hygiene and water. Almost no mention was made of specific pathogens, although among physicians and others with advanced public health training, there was acknowledgement that there are viral and bacterial causes.
All of the subjects identified poor sanitation and hygiene behaviors, such as unsanitary food handling and storage, lack of hand washing after latrine use, and improper waste disposal, as the most important and common causes of diarrhea. In addition, lack of access to potable water was also cited as a frequent cause of diarrheal disease.
Respondents in all the countries cited the lack of laboratory diagnostics and surveillance as a barrier to determining the type and causal agent of diarrheal disease, often leading to potentially inappropriate treatment recommendations.
D. Prevention of diarrheal disease
Prevention was closely linked to cause. Public education was cited as the most important prevention effort, with particular focus on parents, in order to improve hygiene practices and convey the importance of clean water. In addition, respondents cited education about exclusive breastfeeding of infants as another important preventive approach.
In Ukraine, educating food handlers in restaurants and shops was thought to be the most effective and efficient intervention to prevent diarrheal disease. In Nicaragua, there was interest in behavior change efforts aimed at parents to improve overall hygiene. In India, and to some extent Indonesia, there was strong interest within the public health community in renewing the focus on diarrheal disease prevention at the community and national levels.
In all of the countries findings indicated that community education campaigns were no longer being conducted to the extent and with the frequency they once were.
The use of oral rehydration solution was frequently cited as a successful treatment. In India, several respondents indicated that despite past public education efforts, use of oral rehydration therapy was relatively low. In Nicaragua, some participants indicated that many parents did not use oral rehydration solution appropriately.
In India, Thailand, and Indonesia, the use of various oral rehydration therapies such as milks, tea, water, juice and other liquids were often mentioned as important treatment methods.
In several countries ineffective and potentially dangerous diarrheal disease management practices were said to be practiced. In Nicaragua, India and Indonesia, in particular, purging with laxatives and other agents, stopping breastfeeding, massage, and withholding food and water were said to be common practices, particularly among low-literate populations. In all of the countries, inappropriate use of antibiotics and anti-diarrheal medications were also frequently mentioned.
F. Zinc treatment
Recent studies indicate that treating diarrhea with zinc can significantly reduce the burden of dehydration caused by diarrheal disease among children under 5 in developing countries [13
]. These studies suggest that 20 mg of zinc per day over 10–14 days at the onset of diarrhea can significantly reduce the duration and severity of the illness, stool output, and the need for hospitalization. Zinc may also prevent future episodes of the disease for up to 3 months, and has been shown to reduce the inappropriate use of antibiotics.
Questions and considerations of zinc treatment were added late to the discussion guide, as a result, discussions about zinc were conducted only in the interviews and FGD held in India, Ukraine, and Thailand. Participants were asked about their knowledge of zinc as an intervention for controlling diarrhea. Most indicated little or no knowledge of zinc as a treatment for diarrhea.