Assessment of the household availability of oral rehydration salt in rural Botswana

Introduction Diarrhea contributed for 17.6% of under-five deaths in Botswana. Oral rehydration salt (ORS) therapy has been the cornerstone in the control of morbidity and mortality secondary to diarrheal diseases. The study was aimed at assessing the household availability of ORS following the nationwide campaign of availing ORS at household level. Methods A cross sectional community based study was conducted in August 2012. EPI random walk method was used to identify households. Data was collected using interviewers' administered structured questionnaire. SPSS software was used in data entry and analysis. Results Oral Rehydration Salt (ORS) was available in 50.8% of the households with under-five children. Information on ORS is well disseminated whereas only three-fourth of informed participants had adequate knowledge of ORS preparation. The sources of information were predominantly the Child Welfare Clinic (88.8%). Being grandmother as a care taker was a negative predictor of household availability of ORS (AOR 0.25, 95% CI 0.09-0.69) while respondents who are knowledgeable about ORS preparation were more likely to have ORS available at home (AOR 1.92, 95% CI 1.10-3.34). Conclusion The campaign has brought a significant coverage in terms of availability of ORS. The health education and community sensitization efforts need to go beyond health facilities via other means like the media and community based approaches. Approaches aimed at improving the knowledge of care takers on the importance of ORS, its preparation, correct use and restocking are of paramount importance. Availing community based outlet for ORS is an alternative to enhance accessibility.


Introduction
Globally there were 6.9 million deaths of children under the age of five years in 2011. The causes in two-third of the deaths were preventable infectious diseases. The largest global burden of childhood death is found in Sub-Saharan Africa housing 23 countries with Under-five mortality rate above 100 deaths per 1000 live births.
The 2011 under-five mortality rate in Botswana was reported to be 26 deaths per 1000 live births [1]. A systematic analysis in 2008 estimated that the contribution of diarrheal diseases towards childhood mortality was 15% globally and 19% in Africa alone [2].
In 2007, Diarrhea and Pneumonia were reported as the major causes of under-five deaths in Botswana (17.6% and 14.7% respectively) [3].
Availability of ORS at community level has been shown to reduce diarrhea related mortality among under-five children [4]. Combining ORS with other interventions has also been shown to significantly increase the extent of reduction in diarrhea related morbidity [14].
Oral rehydration therapy has been the cornerstone in the control of morbidity and mortality secondary to diarrhoeal diseases since 1979.
With the increased use of ORS around the world, the overall mortality secondary to diarrhoeal disease has dropped dramatically [5]. In April 2012 the Ministry of Health of Botswana launched a national campaign to ensure that all households with children under the age of 5 years have ORS and Zinc tablets readily available at home. This approach was suggested in response to the increasing number of children presenting severely dehydrated to the health facilities with resultant deaths. The aim of this study was therefore to assess the household availability of ORS following the introduction of the nationwide campaign.

Study site and population
A descriptive cross-sectional study was conducted in Kweneng District of Botswana. According to the 2011 housing and population census, Kweneng district has an estimated total population of 304,674 with a density of 9.8 persons per square kilometer [15].
The study participants were recruited from Molepolole village which is the headquarters of Kweneng district. This village has a population of 67,598 [15]. The study was conducted amongst households in Molepolole with children under the age of 5 years.
The participants of this study were parents or guardians of children under the age of 5 years.

Sample size and sampling
The sample size was determined using EpiInfo 3.5.3 software. The coverage of the current ORS availability was assumed to be 25%.
There is no estimate for household availability of ORS and one quarter of the households with under-five children were expected to have ORS at the early phase of the nationwide campaign. With margin of error of 5% and 5% level of significance, a sample size of 288 was targeted. In the actual data collection, a sample size of 295 was attained. EPI-random walk method was used to select the households around the areas served by the 4 clinics in Molepolole.

Data collection and analysis
A questionnaire was adapted from the standard Demographic and Health Survey questionnaire [16]. The questionnaire was prepared and administered using the local language. Five enumerators trained on the data collection instrument collected the information. The principal investigators were involved in the supervision of the data collection. Data was collected between August 11-13, 2012.
Epi-Info software version 3.5.3 was used for data entry and descriptive data analysis while SPSS software version 20 was used for bi-variate and multi-variate analysis. Frequency, percentage and mean were computed to describe the findings. The crude and adjusted odds ratio (COR/ AOR) and 95% Confidence Interval (CI) were analyzed to explore associations and a p-value of 0.05 or less was considered statistically significant.

Ethical issues
Ethical approval was obtained from the University of Botswana

Institutional Review Board and Botswana Ministry of Health
Research unit. Permission was granted by the local administrators and written informed consent was secured from each participant before the conduct of the interview.

Results
A total of 295 care takers of children were enrolled in the study with mean age of 35 and a standard deviation of 13 years. The study participants were predominantly females with the large majority reporting some form of formal education. Mothers and grandmothers constituted one-third and one-six of the sample population respectively ( Table 1).
Over  The sources of ORS among the 150 households with ORS were the Child welfare Clinic (88%) and a public hospital (8.7%) while 3.3% did not specify the source (Figure 1)

Discussion
Reducing diarrhea morbidity and mortality isa key to achieving the fourth MillenniumDevelopment Goal of reducing child mortality by two-thirds by 2015 (MDG4) [17]. ORS therapy has been shown to play significant role in the reduction of child mortality secondary to diarrheal disease [4,5,14]. The findings from this study highlight the areas that need attention in order to improve knowledge, availability and use of ORS.
It is noted that while information on ORS is widely available, only three-fourth of informed participants had adequate knowledge of ORS preparation. Adequate knowledge refers to acquaintance to the method of reconstitution from the packet and daily preparation. A The study demonstrated that grandmother caretakers were less likely to have ORS at home. This calls for targeted health education efforts to increase knowledge and bring about behavior change among the grandmother caretakers. Participants who are knowledgeable about ORS preparation and correct use were more likely to have ORS available at home. Knowledgeable parents or guardians will make sure that ORS is available at home and use it appropriately. This makes increasing parents and guardian's knowledge about ORS much more imperative and a more effective way of ensuring that most households have a knowledgeable caretaker.
The study finding needs to be interpreted with some caution. The study did not directly assess the association between home availability of ORS and the treatment of children with recent history of diarrhea, and positive outcome of morbidity and mortality reduction. The use of non-probability sampling is also another limitation to note which will affect the generalizability of the findings to populations outside of the study area.

Conclusion
The