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Perceptions and practices of oral rehydration therapy among caregivers in Cork, Ireland

WHO defined diarrhoea as the passage of three or more loose or liquid stools per day (or more frequent passage that is normal for the individual). Worldwide, diarrhoeal diseases are a leading cause of paediatric morbidity and mortality, with 1.5 billion episodes and 1.5-2.5 million deaths estimated to occur annually among children under 5 years. 1,2 A substantial decrease in mortality is attributable to worldwide campaigns to treat acute diarrhoea with oral rehydration therapy (ORT). In highincome countries, implementation of ORT has not been as successful as in low-income countries. 3,4 Diarrhoeal disease or acute gastroenteritis (AGE) is very common in children and accounts for many emergency department visits and hospitalisations. 5 Approximately 10% of children under 5 years present to the health care services with AGE each year. 5 In Europe, the incidence of AGE ranges from 0.5 to 1.9 episodes per person per year with a higher risk for children under 3 years of age. 6

thereby exposing other hospitalised children to the illness or themselves contracting other nosocomial infections. Recommendations from the European Society for Paediatric Gastroenterology Hepatology and Nutrition/European Society for Infectious Disease (ESPGHAN/ESPID) published in 2008 clearly state that the first line of treatment of AGE should include oral rehydration with standard Oral Rehydration Solution (ORS), the composition of which is specified within same recommendations. 8,9 NICE emphasizes the use of ORS as the main stay in prevention and treatment of dehydration. Implementation of these guidelines on AGE management in children can lead to reduction in invasive procedures, hospital admissions, and hospitalization periods. 10,11 The morbidity and economic burden associated with AGE appear very significant. Families are the key to achieving the goals set for managing the disease by making the recommendations routine practice in the homes and health facilities.
There was a total of 369 paediatric admissions for AGE in 2016, with 88% being under 5s, in Cork University Hospital, a tertiary hospital in Ireland. There has been no study to ascertain the knowledge and use of ORT in Ireland, although AGE remains one of the major causes for admission in paediatric settings nationwide.
Studies have clearly shown that caregivers' responses and the use of ORT are aligned to their knowledge and attitude towards diarrhoeal disease and the therapeutic option. 12,13 The primary aim of this study was to evaluate the perception and use of ORT in the management of AGE, and secondary to increase the awareness and its use at the community level.

Study design and setting
This was a descriptive cross-sectional study, which ran from September to December 2016 in Cork University Hospital, a major tertiary teaching hospital in Cork, Republic of Ireland. Cork is the largest city in County Cork with approximately 126,000 inhabitants, with a density of 3,367 people/km 2 . 14

Study population, and sampling method
The study population consisted of parents/guardians, referred to as caregivers, of children attending the Paediatric Day Ward or Paediatric Outpatient Department in CUH. Only caregivers who voluntarily consented were included in the study. Caregivers whose children were admitted on the paediatric wards or seen in the emergency department were excluded. Using the sample size calculator Raosoft TM (Raosoft Inc., Seattle, WA, USA), 15 at a margin of error of 5%, confidence level of 95%, and a response distribution of 50%, the sample size was projected to be 377. Selection of the respondents did not substantially disrupt the consultation process because the interviews would start long before the start of consultation.

Data collection
A questionnaire consisting of 30 questions was originally designed by the first author to include all the study variables. To assess the feasibility of this study, a pilot study was performed on 15 respondents, but the results were not included for analysis. All respondents provided signed informed consent, prior to completion of the questionnaires. It took an average of 7 minutes to complete each questionnaire. No interpreter was needed.
ORS (dioralyte is the brand in Ireland) use was the dependent variable. Independent variables included socio-demographic data of caregivers (age, sex, residence, religion, employment status, number of children). Data was also collected related to the caregivers' knowledge regarding ORS, diarrhoea, and its clinical features of severity, and to the caregivers' attitude towards the use of ORS in the treatment of diarrhoeal disease.
The accepted definition of diarrhoea was represented by "frequent watery or loose stools".

Statistical analysis
Data were entered and analysed using Microsoft Excel 2010. For descriptive statistics, categorical data were analysed and results presented as proportions, percentages or frequencies. Numerical continuous data were analysed and results presented as means with their standard deviations. Correlations and comparison between groups of categorical data was done and results presented by use of chi-squared test. Statistically significant results were accepted at a p-value of less than 0.05.

Ethical approval
Permission to undertake the study was granted by Clinical Governance Department, Cork University Hospital, Cork. Approval from the Clinical Research Ethics Committee was not needed because of the nature of the study (on site questionnaire administration). All the respondents gave written informed consent. The questionnaires were anonymous; serial numbers were used for identification

Demographic data
A total of 402 caregivers answered the questionnaires. Most them were Irish (n=346) 86% aged between 30 and 39 years (n=135). Mothers filed in the questionnaires in most cases (n=333). 73.1% (n=294) were married, and 21% (n=84) were single parents. The majority (n=290) were employed or self-employed. 68.2% (n=274) had children less than five years old. The summary of the demographic characteristics is given in Table 1.     Figure 1.

Knowledge and perception of ORT
81.3% (n=327) of caregivers had heard of ORT, mainly from pharmacies (n=169), and relatives/friends (n=125). 91.7% (n=300) of caregivers correctly stated that ORT was used to prevent dehydration.  (Table 3). 54.1% (n=177) of the caregivers will present to the GP in the event of vomiting during rehydration with ORS at home.

Diarrhoeal experience and interventions
48.8% (n=196) of caregivers reported their children having diarrhoea at least once in the preceding twelve months. Diarrhoeal illness within the previous year was significantly more common in children younger than 5 years (p<0.001). 10.7% (n=21) were hospitalised following GP referral. The general ORT practices were very poor. Only 8.7% (n=17) used ORS as first line intervention at home. Other interventions were further reported in 7.7% (n=15) of caregivers: Lucozade sport (6 cases), Calpol (2 cases), plain water and Imodium in 3 and 4 cases respectively.

DISCUSSION
This study is the first in Ireland to assess the perceptions, knowledge and practices of caregivers regarding oral rehydration therapy (ORT).
As expected, the study sample was mostly represented by women in the age groups 20-49 years. Surprisingly the percentage of respondents who could give the correct description of diarrhoea was only 76.6%, likely accounting for a similar percentage (70.6%) aware of the seriousness of the condition.
The major source of information on ORT was from pharmacies, relatives and friends. It is interesting to reveal such a less number of caregivers receiving information on ORT from GPs or other health care providers. Other studies have shown that it is necessary to strengthen parents' knowledge about diarrhoea and its treatment during hospital consultations and through media. 16 Almost all respondents who knew about ORT (91.7%) correctly identified its function in preventing dehydration. However, most of the caregivers would rather initiate ORT when diarrhoea becomes continuous than at disease onset. An important finding was that although a high percentage of respondents (81.3%) knew about ORT, only 27.2% considered that ORT is efficient in treating diarrhoeal disease. Caregivers argued strongly that IV fluids and anti-diarrhoeal medication are better first line treatment options. This is like other studies, showing that parents prefer IV rehydration, and treatments that shorten diarrhoea duration. 17,18 The ORT practices found among the caregivers were generally poor. 73.7% caregivers reported to have used oral rehydration solutions (ORS) at some stage. However, out of 196 (48.8%) caregivers reporting diarrhoea in the preceding twelve months, only 8.7% (n=17) used ORS as therapeutic intervention at home. Also, the low percentage (37.6%) of caregivers who knew the correct formulation of Dioralyte shows insufficient knowledge on ORT. These data highlight the need for parental education on initial management of diarrhoea at home.
In this study, caregivers were seen to rely more on their GPs when vomiting develops during ORT 54.1% (n=177) of caregivers will visit the GP as next line of action when a child presents vomiting during ORT. Vomiting is a recognisable barrier to the effective use of ORT, as shown in other studies, mainly because caregivers are unaware of the need to continue ORT after the vomiting has subsided. 19 Although use of ORT does not reduce the incidence of diarrhoea, more than 90% of dehydration from diarrhoea can be prevented with its use, leading WHO to make it the mainstay of diarrhoea management. 20 In recognition of the fact that successful management of diarrhoea lies in the hands of well-informed caregivers rather than the health care system, the way forward is to support and inform caregivers about ORT so that they are more inclined to use it. Studies have shown that too many children are referred to hospitals, and that a significant number of the hospital admissions can be avoided. 21 Most children with diarrhoeal illness can and should be managed in the community, reducing health-care related costs and the risk of nosocomial infections. 22

Strengths and limitations
The major strengths of this study lie in the adequate sample, the 100% response rate and exclusion of caregivers of sick children, minimising perception bias. One limitation is related to the fact that the findings were based on self-reporting; it was however, designed mainly to indicate a pattern of perception and practice.

CONCLUSION
The observed reduced uptake of ORT appears to be a result of caregivers' insufficient information and/or negative perceptions on it.
There is need for educational and other support strategies for patients/caregivers to improve ORT practices. Application of evidence-based recommendations in the management of acute diarrhoeal illness in a local setting may significantly improve the quality of healthcare.