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Pakistan Journal of Nutrition 1(3): 143-150, 2002
© Asian Network for Scientific Information 2002
143
Update on ORS Usage in Pakistan: Results of a National Study
Donald E. Morisky, Snehendu B. Kar, Abdul Sattar Chaudhry , Kai Ren Chen,
1
Magda Shaheen and Kirstin Chickering
Department of Community Health Sciences, School of Public Health, University of California,
Los Angeles 650 Charles E. Young Drive South, Los Angeles, CA 90095-1772, USA
Ministry of Health, Government of Pakistan, Islamabad, Pakistan
1
Abstract: Diarrhea disease continues to rank as one of the leading causes of child mortality throughout the world. It is
estimated that 1 billion episodes of diarrhea occur in young children each year, The World Health Organization has recommended
the use of oral rehydration solution (ORS) for the treatment of dehydration associated with diarrhea. Numerous studies have
documented the effectiveness of ORS in treating diarrhea and reducing mortality. Diarrheal disease in Pakistan has been
identified as the major cause of child mortality in Pakistan, accounting for an estimated 200,000 - 300,000 deaths each year.
This paper reports the results of a nationwide survey conducted in Pakistan to obtain information regarding the practices of
mothers concerning child health care and factors that influence these practices. The purpose of the survey was to collect
baseline data on a variety of issues, in order to develop effective health education programs and evaluate ongoing ones. Within
the context of two theoretical models (diffusion of innovation and stages of change), adoption practices of the population with
respect to use of ORT treatment are described and assessed. These results pose new challenges to health care professionals
in their ability to influence and persuade adoption of effective public health practices. Recommendations are provided as how
to modify the misconceptions of mothers with young children in the treatment of diarrhea.
Key Words: ORS, diarrhea, theory, behavioral determinants
Introduction
Diarrhea is one of the leading causes of child mortality in many
developing countries. It is estimated that diarrheal diseases cause
3.3 million deaths annually among children under the age of five
in the developing world (Bern et al., 1992), accounting for 23% of
child mortality worldwide. An estimated 1 billion episodes of
diarrhea occur in young children each year, equivalent to 2.6
episodes per child per year (Bern et al., 1992; Gadomski et al.,
1988).
Diarrhea in developing countries is caused by a variety of bacterial,
viral, and parasitic pathogens; some of the most common are
rotavirus, E. coli, campylobacter, shigella, and salmonella (Taylor,
1993). The health consequences of frequent or persistent diarrhea
can be severe, including malnutrition and impaired growth and
development (Chen and Scrimshaw, 1983). Moreover, diarrhea
can be viewed as both a cause and an effect of malnutrition since
it can be difficult to determine whether diarrhea precedes
malnutrition of vice-versa in individual cases (Walker-Smith, 1993).
Diarrheal episodes can lead to a dangerous spiral of illness because
diarrhea impedes growth and malnutrition increases the frequency
of diarrhea (Guerrant et al., 1992).
The World Health Organization recommends the use of oral
rehydration solution (ORS) for the treatment of dehydration
associated with diarrhea (WHO, 1991). Numerous studies have
documented the effectiveness of ORS in treating diarrhea and
reducing mortality (WHO, 1997; Varavithya et al., 1991; Richards
et al., 1993). ORS is particularly appropriate for the treatment of
diarrhea in the developing world because it is inexpensive and can
be administered in the home.
Improved use of ORS in conjunction with appropriate feeding
practices could markedly reduce the morbidity and mortality
associated with diarrhea. For this reason, ORS education and
distribution programs have been implemented throughout the
world, increasing the availability, accessibility and afford ability of
ORS (Merson, 1986). Yet despite the widespread availability of
ORS, many mothers continue to use alternative therapies to treat
childhood diarrhea or they use ORS incorrectly (Merson, 1986;
Hudelson, 1993; Mull et al., 1988).
Many factors contribute to the failure of some populations to
adopt ORS, but one of the most important is a paucity of social
support for the behavior. Cultural beliefs and practices may
encourage the use of traditional therapies, and disagreement
among health care providers about which treatment is best may
further impede the adoption of oral rehydration therapy in some
societies. The inappropriate use of antibiotics to treat diarrhea has
become commonplace in many developing countries because
doctors continue to prescribe them unnecessarily, many women
believe this is the only appropriate treatment for illness (Hudelson,
1993).
Modern pharmaceuticals are readily available without a prescription
in many developing countries. A study in the Philippines
demonstrated that most childhood illness were treated without
the advice of a physician, yet half of these treatments involved the
use of pharmaceuticals (Hardon, 1987). Another study in India
showed that, even when physicians were consulted, prescription
practices were inappropriate and sometimes dangerous
(Greenhalgh, 1987). Paredes et al., 1996 identified physician
prescribing practices for Peruvian mothers who brought their
children to the health center for diarrheal management. Most
physicians reported that family members usually expect to receive
a prescription when they visit a physician. If a prescription is not
given, the physician would be considered to lack experience or to
'know nothing about treating diarrheal disease'. Furthermore,
mothers who reported receiving 'only' ORS left the consultation
often unhappy or frustrated. They reported that this was
because they did not receive a prescription but only ORS (Paredes
et al., 1996).
ORS promotion in Pakistan: Diarrheal disease in Pakistan has been
identified as the major cause of child mortality in Pakistan,
accounting for an estimated 200,000 - 300,000 deaths each year
(Lambert, 1986). Nearly 50% of child hospital admissions are
related to diarrhea. Furthermore, a recent survey found that
14.5% of children under the age of 5 years had experienced an
episode of diarrhea during the preceding 24 hours (UNICEF, 1991).
Rates were highest among children under one year of age, and
declined steadily with age. The need to promote appropriate
treatment of diarrhea, especially in young children, is clear.
In 1984, the Government of Pakistan launched a program to
control diarrheal diseases (CDD). The program has promoted the
use of ORS through an intensive public health education campaign.
Previously conducted surveys have indicated that knowledge
concerning ORS has been steadily rising, from 38% in 1984 to
more than 85% in 1987 (ORS-KAP Survey, 1987). However, while
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
144
Fig.1: An integrative model of diffusion of innovation and the transtheoretical model
awareness of ORS remains high, ORS use lagged significantlyinnovation, as perceived by the members of a social system,
behind. A nationwide survey of about 5000 Pakistani households which determine its rate of adoption. These factors include
commissioned by the Pakistan Ministry of Health in 1987 foundrelative advantage, compatibility, complexity, trial ability and
that 90% of those interviewed knew that a 1-liter packet of ORS observ ability. A more recent health education and health
should be mixed with 1 liter of water. However, detailedpromotion diagnostic framework (PRECEDE/PROCEED) developed
questions regarding the preparation and administration processby Green and Kreuter, 1999 addresses these issues and identifies
were not asked. Mull and Mull (1988) state that WHO's currentspecific factors in the adoption process, including various
estimate that ORS is being used `effectively' by 80% of diarrhea predisposing, enabling and reinforcing factors which can help
cases is much too optimistic, at least for Pakistan. explain why mothers do not translate their knowledge of ORS into
Theoretical framework: The Diffusion of Innovation Modeltwo theoretical constructs and potential linkages of stages of
provides a useful framework for examining the adoption of ORST behavioral change in the models. The current study presents an
in Pakistan. This model categorizes individual behavior change into opportunity to link and test these two classical models with
five stages: awareness, interest, persuasion, decision, andempirical data.
adoption (Rogers, 1971). Individuals pass through these stages
and adopt new behaviors at different rates. The model classifies Background of Pakistan: Pakistan is the seventh most populous
these different rates of adoption by dividing the population into
five groups: innovators, early adopters, early majority, late
majority, and laggards (Rogers, 1971). When a new behavior is
introduced into a population, the cumulative curve follows an S-
shaped rate of adoption, as more individuals reach the fifth stage
and adopt or internalize the new behavior.
The Diffusion of Innovation Theory is closely linked to the
Transtheoretical Model of behavior change (Prochaska et al.,
1984). Prochaska and DiClemente have identified five stages of
change through which an individual must pass before achieving
behavior change precontemplation, contemplation, preparation,
action, and maintenance. Both Diffusion of Innovation Theory and
the Transtheoretical Model are based on the assumption that
individuals pass through several stages before successfully
achieving behavior change. The major distinction between these
two models is that the Transtheoretical Model limits examination
of behavior change to the individual level, while Diffusion of
Innovation goes beyond the individual to describe behavior change
in a population. The Transtheoretical Model has traditionally been
used to analyze the cessation of addictive behavior from a
psychological perspective. However, if the Transtheoretical Model
is expanded and viewed from a community/public health
perspective, the two theories appear to have many shared
components. Rogers has conceptualized the characteristics of an
taking action. Fig. 1 presents the comparative features of these
country in the world, with an estimated population of 125 million
in 1995. The country is divided into five provinces. Punjab is the
most densely populated with 55% of the population, followed by
Sindh with 22% of the population. The two least populous
provinces are North West Frontier Province (NWFP), with 13% of
the population, and Balochistan, with 5%. Approximately 70% of
the population is rural, and 90% is Muslim.
In 1991 and 1992, a nationwide survey was conducted in Pakistan
to obtain information regarding the practices of mothers
concerning child health care and factors that influence these
practices. The purpose of the survey was to collect baseline data
on a variety of issues, in order to develop effective health
education programs and evaluate ongoing ones. Several of the
survey questions addressed knowledge, attitudes, beliefs and
practices regarding ORS. Several other questions were designed
to gather information about the respondents' sources of health
information. Taken together, these two components of the
survey can help to direct the development of an anti-diarrhoeal
treatment/ prevention program in Pakistan.
Materials and Methods
The Pakistan Health Education Survey (PHES) was conducted
throughout the entire country during October 1991 and February
1992. The major objective of the survey was to collect
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
145
Table 1: Number and Percent of Primary Sampling Areas(PSUs) by according the 1981 population census, namely Karachi, Lahore,
Urban and Rural Areas and Total Sample Size
Urban Rural Total Total Sample Size
Province/Area
Punjab 48 72 120 2400
Percent 40 60 45
Sindh 30 30 60 1200
Percent 40 60 22
N.W.F.P. 16 24 40 800
Percent 40 60 15
Balochistan 12 18 30 600
Percent 40 60 11
AJK 8 12 20 400
Percent 40 60 7
TOTAL 114 156 270 5400
Percent 42 58 100
information on health-related knowledge, attitudes, and maternal
and child health concerning practices of women with children
under two years of age. This information will provide baseline
data on which to initiate new programs as well as to evaluate
ongoing health education and service delivery activities.
The design for this survey is a stratified, clustered and systematic
sample of households. The universe consists of all urban and rural
areas of the four provinces of Pakistan and Azad, Jammu and
Kashmir (AJK), defined as such by the 1981 Population Census.
The universe excluded military restricted areas, areas of D.G. Khan
District, Kohistan, Chitral and Malakand Districts as well as the
Federally Administered Tribal Areas (FATA), because of
governmental restrictions and safety of visiting health nurses.
The population of these excluded areas constitute approximately
4 percent of the total population. The population of the survey
covers mothers with children 2 years of age or less and is
estimated to be between 6-7 percent of the total population of
120 million.
Sampling frame-urban domain: The sampling frame for the urban
domain consists of lists of enumeration blocks provided by the
Federal Bureau of Statistics. Each city or town had been divided
into a number of small areas called Enumeration Blocks. Each
Enumeration Block is a compact area consisting of 200 to 225
households on the average with well-defined boundaries recorded
on the prescribed forms. Each Enumeration Block is demarcated
on the map with physical features describing the locality and
physical features.
Sampling frame-rural domain: The sampling frame for rural
domains consists of all mouzas/dehs/villages prepared by the
Population Census Organization as a result of the 1981 Population
Census. A mouza/village/deh is the smallest revenue estate
identified by its name.
Several factors were considered in determining the sample size of
the survey, including: the main objectives of the survey, level of
estimate, acceptable level of error in the estimate, proportionality
of study population, strata/sub-strata requirements, minimum
number of observations, time and resource constraints, and
coverage problems. Table 1 presents the distribution of samples
in the urban and rural domains of the four provinces and AJK
according to the Primary Sampling Area (PSU). Approximately 20
households were surveyed within each PSU.
The total sample size of 5,400 eligible respondents (women having
children equal to or less than 2 years of age) was expected to
provide valid reliable estimates at national level of key variables
with a +/- 5% coefficient of variability at the 95% confidence
level.
Stratification Plan: In consideration for the level of estimates
desired and required heterogeneity in the population, stratification
has been done according to self-representing cities, by urban and
rural areas. Cities having populations of 500 thousand and greater
Faisalabad, Gujranwala, Rawalpindi, Multan, Hyderbad and
Peshawar have been taken as self-representing cities. Islamabad,
the national capital and Quetta, a provincial capital have been
specially considered as a self-representing city (SRC). Each of the
SRC's constitute an independent or explicit stratum. After
excluding the population of SRCs from the respective districts of
a province, the remaining urban population in each division of the
Punjab, Sindh, N.W.F.P. and Balochistan Provinces have been
grouped together to form another stratum in all the four
provinces of Pakistan. Each SRC was further divided into three
sub-strata according to low, middle and high income groups based
on the information collected from each Enumeration Block at the
time of demarcation and updating of the urban sampling frame.
Rural populations of each District in the Punjab, Sindh, and
N.W.F.P. Provinces have been grouped to form a stratum. For
Balochistan Province, each division has been considered as a
stratum.
Sample Design: A two-stage stratified sampling design was
adopted for the survey. The sample PSUs from each urban
stratum were selected with a probability proportional to the
number of households. The sample PSUs from each rural stratum
were selected with a probability proportional to the population
enumerated in the 1981 census. The second stage of sampling
consisted of selection of households in the selected cluster, done
on a random basis. Standardized sampling procedures were used
to identify households in each cluster. The interview team went
into the middle of the cluster and through a randomized procedure
determined the starting quadrant for the first household. The first
house was selected by the first digit of a currency note.
Thereafter, each door was approached to find an eligible
respondent.
Questionnaire: The PHES questionnaire was developed by a multi-
disciplinary team of experts from the Ministry of Health, including
health education experts, members of the Federal Communication
Advisory Group, program managers of various categorical
programs (TB Control, Expanded Program on Immunization,
Center for Diarrheal Disease, etc.), international agencies, and
technical experts. The questionnaire was translated into the
national language, Urdu, and pre-tested prior to its
implementation. The content areas of the questionnaire included
background socio-demographic characteristics, breast feeding
practices, knowledge, attitudes and practices concerning
diarrhoea, immunization, malaria and smoking. Questions
concerning knowledge about AIDS, and its routes of transmission
were also asked of each respondent.
Recruitment, Training and Fieldwork: Health education supervisors
from each of the four provinces and AJK were trained during a
three-day session in the Ministry of Health, Islamabad. These 17
individuals were instructed in the techniques of interviewing,
probing, and monitoring. Regional training was conducted in five
areas of the country, in which health education supervisors
trained a total of 64 lady health visitors who conducted the
interviews with the mothers. All interviewers were female. The
fieldwork began in November 1991 and concluded in February
1992. A 10% random sample of interviews were field checked by
the health education supervisor following each days work.
Throughout the survey, health education staff in Islamabad
monitored closely all 16 teams by direct communication and spot
checking. All questionnaires were transcribed to data coding
sheets by field supervisors and express mailed to Islamabad for
data entry. Coding sheets were also randomly checked with the
original questionnaires and incorrect entries were less than 0.1%.
Data Entry and Cleaning: All data were entered an IBM personal
computer using an SPSS-PC Data Entry II software program
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
146
Table 2: Demographic Characteristics of the Sampled Population Table 3: Percent of Best Treatment for Diarrhea, by Province,
Demographic Data NPercent
TOTAL 5433 100.0%
Province
Punjab 2406 44.3%
Sindh 1176 21.6%
N.W.F.P. 812 14.9%
Balochistan 640 11.8%
AJK 399 7.3%
Residence
Rural 3167 58.3%
Urban 2266 41.7%
Age
15 - 19 196 3.6%
20 - 24 1063 19.6%
25 - 29 1842 33.9%
30 - 34 1303 24.0%
35 - 39 740 13.6%
40 - 44 236 4.3%
45 - 49 53 1.0%
Education
None 3953 72.8%
Primary 574 10.6%
Middle 298 5.5%
>=Secondary 608 11.2%
Monthly Income
< RS 1,000 1727 31.8%
RS 1,000 - 1,999 1613 29.7%
RS 2,000 - 3,499 1018 18.7%
RS 3,500 - 4,999 346 6.4%
> RS 5,000 293 5.4%
Don't Know 436 8.0%
which allows the identification of each variable, its value, and a
value range to signal incorrect entries. Frequency distributions of
all variables identified outlier which were confirmed by examining
the original questionnaire. Logic checks were performed on all
meaningful variables to identify incorrect entries. Data were
analyzed using a mainframe IBM computer, with SPSS statistical
software programs.
Results
Socio-demographic Characteristics: Table 2 presents the
frequency and percent of various socio-demographic
characteristics of the surveyed. A total of 5433 women were
interviewed throughout the five provinces population, 33
individuals more than the minimal sample requirements. The
largest surveyed area was Punjab with 44.3% of the total sample.
The respondents are not proportionate to the population of
provinces and area of residence (Urban:Rural) in order to maximize
the homogeneity and heterogeneity of populations in different
provinces and areas of residence. The urban population
constituted approximately 40% of the sample and the rural
population constituted approximately 60%. The mean age of the
population was 26.5 with the largest number of respondents
(33.9%) falling into the age group 25-29 years followed by 24%
belonging to the age group 30-34. A total of 72.8% of the
respondents have no education, 10.6% have attained primary
education, 5.6% have gone to middle level and 11.2 % secondary
and above. Thirty-two percent of the households have less than
Rupees 1000 monthly ($40) income which can be considered
below the poverty line.
Awareness of ORS: Knowledge is often considered to be a
necessary but not sufficient condition for behavior change. Shea
and Basch's review of five major community cardiovascular
disease prevention programs highlighted the significance of
knowledge transfer and innovation diffusion as the most
important link in the causal chain of adoption behavior (Shea and
Basch, 1990).
Residence, Age and Education
Home ORS Home liquids Drugs Don't
Liquids and ORS know
PAKISTAN 8.2 40.5 7.3 39.7 4.3
Province
Punjab 9.0 28.9 9.9 47.5 4.7
Sindh 5.7 42.9 4.0 44.0 3.4
N.W.F.P. 4.8 50.5 11.7 29.8 3.2
Balochistan 14.2 35.9 2.2 39.4 8.3
AJK 7.5 90.5 0.0 0.5 1.5
Residence
Rural 9.8 38.5 5.1 41.2 5.4
Urban 5.8 43.4 10.2 37.6 3.0
Age
15-19 7.7 41.3 10.7 30.1 10.2
20-24 7.5 39.7 9.9 38.3 4.6
25-29 7.5 43.3 6.2 39.0 4.0
30-34 8.5 41.4 5.0 41.2 3.9
35-39 9.5 35.8 7.4 43.4 3.9
40-44 10.2 33.5 11.0 40.3 5.0
45-49 9.4 34.0 13.2 35.8 7.6
Education
None 8.9 37.3 6.2 43.3 4.3
Primary 5.7 49.1 8.4 32.9 3.9
Middle 6.0 49.0 11.4 29.9 3.7
>=Secondary 6.9 49.5 11.2 29.3 3.1
Awareness of ORS was high for most respondents in the survey.
Overall, 91% of mothers responded that they had heard of ORS.
There was some variation by province 81.4% of respondents had
heard about ORS in Balochistan compared with 97.7% in AJK.
Education, income, and urban residence were all positively
associated with awareness of ORS. This is a significant increase
from 1984 when only 38% of mothers had heard about ORS
(National Nutrition Survey 1985-1987, 1988).
Knowledge of Treatment for Diarrhea: Table 3 presents
comparisons of knowledge of treatment for diarrhea by education,
income, and residence. When asked about the best treatment for
childhood diarrhea, 56% of mothers identified oral rehydration
therapy (ORT), while 39.7% stated that drugs were the best
treatment. Variability between provinces was significant, with
90.5% of respondents in AJK answering correctly and only
28.9% responding correctly in Punjab. The higher level of
knowledge among AJK residents is attributed to recent
information campaigns conducted in this area. These results
indicate a significant gap between awareness and knowledge.
Although 91% of mothers know about ORS, only 57% believe it
is the best way to prevent diarrheal dehydration.
Use of ORS: Actual use of ORS is even lower than knowledge.
Only 34.7% of mothers gave ORS to their infants during their last
episode of diarrhea. Another 22.9% responded that their infant
was treated in the hospital. Other responses included antibiotics
(11%), other pills or syrups (9.2%), and home remedies (6.8%).
These results support the findings of previous studies in Pakistan
which have found that practice of ORT has consistently lagged
behind knowledge.
Availability of ORS in the home: Mothers who reported knowing
about ORS were asked if they had a packet of ORS at home. Only
27.5% of these mothers responded in the affirmative. Income,
education, and age of the mother were all predictive of having
ORS in the home, with wealthier, more educated, and younger
women being more likely to have it. To verify their responses, the
mothers who indicated that they had ORS at home were asked to
show the ORS packet to the interviewer. Over 90% of these
women were able to produce the ORS packet.
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
147
Table 4: Respondents who continued giving food when child had diarrhea by Province, Residence, Age, Education, Income level
Food given when child in diarrhea
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Continued Discontinued Reduced DK % valid N
Demographics N=4,487 N= 318 N=335 N=293
PAKISTAN 82.6% 5.9% 6.2% 5.4% 100.0% 5,433
(Total Percent)
Province
Punjab 82.6% 3.7% 4.7% 9.1% 100.0% 2,406
Sindh 78.9% 8.1% 12.4% 0.6% 100.0% 1,176
N.W.F.P. 79.3% 8.3% 6.2% 6.3 100.0% 812
Balochistan 83.7% 9.8% 4.1% 2.3% 100.0% 640
AJK 98.2% 1.3% 0.3% 0.3% 100.0% 399
Residence
Rural 84.2% 4.6% 5.3% 6.0% 100.0% 3,167
Urban 80.4% 7.6% 7.4% 4.6% 100.0% 2,266
Age
15-19 77.0% 5.1% 4.1 13.8% 100.0% 196
20-24 81.0% 6.3% 6.2 6.5% 100.0% 1,063
25-29 83.3% 5.6% 5.9 5.1% 100.0% 1,842
30-34 83.3% 6.3% 6.0 4.5% 100.0% 1,303
35-39 82.7% 5.8% 7.2 4.3% 100.0% 740
40-44 84.7% 4.2% 7.6 3.4% 100.0% 236
45-49 81.1% 3.8% 5.7 9.4% 100.0% 53
Education
None 82.7% 6.1% 6.0% 5.2% 100.0% 3,953
Primary 81.7% 5.2% 6.1% 7.0% 100.0% 574
Middle 81.5% 7.7% 5.0% 5.7% 100.0% 298
>=Secondary 82.9% 4.1% 7.7% 5.3% 100.0% 608
Monthly Income
RS < 1,000 82.5% 4.1% 6.3% 7.2% 100.0% 1,727
RS:1,000-1,999 83.3% 5.7% 6.4% 4.6% 100.0% 1,613
RS:2,000-3,499 83.8% 5.7% 6.0% 4.5% 100.0% 1,018
RS:3,500-4,900 85.8% 4.9% 6.9% 2.3% 100.0% 346
RS > 5,000 88.1% 3.1% 4.8% 4.1% 100.0% 293
DK * 71.6% 16.5% 5.5% 6.4% 100.0% 436
* DK : Do Not Know
Feeding Practices During Diarrhea: Studies conducted during thetreatment of diarrheal disease. These variables were entered into
early 1980s found that the majority of mothers stopped givinga logistic regression model with the dependent variable being
food and/or liquids to the child during diarrheal episodes. For"perceived best way to prevent diarrheal dehydration" (1 = ORS
example, before the CDD campaign, only 40% of mothers+ both ORS and home remedy and 0 = others). These
continued giving food and liquids during diarrhea. Failure toindependent variables included the number of individuals consulted
provide food and liquids is an extremely dangerous practicefor child health, mother's education, mother's age (continuous
because it accelerates dehydration and denies the child essentialvariable), number of household appliances (continuous variable),
nutrients. As part of the CDD program, a massive public healthresidence (rural or urban), and income (<= RS 1999 = 0; > RS
campaign was launched to encourage mothers to continue feeding 2000 = 0). Together, these six variables accounted for 62.6% of
during diarrheal episodes. An evaluation of the CDD programthe variability in the identification of ORS as the best way to
undertaken in 1988 indicated that an increasing proportion ofprevent diarrheal dehydration. Table 5 presents the results of the
mothers - 59% - were continuing to give food and liquids to their logistic regression. All independent variables except number of
children during diarrhea. These results are confirmed by the PHES health consultants were found to be significantly associated with
survey. ORS as the best treatment. Mothers with more appliances in the
In response to a question about feeding practices during diarrhea, household (such as radio, television, etc.) are 30% more likely to
82.6% of mothers indicated that they continued to provide foodperceive ORS as the best way to prevent diarrheal dehydration.
for the child. Feeding practices differed between provinces 98% Mothers whose household income <= RS 1999 are 40% more
of mothers in AJK reported continuing food, while lower levels of likely to perceive that ORS and home remedy are the best ways to
79% were found in Punjab and Balochistan. Feeding practices did prevent diarrheal dehydration in comparison to those from higher
not differ significantly with respect to income, education, or ageincome.
of the mother. Table 4 provides a more detailed description of the A second logistic regression model was used to assess the
factors found to be associated with feeding practices. influence of several variables on "mother used ORS during the last
Since dehydration is the biggest risk associated with diarrhea, the episode of diarrhea" Independent variables entered into the model
continuation of liquids is essential to recovery. This study foundincluded mother-in-law as a consultant for child's health, doctor as
that most mothers, 90.8%, continue to give liquids when theira consultant for child health, residence, mother's age, reading
child has diarrhea. The urban-rural differential was small, but there newspaper, and income level. Together, these six variables
was significant variability according to age. Young mothers, 15-accounted for 62.6% of the variability in using ORS during the last
19, were least likely to continue providing liquids compared toepisode of diarrhea. Mothers who indicate that the mother-in-law
older mothers. was identified as a consultant for the child's health are 42% more
Multi variate analysis: Several variables were found in the bivariate individuals who do not use a mother-in-law as a consultant. Also,
analyses to relate significantly with the use of ORT as the bestmothers who read the newspaper are 32% more likely to use ORS
likely to use ORS during the last episode of diarrhea compared to
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
148
Table 5: Logistic Regression Analysis for Feeding Pattern for Children, Pakistan National Health Education Survey 1991-92
Variable BS.E. Wald test Significance RExp(B)
Area of residency ! 0.10 0.074 1.93 0.165 0.00 0.90
Mother's age ! 0.02 0.006 13.63 0.0002 ! 0.05 0.98
Mother's education *
- no education 0.94 0.112 71.15 0.000 0.11 2.56
- primary education 0.64 0.124 26.29 0.000 0.07 1.89
NO. of consultants for child health ! 0.17 0.037 21.10 0.000 ! 0.06 0.84
"Having radio, TV, newspaper" ! 0.08 0.039 4.67 0.030 ! 0.02 0.92
Age to begin breast-feeding ! 0.29 0.039 55.38 0.000 ! 0.10 0.75
Age of child (month) ! 0.07 0.005 160.16 0.000 ! 0.17 0.93
Constant 2.96 0.245 146.07 0.000
Model Chi Square = 367, Significance = .000, Prediction = 76.8%
* Mother's education : using the secondary education category as a reference category
Table 6: Multiple Regression Analysis for Predicting Mother's Adherence To Beneficial Surrounding Diarrhea
Variable BS.E. B T sign. Adj. R2
(unstand.) (stand.)
1 2
Mother-in-law as a consult for child's health 0.09 0.02 0.05 3.8 0.002 0.268
Doctor as a consultant for child's health 0.05 0.02 0.03 2.2 0.030
Have ORS at home 1.04 0.03 0.49 41.9 0.000
Having radio, TV, newspaper 0.06 0.01 0.07 5.4 0.000
Perceived diarrhea as a major childhood Disease 0.09 0.02 0.05 3.9 0.001
Constant 2.15 0.03 77.9 0.000
unstand. = unstandardized regression coefficient stand. = standardized regression coefficient
1 2
than those who do not read the newspaper. theories of behavior change described above. A total of 56%
A multiple linear regression stepwise method was used to believe it is the best way to prevent diarrheal dehydration
determine the effects of several independent variables on the(contemplation/persuasion), 34.7% used it during the last episode
number of positive practices mothers use for treatment of(action), and 27% keep ORS is the home (maintenance). Some
diarrhea (such as continue providing solid food, liquids, ORS, etc). individuals and communities have moved along the continuum
Independent variables regressed in this analysis consisted ofquickly; others, for one reason or another, are detained at one
whether ORS was at home, having a radio, TV or read newspaper, stage and must be convinced to move to the next stage. The
perceived diarrhea as a major childhood disease, mother-in-lawstages of change provide points of intervention for future health
used as a consultant for child health, and doctor was used as aeducation efforts; for example, it would be beneficial to determine
consultant for child's health. Table 6 identifies the unstandardized what prevented 20% of mothers who believe ORS is the best
and standardized regression coefficients with respective levels of treatment from actually practicing it, and to concentrate on
significance. Overall, the model explained 26.8% of the variability removing those barriers.
in number of positive treatment practices. The strongestThe knowledge-practice gap suggests that current messages and
predictor was whether or not ORS was available at home. channels have been successful in raising awareness of ORS, but
Discussion
The results of this survey indicate that the CDD program and
media and other influences has been successful in increasing
knowledge regarding ORS. However, actual use of ORS continues
to lag far behind knowledge while 91% of mothers have heard of
ORS, only 34.7% adminisd it during their child's last episode of
diarrhea. This gap between knowledge and practice suggests that
ORS education programs are effectively reaching the target
population, but that the messages are failing to change behavior.
Clearly, there is a need to change the direction of the program and
focus on encouraging mothers to translate their knowledge into
action.
By linking diffusion of innovation and interpersonal change
theories together, it becomes clear that public health education
programs must address the specific needs of both individuals and
communities to be effective. One implication of this is that health
educators must determine where individuals and communities lie
along the behavior change continuum before designing
interventions; otherwise, program may not be matched to the
needs of the target audience. Thus, health education programs
must have two objectives: (1) to provide behavior change
programs sequentially to match the individual's stage of change,
and (2) ensure that individuals in the target population are moving
through the stages of behavioral change (i.e., that the behavior is
diffusing through the population).
The results of this study provide evidence that the population is
moving along a continuum of behavior change 91% are aware of
ORS. This is the precontemplation/awareness stage in the two
unable to persuade mothers to use it. Knowing that the target
population is aware of the product suggests that ORS promotion
messages should begin to focus less on providing information and
more on persuasive communication. At this middle stage of
behavior change, mothers need advanced education regarding
ORS; for example, they must be convinced that ORS is more
effective than other methods to treat their child's diarrhea, and
they must be taught to mix and administer it properly. Research
by Prochaska demonstrates that an individual's evaluation of the
pros and cons of a specific behavior were linked to their decision
to perform that behavior, and subsequent maintenance of the
behavior (Prochaska, 1994). In the case of ORS, this means
identifying perceived advantages and barriers to using ORS.
According to the Diffusion of Innovation Model, those individuals
in Pakistan most likely to adopt ORS have already done so; the
next challenge is to reach the remaining individuals. More research
is needed to determine the exact characteristics which separate
the early adopters from the late adopters in each community. The
need for more research in this area is underscored by a study in
Haiti which found that the most important predictors of ORT
knowledge and practice were the attributes of the individuals
studied (Coreil et al., 1988) . More information about the target
population will help health professionals identify the resources in
the community which are more closely matched to the individual
and community stage of change.
The Diffusion of Innovation Model demonstrates that the
acquisition of new information does not necessarily correspond to
subsequent behavior change. In Pakistan, 91% of mothers have
reached the first stage of change, awareness of ORS, but only
Morisky et al.: Update on ORS Usage in Pakistan: Results of a National Study
149
34.7% have reached the fifth stage and adopted ORS use. Thisreinforces the belief in the community that ORS is not an effective
underscores the need to better understand what motivates
individuals to move through the stages of change. Some of the
differentiation can be explained by predisposing characteristics
some individuals are simply more ready to change than others or
are more likely to defy social norms. These characteristics are
associated with other socio-demographic characteristics. For
example, it is generally believed that early adopters tend to be
more educated, wealthier, and more urban-dwelling than late
adopters a belief that is further supported by the results of this
survey.
Due to these predisposing characteristics, early adopters have
more access to the mass media, and they tend to rely on it as a
source of health information. As a result, early adopters are more
easily influenced by the mass media. Late adopters less educated,
poor, and rural-dwelling individuals pose a challenge to health
educators because they cannot be as easily reached or influenced
by mass media channels. Late adopters rely more on interpersonal
communication channels for information, and may be distrustful
of other sources. This suggests that some Pakistani women may
have heard about ORS through communication channels that are
not likely to influence them. Health education campaigns,
especially in the later stages, need to consider which
communication channels will be most effective at persuading this
audience.
Social influence is another important determinant of behavior. As
the diffusion curve begins its ascent, precedent and support for
the new behavior is developing simultaneously. Early adopters of
the behavior can be used to influence late adopters both by
serving as an interpersonal communication channel and providing
an example.
Cultural belief systems may have a significant impact on the
adoption or rejection of ORT within a community, yet many ORT
promotion campaigns have been implemented with little
understanding of the local cultures and dominant belief systems
into which they are introduced. (Mull and Mull, 1988; Weiss,
1988). Mull found that remarkably little is known about how
Pakistani women perceive ORT, resulting in culturally inappropriate
messages (Mull and Mull, 1988). An improved understanding the
issues and beliefs surrounding child health care will drastically
improve the chances that messages will be received by the
population.
A carefully selected communication channel can increase the
salience and appeal of health education message. In Pakistan,
where the mass media has already reached the early adopters,
ORS promotion campaigns should use the existing social networks
to channel information. For example, a poor or rural mother may
be more receptive to receiving health information from other
mothers, especially ones she knows. For this reason, a mother-to-
mother dialogue should be actively encouraged. Where the
existing social networks are inadequate, health outreach workers
should be trained and dispersed to provide health education in the
community and to build support for ORS.
The survey results indicate that many mothers continue to treat
diarrhea with antibiotics and/or other drugs. In most cases, this
is entirely unnecessary and potentially dangerous. Mothers must
be convinced that ORS is the most effective way to prevent
diarrheal dehydration. Promotion campaigns should also stress
the added advantages of ORS, i.e. inexpensive, widely available,
and does not require a visit to a doctor.
Research by Coreil and Genece in Haiti documented the pivotal role
of medical institutions can play in dissemination of information
about ORT (Coreil, 1988). However, current prescription practices
in Pakistan are not supportive of ORS use. Health professionals
sometimes view ORS as an adjunct approach to prevent diarrheal
dehydration, to be used as a supplement to antibiotic therapy.
Health professionals also need to be better educated about ORS
and encouraged to prescribe it in place of antibiotics when
appropriate. When health providers continue to recommend
antibiotics to their patients, even in conjunction with ORS, it is
way to prevent diarrheal dehydration. Furthermore, when
consulted about childhood diarrhea, health professionals should
take advantage of this teachable moment to educate the mother
about ORS instead of prescribing only antibiotics. Broader policy
issues regarding the availability of drugs in Pakistan must also be
addressed.
Conclusion: ORT is not the final solution for childhood diarrhea.
Since diarrheal diseases are caused in part by social and
environmental conditions that facilitate their transmission, the
most significant improvements in child health will come as a result
of improved sanitary conditions, personal hygiene, and living
conditions. To be optimally successful, ORT promotion must be
incorporated into an overall program of social and economic
development. The combination of these two approaches,
including targeted interpersonal modeling will be an important
stimulus to move the remaining 65 percent of the population into
the trial and adoption stages of behavioral change.
Acknowledgement
The research presented in this article was conducted by Donald E.
Morisky and Snehendu B. Kar, WHO short-term consultants to the
Ministry of Health, Division of Health Education, Islamabad,
Pakistan 1990-1991. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the World Health
Organization
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