THE EFFECT OF HEALTH EDUCATION ON THE

KNOWLEDGE, ATTITUDES, AND PRACTICES (KAP) ON

THE MOTHERS ON DIARRHEA IN BARANGAY
PAGLAUN, DUMALINAO, ZAMBOANGA DEL SUR



A RESEARCH PAPER
PRESENTED TO
THE FACULTY OF THE
ZAMBOANGA MEDICAL SCHOOL FOUNDATION, INC.
ZAMBOANGA CITY


IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF MEDICINE






AIREEN M. CABATBAT


ZAMBOANGA MEDICAL SCHOOL FOUNDATION, INC.
MARCH 1999








ABSTRACT

This is an interventional study done to determine the effect of Health Education
on the Knowledge, Attitudes, and Practices (KAP) on mothers on diarrhea in Barangay
Pagluan, Dumalinao, Zamboanga del Sur. This study aims the following: to determine the
initial KAP of mothers before and after interventions; to determine the effect of an
intervention to the KAP of mothers; and at the sane tine, determine the incidence of
diarrhea in the locality. Mothers with children 0-5 years were the subjects of this study.
They were interviewed by the primary researcher with the help of two (2) trained
Barangay Health Workers using a questionnaire which was formulated after a Focus
Group Discussion (FGD). After giving the Health Education intervention, a post
intervention KAP was done to the same respondents, but only 124 from the initial 155
mothers were interviewed. The data were collated and analyzed using descriptive
analysis, Chi-Square Test, and paired students T-Test to determine the P-value with help
of the staff from Pediatric Research center for Mindanao (PRCM).

The initial KAP of mothers were determined. After the intervention, there were
significant changes especially in the knowledge of the mothers on the definition, causes,
complications of diarrhea, signs and symptoms of dehydration, and significance and
usage of oresol. It showed a mean P value of .000. Likewise, there was an effect to the
attitudes and practices of the respondent mothers. There fore, regular training on Health
Education is recommended, particularly to mothers who are the caregivers in the home
using different teaching tools like lectures (with visual aids prints and drawings), small
group discussion with audience active participation, and demonstration.



I. BACKGROUND

Each year, over two (2) million children in developing countries die from
diarrheal disease. Even if it is a preventable disease, it remains one of the major health
problems in these countries, like Philippines, making it a leading cause of illness and
death among children. About 80% of deaths are due to diarrhea with the highest mortality
in the first two years of life. The main cause of death from acute diarrhea is dehydration,
the loss of fluid and electrolytes in diarrheal stools. Diarrheal disease also represents an
economic burden for developing countries as more than a third of hospital beds for
children are occupied by patients with diarrhea.

Studies have shown that poor personal hygiene, poor environmental sanitation,
poor food and water handling practices contributed greatly to the prevalence of the
disease. A closer analysis of the results show that diarrhea is most common among the
poor. High rates of deaths and illness have direct correlation with poverty and lack of
education, specifically of the mothers.

The many causes if diarrhea necessitate a comprehensive control plan that aims a
change in the behaviors in the community, family and individual that may cause the
disease. The Department of Health (DOH) in coordination with WHO, started the Control
of Diarrheal Diseases (CDD) in October 1980. In 1987, the program was expanded to
incorporate preventive and control measures. The new thrust of the CDD program is the
emphasis on the three (3) rules of home therapy increased fluids, continued feeding and
timely care seeking. Much effort is directed towards the full empowerment of families
and communities to deal with the problems of their children with diarrhea. A national
control program for diarrhea can only succeed through the active participation of public
and private sectors in its formulation, planning, implementation, and evaluation.

Despite the CDD Program, diarrhea still ranked fist in morbidity, ninth in
mortality and second in infant mortality in Region IX as reflected in the 1995 Annual
Report of the DOH Regional Field Office 09, Zamboanga City.

The result of the survey conducted by the Dumalinao Group, a group of students
from the Zamboanga Medical School Foundation, last October 1995 in Barangay
Pagluan, Dumalinao, Zambonga del Sur, showed that diarrhea ranked second in
morbidity. This shows that the disease remains a big health problem in the locality.

Inspired by the CDD Program, 93.62% of the households were able to install
water-sealed toilets, 35.19% installed water faucets, while 49.79% have deep wells.
Despite these facilities, diarrhea still remains prevalent.






II. SIGNIFICANCE

In the Philippines, diarrheal dehydration is a major child killer. About 75%
diarrheal deaths in the country occur in under five years old children and 30% to 50% of
all pediatric hospitals admission can be attributed to diarrheal cases. These figures exist,
although diarrheal diseases are preventable and dehydration and its effects can be avoided
through Oral Re-hydration Therapy (ORT). And complication, as a cause of death, can be
easily prevented at home through ORT, continued feeding and increased intake of fluids
like water, breastmilk, am, and oral re-hydration solution.

Previous studies indicated that most diarrhea cases in the Philippines were
managed at home (79%). Only 16% of all diarrhea cases in this country were seen by
private practitioners and only 5% were brought to government health facilities.
Therefore, it is essential to reach parents and caregivers at home. In reaching out, the first
thing that we should do is to determine the effectiveness of the intervention that we are
going to apply. Knowing the initial knowledge, attitude, and practices of the mothers will
also help in determining points to be emphasized regarding diarrhea during intervention.
Hence, this study.

An intervention aims at both supplementing and enhancing caregivers
knowledge. It also corrects their misconceptions. Armed with the knowledge, mothers
can now properly identify if their children are having diarrhea and therefore can manage
them with ORT to prevent complications. Furthermore, this will aid them to identify
signs and symptoms of dehydration for them to decide when to refer or not. Lastly and
most vital, with the knowledge on the causes of diarrhea and its prevention, its
occurrence can be controlled.

III. OBJECTIVES

A. General

To determine the effect of an intervention on the knowledge, attitude and
practices of mothers in Barangay Paglaum, Dumalinao, Zamboanga del Sur
regarding Diarrheal diseases.

B. Specific

1. To determine the incidence of diarrhea in Barangay Pagluum, Dumalinao,
Zamboanga del Sur.
2. To determine the KAP of mothers on diarrheal diseases before and after an
intervention.
3. To determine if an invention has effects on the KAP of the mothers
regarding diarrhea.



IV. METHODOLOGY

A. Research Design

This is an Interventional Study of mothers in Barangay Paglaum, Dumalinao,
Zamboanga del Sur, regarding diarrheal diseases. Only mothers with children five years
and below served as subjects. A prepared questionnaire was used as a tool for this survey.

B. Subjects

1. Inclusion Criteria Mothers who have children five years old and below.
2. Exclusion Criteria Mothers who have children more than five years old,
but have no children five years old and below.

Convenience sampling was used in this study. Convenience sampling, a non-
probability sampling design, is a process of taking those members of the accessible
population who are easily available. All 155 respondents from the list of mothers who
have children 0-5 years old were interviewed for the KAP pre-intervention survey.
However, only 124 respondents were interviewed after the intervention. Thirty-one (31)
mothers were dropped because they could not be reached during the intervention and
post-intervention phases. Most of the dropouts were out of town during the period, while
the other have changed residence of nearby barangays and cities.

C. Research Setting

The study conducted in Barangay Paglaum, Dumalinao, Zamboanga del Sur,
Barangay Paglaum has a total land area of 133 hectares with terrain classified as plain
and hilly.

The survey conducted in October 1995 covered 1,276 or 94.07% of the 1,345 total
population. Of the 1,276 population, 688 were females and 608 were males. Of the 688
females, 320 (15 to 45 years old) were in the reproductive stage. The people were
distributed into six puroks: Malinawon A 217 residents, Malinawon B 309,
Maabtikon 280, Riverside 49, Badian 294, and Gemelina 127.

The residents get water from deep well, shallow wells, artesian wells, faucets, springs,
and from the rain. Excreta disposal is through water-sealed toilets.

For conclusion and other health needs, the people usually to the Rural Health
Unit.






D. Data Collection

Preparations and meetings were done during the first three years of community
exposure. Research assistants were recruited, trained on how to conduct an interview and
oriented on the study. Then Focus Group Discussion was done to 14 people from one
purok 9Riverside) in the barangay about diarrhea to gather information to be used in the
questionnaire. The questionnaire was then formulated, pre-tested and revised accordingly.
Then, it was translated from English to Bisaya, the predominant dialect in the
community, and translated back to English to make the questionnaire reliable. KAP pre-
intervention survey from house to house was conducted by two research assistants with
close follow-up. The collected questionnaires were manually coded for easy encoding at
the Pediatric Research Center for Mindanao.

The data were analyzed and results were evaluated to determine the focus of the
intervention. The Public Health Nurse was invited to conduct a lecture on the important
aspect of diarrheal diseases, particularly the significant points from the results of the
survey. For the lecture to be more effective, the speaker used visual aids (prints and
drawings). Other methods like demonstration on the preparation of oresol and small
group discussions were also applied. Likewise, pamphlets on diarrhea and packets of
ORS were distributed to the mothers. These materials/supplies were provided by the
Department of Health Regional Office IX, as requested. The primary researcher also
served as a lecturer during the health education seminar.

Previous experience on Health teaching showed that it was difficult to gather
people in one place, because of distance. Thus, the 7 puroks were divided into 2 small
groups. However, attendance still was not 100%. For those mothers who failed to attend
the small group sessions, the primary researcher with the help of Barangay Health
Workers (BHWs) conducted a purok to purok lecture using the same strategy.

The KAP post-intervention survey was given to the same respondents about a
month after the intervention. Only 124 out of the 155 respondents were interviewed. The
gathered data were encoded and analyzed. The pre and post-interventions KAP were then
compared and analyzed using descriptive analysis, Chi-square, and paired students T-
Test.












FLOW OF ACTIVITIES

Review Records at Health Center for Number of Diarrhea Cases

Conduct Focus Group Discussion (FGD)

Questionnaire Development and Translation


Pre-testing


Revision of Questionnaire

Finalization


Pre-Intervention KAP Survey


Analysis

Intervention (Health Education, CDD Program Mobilization)

Post Intervention KAP Study (1 month after)

Data Analysis

Review of Diarrhea Cases

Prepare Draft of Presentation

Presentation of Research Output














V. RESULTS

A. Demographic Profile

One hundred fifty-five (155) respondents were interviewed during the pre-
intervention phase, however only 124 subjects were interviewed after the intervention.
The demographic characteristics of the respondents are shown in Table 1. The
respondetns came from seven (7) puroks of Barangay Paglaum. Out of 124 respondents,
23.4% were from Purok Malinawon, 12.9% from Maabtikon B, 20.2% from Purok
Badian, 16.9% from Purok Subis, 10.5% from Gemelina, 8.1% from Malinawon A, and
8.1% from Riverside.

As shown in the table, the age of majority of the mothers (47.6%) ranges from 26 to
35 years old. It showed that 81 mothers or 65.3% grew up in Dumalinao, while the rest
were from the neighboring cities and provinces. Roman Catholic is the predominant
religion of the respondents accounting to 75.0%. Bisayan tribe accounted to 76.6% of the
mothers, followed by the Subanens (12.9%). As to educational attainment, most of the
respondents reached high school (34.7%), followed by those who only had elementary
education (29.8%). Sixteen point one percent (16.1%) graduated in college, 16.9% were
college level, while only 2.4% of the respondents had never attended school.

The table showed that more than 50% of the respondents have stayed in Dumalinao
for a decade or less, 68.5% were housewives, and 58.9% of the mothers have 1 to 3
children. Most of the families (50.0%) were earning less than P 2,000.00 a moth.






















Table 1. Demographic Characteristics of Respondents
n-124

Category Number Percent
Age
17-25 years old
26-35 years old
36-45 years old
46-65 years old

29
59
31
5

23.4
47.6
25.0
4.0
Place Grew Up
Dumalinao
Pagadian
Others

81
13
30

65.3
10.5
24.2
Religion
Roman Catholic
Pentecostal
Others

93
9
22

75.0
7.3
17.7
Tribe
Bisaya
Subanen
Ilonggo
Others

95
16
5
8

76.6
12.9
4.0
6.4
Highest Educational Attainment
College Graduate
College Level
High School
Elementary
None

20
21
43
37
3

16.1
16.9
34.7
29.8
2.4
Years in Dumalinao
0-10
11-20
21-30
31-45
46.88

63
29
15
15
2

50.8
23.4
12.1
12.1
1.6
Occupation
Housewife
Government Employee
Private Employee
Business
Farmers
Others

85
13
2
17
5
3

68.5
10.5
1.6
13.7
4.0
1.6
No. Children
1-3
4-6
7.12

73
38
13

58.9
30.6
10.5
Family Monthly Income
0 1,9999
2,000-4,999
5,000 9,999
10,000-14,999
15,000-19,999
20,000- 25,999

62
41
13
4
2
2

50.0
33.1
10.5
4.0
1.6
1.6


B. Incidence

In Barangay Paglaum, diarrheal disease was common among children aged 0-12
months (52.88%), followed by children aged two (2) years (16.35%).

Fig. 1 Diarrheal Cases By Age
October 1995 January 1999
Barangay Paglaum, Dumalinao, ZDS
Most of the cases were experienced by the male group (53.95%) compared to the
female group (46.05%).

Fig. 2. Diarrheal Cases By Sex
October 1995 January 1999
Barangay Paglaum, Dumalinao, ZDS


0
10
20
30
40
50
60
1 year
old
2 years
old
3 years
old
4 years
old
5 years
old
42
44
46
48
50
52
54
Male Female
May to July and January to February were the usual months most cases of
diarrhea occurred.


Fig. 3 Diarrheal Cases By Month
October 1995 January 1999
Barangay Paglaum, Dumalinao, ZDS

















C. Knowledge, Attitude, and Practices

Maternal knowledge on the definition of diarrhea has increased from 65.2% to 79.5%
with a significant P-value of .0034 after the intervention. Most of the respondents defined
diarrhea as the passage of water stool three of more times a day.

Table 2. Knowledge on the Definition of Diarrhea
Pre and Post Interventions
Chi-Square Test
n-124



Pre-intervention
Frequency %
Post-intervention
Frequency %
P-value
Passage of watery stool 31 25.2 35 28.7 .6069
Passage of stool 3 x a day 18 14.6 21 17.2 .7353
Passage of water stool 3 or more times a day 78 65.2 97 79.5 .0034*

* Significant p-value <0.05

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The knowledge on the possible causes of diarrhea are summarized in Table 3, 4, a
5 under the headings Behaviors that Increase the Risk of Diarrhea, Host Factors that
Increase the Susceptibility, and Environmental Factors that Contribute to Diarrhea.

Contaminated drinking water (77.2), contaminated food (36.6%), failure to wash
hands after defecating (34.1%), handling food without washing hands (30.1%), direct
contact with infected flies (29.3%), and failing to wash hands after handling feces
(22.8%) were the responses most of the respondents answered. The rates on the above
behaviors increased significantly after the intervention, as shown in Table 3. The
intervention also improved the knowledge of mothers on the good effect of breastfeeding
from 3.3% to 31.7%). Unfortunately, responses on teething increased form 5.7% to 7.5%
with a p-value of .7905, while indigestion got the same rate of 3.3% in pre-post
interventions. These are the usual misconceptions of the mothers on the causes diarrhea.

VI. DISCUSSION

The study that health education has an effect on the KAP of the mothers on
diarrhea. The respondents were able to understand the lectures, especially on the
definition, causes and complications of diarrhea, signs and symptoms of dehydration,
significance, preparation and usage of oresol, and the program of the government on
diarrhea. This may be attributed to the fact that the respondents are mostly educated
(97.6%). Only 2.4% of the respondents have no formal education. Also, the dialect used
during lecture was Bisaya, the predominant dialect (76.6%) in the barangay.

A high percentage of the respondents (79.5%) now know the definition of
diarrhea from the initial 65.2%. Diarrhea is defined in epidemiological studies as the
passage of three or more loose or watery stools in a 24 hour period.

There was also significant rise of knowledge on the causes of diarrhea as shown
in the tables. Initially, contaminated drinking water (77.2%) and contaminated food
(36.6%) were the most chosen answers by the respondents for behaviors that increase the
risk of diarrhea. The infectious agents that cause diarrhea are usually spread by faecal-
oral route.

After the intervention, aside from the previous choices, many respondents are
now aware (31.7%) and 20.0%) of the good effect of breast-feeding for children, as
preventive measure against diarrhea. Failure to breast-feed exclusively for 4 to 6 moths of
life and failure to continue breast-feeding until at least one year of age are under the
behaviors that increase the risk of diarrhea. Breast-fed babies are less susceptible to
diarrhea than artificially-fed babies. While breast-feeding plays an important role in
protecting babies and young children against a range of diseases, it is particularly
important in protecting against diarrhea, since the introduction of the breastmilk
substitute entails a risk of infection.

The rate on the knowledge on other causes of diarrhea rose after the intervention.
However, teething and indigestion (7.5% and 3.3%), to some mothers, are still causes of
diarrhea. This shows that some misconceptions can not be changed overnight. Therefore,
this can be emphasized more in the future health education.

On attitude, the percent increase was significant with a mean p-value 0.201. The
questions were more on the treatment and prevention of diarrhea. Initially, 48.4% of the
respondents believed that medicine is needed in the cure of diarrhea. The rate decreased
to 25.9%. This was so, because this was how it was explained during the intervention.
Proper hygiene, washing hands before eating and after defecating, drinking clean and
clear water, clean surroundings, and proper garbage disposal as preventive factors to
diarrhea were strongly agreed by the respondents. Preventive measures against diarrhea
were also tackled during the health education sessions.

Sixty point five percent (60.5%) from the initial 51.8% of the respondents now
filter their drinking water and 66.9% from 64.5% use boiling water as methods of water
purification. The changes in the practices were due to the emphasis made during the
lecture that contaminated water is one of the causes of diarrhea. Hand washing is also
practiced by them even before the study (99.2% to 100%). Containers were water is being
stored are washed everyday (66.9% to 69.4%). They usually wash the food before eating
934% to 46.8%), and flush the toilets after using (94.3%). Others do the cleaning of the
toilets everyday. The mean p-vale is significant in Practices.

After the intervention, 76.6% of the mothers use oresol when their children have
diarrhea (from 59.3%). Likewise, the mothers are now aware that when a child has
diarrhea intake of foods and fluids is necessary. During the intervention, it was
emphasized that dehydration as a complication can result.

As for the incidence, diarrhea is most common among children ages 0-12 months
old, and to the male populace. Similarly, as stated in Reading on Diarrhea Student
Manual, most diarrheal episodes occur during the first two years of life. Incidence is
highest in the age group 6 to 11 months when weaning often occurs. This pattern reflects
the combined effects of declining levels of maternally-acquired antibodies, the lack of
active immunity in the infant, the introduction of food that maybe contaminated with
fecal bacteria, and direct contact with human or animal d\feces when the infant start to
crawl. The diarrheal diseases occur mostly during the months of January to February and
May to July. Distinct seasonal patterns of diarrhea occur in many geographical areas. In
tropical areas, rotavirus diarrhea occurs throughout the year increasing in frequency
during the drier, cool months, whereas bacterial diarrheas peak during the warmer, rainy
season.

The time allotted for the study maybe enough, however sometime of the research
was used up in the relocation of the primary researcher. The respondents, sometimes,
could not be found at home when visited for interview. Going back and forth consumed a
lot of time considering the distance of the respondents from where the primary researcher
has been transferred.

Furthermore, during the intervention the attendance of the respondents during the
sessions most often was not perfect due to the occupation and other concerns of the
respondents to be attended to. The purok to purok method in reaching out the respondents
and the help of the Barangay Council, particularly the Barangay Captain, contributed a
lot.

VII. LIMITATION OF THE STUDY

The study did not look into the effect of intervention on the incidence of diarrhea in
Barangay Paglaum because of time constraint. No review of diarrheal cases after the
intervention.

VIII. CONCLUSION

An Interventional Study was conducted in Barangay Paglaum, Dumalinao,
Zamboanga del Sur. Two surveys, KAP Pre-Intervention Survey and Post-Intervention
Survey, were completed one after the other to determine the effectiveness of the study.
The results of the study showed a change of KAP among the respondents mothers, with
the highest impact on the K-Knowledge.

The KAP of mothers on diarrheal diseases were significantly improved after the
application of an intervention of Health Education.

It also showed that for an intervention to be effective different teaching tools
should be used, like lecture with visual aids (prints and drawings), small group
discussions with active participation by the participants and demonstration.


IX. RECOMMENDATION

1. The conduct of regular Health Education sessions if highly recommended,
particularly to mothers with children who are most susceptible to diarrheal
diseases. The health Education program should include sessions on the causes of
diarrhea, its prevention, usage of ORT, and the proper use of drugs. Corrections
of misconceptions should likewise be emphasized in the future sessions.
2. Health teaching should be at the level of the people.

X. DEFINITIONS OF TERMS

1. Diarrhea passage of three or more loose or watery stools on 24 hour period.
2. Knowledge awareness of the presence, prevention, control, and management of
diarrhea.
3. Attitude ones belief, point of view, and position with regards to diarrheal
diseases.
4. Practice the proper prevention and management of diarrheal diseases
5. Infant mortality the number of infants (newborn to one year) who die pers 1,000
live births
6. Mortality dealth due to a disease entity.

XI. BIBLIOGRAPHY

1. Improving Child Health
IMCI: The Integrated Approach, Division of Child and development World
Health Organization
2. Readings on Diarrhea by the Association of Philippine Medical Colleges
Foundation
3. Diarrhea Disease, Philippin Pediatric Society
4. Readings on Diarrhea, Student Manual
Programme for Control of Diarrheal Diseases
World Health Organization, Geneva
5. 1997 Annual Report, Department of Health, RFO IX
6. 1997 Annual Report, Department of Health, RFO IX3
7. Community Diagnosis, Barangay Paglaum, Dumalinao, Zamboanga Del Sur by
Medical Students of the Zamboanga Medical School Foundation
8. Oral Rehydration on the Philippines. A Case Study
9. 1995 Mid-Decade Goals for Filipino Children
A Call to Action Towards Phillipines 2000, UNICEF, United Nations Children
Funds
10. Fact Sheet, Oral Rehydration Therapy
11. Department Circular, no. 179 s. 1993, DOH