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WATS

Operated by CDM and Associates

Sponsored by the U.S. Agency for International Development

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LINKING WATER SUPPLY AND SANITATION

TO ORAL REHYDRATION THERAPY IN THE CONTROL OF DIARRHEAL DISEASES

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2A!v;r/..-;:c.v ^ " '• -5 ZUPPUy A;Y1

WASH TECHNICAL REPORT No, 31

JULY 198i

The WASH Project is managed by Camp Dresser & McKee International Inc. Principal cooperating institutions and subcontractors are: Associates in Rural Development, Inc.: International Science and Technology Institute. Inc.: Research I riangle Institute: Training Resources Croup: University of North Carolina at Chapel Hill

Prepared for Office of Health

Bureau for Science and Technology U.S. Agency for International Development

Activity No. 142

-2Q&H-Ss-li-^)

': UBRARY, INTERNATIONAL REFERENCE : CENTRE"FOR CCWiviUNiTY WATER SUPPLY ' AND SANITATION (iRC) :' P.O. Box 9c 190, 2CGS AD l ho Hague • Te!. (070) 81491 ' ; ex't. : 41 /142

=.RN: S 3 S 3 f i s N *

WASH Technical Report No. 31

LINKING WATER SUPPLY AND SANITATION TO ORAL REHYDRATION THERAPY IN THE CONTROL OF DIARRHEAL DISEASES

Prepared for the Off ice of Health, Bureau for Science and Technology Agency for Internat ional Development

under WASH Ac t i v i t y No. 142

by

Raymond B. Isely

July 1985

Water and Sanitation for Health Project Contract No. 5942-C-00-4085-00, Project No. 936-5942

Is sponsored by the Off ice of Health, Bureau for Science and Technology U.S. Agency for International Development

Washington, DC 20523

TABLE OF CONTENTS

Chapter Page

L» / \ L v U I 1 V L O \J\ I I l / A l \ l o o o o o o o o o o o o o o o o o o o o o o o o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I I

i « X r i l K l / U U V s l l U P l o o o o o o Q O O o o o o o o o o o o o o a o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Q o o o o o X

2. TRANSMISSION OF DIARRHEAL DISEASESo.................................. 2

C o l U 0 t U 5 C l T # l V C fty C l l t » > « o o o o o o o o o o o o o o o o » o o o o o o o o o o o o o o o o o o o o o o o a a o o o o o C

C. • C. I r u i l S i l l 1 S S 1 O i l K O U U G S • o o o o o e e o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o C

2*3 Intermediate Sources of In fec t ion• • • • • • •ooo. . .o e 0 .«ooo. .o O «.o .oo 4 2o4 Primary Sources of Infect ion and Factors Favoring the Spread of

U r y C l ' l I O l l l * ) o o o o o o o o o o o o o o o o o o o Q e o a o e o e Q o o o o o o o o o o o o o o o Q O O O Q o o o o o Q O 3

3. LINKS BETWEEN WATER SUPPLY AND SANITATION (PERSONAL HYGIENE) AND ORAL I x L I I I U l \ M I X \J P i I n C I \ M i T o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o U

J o l y U d I 1 T>y O T W a L C r U S e O " C O r l d l C e L J K O o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o 0

3.2 Bacterial Qual i ty of the Food Given During O R T . . . . . . . . . . . . . . . . . . 8 3.3 Disposal of Stools of Small C h i l d r e n . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3.4 Community and Women's P a r t i c i p a t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

t o I r l r L i U M I i U I M o I U K I K U b K n r l O o o o o o o o o o o o o o o o o o o o o o o o o e o o o o o o o o o o o o o o o o o o o A U

H » 1 D u b I V r u \ * l » 0 « o o « » o * o * o o o o * o o o « « * * o o o o o o o o » * o » * o o o o o » o o o o o o o o Q o o o o 1 U

4.1.1 The Essential Role of Women 4.1.2 The Same Ministry Administers Both Programs 4.1.3 The Same People Administer Both Programs in the Fie ld

4.2 Practical Suggestions for Coordinated P r o g r a m s . . . . . . . . . . . . . . . . . . 12 4.2.1 Techniques for Linking ORT and Sanitat ion 4.2.2 The Need for Training

4.3 Practical Issues Faced in Focusing Programs on Women 14 4.3.1 Women's Roles 4.3.2 Women's Time 4.3.3 Women's Autonomy

4.4 Program Coordination Issues 15 4.4.1 Coordination wi th in the Minstry of Health 4.4.2 Coordination with the Rural Water Supply Agency 4.4.3 Jo in t Planning of Projects 4.4.4 Coordination wi th in AID

D « O U I I r l M l X T n P I I J V s U r J \ s L » U o l U r i O o o o o « o o a o o « » o o o o o o a o o o o o o o o o o o o a o o o o o o o o o o o o o o X I

K C l U I » L R V L O O o o o o o o o o o o o o o o o o o o a o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o J . O

FIGURES

1. Water Supply and Sanitation in Relation to Diarrheal D i s e a s e . . . . . . . . . 3 2. Issues Linking Water Supply and Sanitat ion wi th Oral Rehydration

I 11 C I Q \Jj o o o o o o o o o o © o o o o o « © o e o o » » o o o o o » o o o o o o o o o o © o o © o o o o o o o o o o o o © o © o o o /

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EXECUTIVE SUMMARY

The control of diarrheal diseases requires the prevention of the complications of diarrhea (dehydration and death), of the nutritional consequences of re­peated and/or prolonged diarrhea, and of the incidence of diarrhea itself. Oral rehydration therapy is effective in preventing dehydration and death, and to a certain degree, in diminishing the weight loss associated with diarrhea. Other measures, however, including water in sufficient quantity and of sufficient quality, and personal and domestic hygiene are needed to reduce the incidence of diarrhea itself.

The primary source of pathogens causing diarrhea is human fecal matter contaminating food, water, hands, and objects in the house and mothers and other caretakers of young children are at the center of this cycle of contamination. A complete program of diarrhea control, therefore, includes educating mothers and other caretakers of small children in the means not only to treat, but also to prevent infection. Health personnel in the field, while working to promote oral rehydration therapy, can also work with populations, and if possible with women's groups, to promote personal, domestic, and food hygiene as well. Because hygiene is not possible without a sufficient quantity of water, improving water supplies becomes an additional part of preventing diarrhea.

To perform these tasks, health workers must be trained and supervised. Obstacles encountered include overloaded workers and supervisors and a lack of funds for fuel and vehicle maintenance.

It is logical therefore to introduce these program elements slowly as workers and communities are able to absorb them. In the case of an oral rehydration program, water supply and sanitation would be introduced only as the program achieves a certain stability, and a water supply and sanitation program would need to be well established before oral rehydration therapy is introduced. A complete program of diarrhea control, however, should eventually incorporate all three elements; water supply, sanitation, and oral reydration therapy.

Planning programs in which water supply and sanitation are linked with oral rehydration therapy requires coordination at three levels:

1. Within the health ministry, where oral rehydration is often administered by one division, and sanitation by another;

2. Between the health ministry and the water supply agency: the latter to plan water supplies that are convenient and reliable for the populations served so that optimal use of water for hand washing, bathing, food washing and other forms of domestic hygiene is possible;

3. Within AID itself sanitation needs to be seen as a central issue linked to oral rehydration therapy and to water supply for the control not only of dehydration but also of diarrhea itself.

-ii-

Joint planning of programs must take account of four factors:

1. Women, as the primary implementers of oral rehydration therapy and sani ta t ion programs, are also the primary t ransmi t ters of diarrheal pathogens.

2. The ministry of health in nearly ewery country has a legal responsibil ity for both oral rehydration therapy and sanitation.

3. Because water in suff icient quantity is needed to make sanitation possible, low-cost water supply schemes" in which community participation is maximized should be planned as part of the overall e f for t to control diarrhea and i t s consequences.

4. In the end, because of the shortage of both sanitarians and rural water supply technicians in most countries, the same peripheral health workers de l iver both oral rehydration therapy and sanitation services.

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Chapter 1

INTRODUCTION

Oral rehydration therapy and water supply and sani tat ion are both components of an overal l control strategy for diarrheal disease con t ro l . The former, focused on the prevention of dehydration and mor ta l i t y , and the l a t t e r on diarrhea prevention, are frequently operated as independent programs in the same c o u n t r y . To the ex ten t p o s s i b l e , however, program planners and administrators should attempt to forge l i n k s between these programs so tha t oral rehydration therapy can benef i t from complementary inputs of water supply and san i ta t ion , and vice versa.

To implement j o i n t programs, issues such as f inanc ing, t r a i n i n g , supervis ion, and f ie ld-worker workloads must be deal t w i t h . Nevertheless, where the incidence of diarrheal disease i s high and both kinds of programs are planned or are i n operation in a country, every e f f o r t should be made to assure complementarity. Where only one kind of program is operated, plans should be made to eventually incorporate elements o f the other .

How can these l i nks be forged? How can such complementarity be assured? To answer these questions, t h i s paper w i l l f i r s t examine the transmission of diarrheal diseases, showing how fecal po l l u t i on of hands and food i s the major transmission route. Then the speci f ic l inkages of water supply and sani ta t ion to oral rehydration therapy w i l l be examined in more d e t a i l . F i n a l l y , pract ical ways to implement programs in the f i e l d w i l l be discussed at leng th .

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Chapter 2

TRANSMISSION OF DIARRHEAL DISEASES

2.1 Causative Agents

A conceptual framework f o r the t ransmiss ion o f d i a r r h e a l diseases i s i l l u s t r a t e d in Figure 1. As one can see on the r i gh t side of the diagram, there are bas ica l ly two types of diarrheas in terms of transmission: those diarrheas transmitted pr imar i ly through contaminated water (cholera, typhoid fever, and g iard ias is) and those transmitted through contamination of food and hands (E . c o l i d i a r r h e a , s h i g e l l o s i s , d ia r rheas caused by species o f Salmonel1 a paratyphi , or by Campy!obacter or Yers in ia, Entamoeba h i s t o l y t i c a , and Rotavirus i n f e c t i o n ) . This c l a s s i f i c a t i o n , while somewhat a r b i t r a r y , takes account of primary transmission routes. There i s also a residium of diarrheas of unknown et io logy which accounts for from 20 to 50 percent of the t o t a l , depending on the seriousness of the i l l n e s s . Some are re lated to measles and others to ma lnu t r i t i on .

The diarrheas of the second group {notably those caused by E. c o l i o f various pathogenic s t r a i ns , by Shige l la , and by Rotavirus) present tfie greatest threat to ch i ld survival in most developing countr ies, except in Bangladesh and areas of India where cholera remains endemic.

Thus, w i t h the l a t t e r except ion i n mind, when a c h i l d requ i res ora l rehydration therapy, the causative agent i s l i k e l y to be Rotavirus, E. c o l i , or Shigella in that order of frequency, although the order of frequency var ies from country to country.

2.2 Transmission Routes

The transmission of these two groups of causative agents, moving from r i gh t to l e f t in Figure 1 , i s through four pr inc ipal routes: contaminated water or food, d i r t y hands, and passive vectors. For the f i r s t group of agents, contaminated food i s the pr incipal transmission mechanism. For the second group, transmission is pr imar i l y through contaminated food as w e l l , wi th contaminated water playing a secondary r o l e . Food is contaminated mainly by women and older g i r l s who prepare meals without washing the i r hands a f te r defecat ion, or clean babies' bottoms without washing t he i r hands af terward. For sh ige l l os i s , hand-to-hand and hand-to-object- to hand transmission play important ro les . Some controversy s t i l l surrounds the question of whether cholera is transmitted through contaminated food, and whether sh ige l los is i s transmitted through contaminated water.

Fl ies may play a less important ro le in the transmission of organisms, p r inc ipa l l y Sh ige l la , Entamoeba col i , and E. c o l i , than previously supposed. Rahaman, e t al in Bangladesh studied Shigel la transmission on an offshore island wi th a heavy f l y population and found no increase in transmission a t t r ibu tab le to the f l i e s .

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2.3 Intermediate Sources of In fec t ion

The t h i r d column from the r i gh t in Figure 1 i l l u s t r a t e s intermediate sources of these causative organisms. Major sources i n t h i s category include pol luted water sources, contaminated food suppl ies, poor personal hygiene, ch i ld ren 's s too ls , and invasion of the house by passive insect vectors.

Water can be pol luted in several ways. Surface water can be contaminated e i ther i n d i r e c t l y , through run-of f from surrounding areas, or d i r e c t l y i f , for example, someone defecates in to the water or i f a baby's diaper or a c lo th used to wipe the baby's bottom are washed i n i t . Well water, the only source for most people in dry areas of the world, can be contaminated through surface run-of f i f the well i s not s u f f i c i e n t l y sealed, i f cracks occur in the cement slab atop the w e l l , i f there is no apron, or i f the apron is too narrow or not slanted enough toward the periphery. Surface contamination can also occur i f receptacles are put on the ground and then plunged in to the w e l l . Well water may be contaminated i f the groundwater on which i t depends i s i n f i l t r a t e d by bacteria and viruses from nearby l a t r i nes or other s i tes of defecat ion. Water can also be contaminated during transport and storage at home, la rge ly through inadequate and i n f r equen t c leans ing o f s torage vesse ls o r by p lung ing contaminated hands or cups in to the water.

The ways of contaminating food are mul t ip le (uncovered le f tover food, unclean vessels, and unclean dishes and eating u t e n s i l s ) , but as demonstrated by the arrow passing d i r e c t l y from contaminated hands to contaminated food in Figure 1 , the ch ie f mode o f contaminating food i s by means o f d i r t y hands, p r i nc ipa l l y those of the women who prepare the food. In f a c t , a study in Central America showed that housewives had nine times as many enter ic pathogens on the i r hands as did nurses working in the pediatr ic ward of a hospital (Mata £ t a l , 1969), and another study in Guatemala (Capparell i and Mata, 1975) showed~that contamination o f t o r t i l l a s was the ch ie f mode o f t ransmit t ing d iarrhea.

The fo l lowing scenario graphical ly i l l u s t r a t e s t h i s po in t . A woman r ises ear ly , perhaps before dawn. She f i r s t takes care of her small c h i l d who has d iarrhea, cleaning up a f te r a bowel movement. She throws the d i r t y c l o th on the garbage heap and proceeds to prepare the morning meal without washing her hands. Twelve hours af terward, another c h i l d a year older has diarrhea as w e l l . The examples can be mu l t i p l i ed over and over again, but the point i s that i t i s d i r t y hands that contaminate food, cooking vessels, dishes, u tens i l s , baby b o t t l e s , and a va r ie ty o f other things re lated to food p r e p a r a t i o n . Weaning foods appear to be p a r t i c u l a r l y suscep t i b l e to contamination. Rowland et a! (1978) showed tha t contaminated weaning porridge was the main vehicle of gast ro in test ina l in fec t ions among infants and small chi ldren in the Gambia. A study in Bangladesh confirms t h i s f ind ing (Black et _al_, 1982).

The remaining intermediate sources of i n fec t i on include f a i l u r e to wash hands a f te r defecation and before food preparat ion, inadequate disposal o f the stools o f in fants and small ch i l d ren , and lack o f protect ion of doors and windows. Soiled hands have already been impl icated in the contamination o f food, and widespread deposit ion of ch i l d ren ' s stools i s a frequent source of mothers' soi led hands. Although of lesser importance, unprotected doors and windows obviously provide entry to passive vectors of p o l l u t i o n .

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2.4 Primary Sources of Infection and Factors Favoring the Spread of Organisms

On the extreme l e f t of Figure 1 a single primary source of infection is given: human fecal matter. Human fecal material is deposited indiscriminately by small children or discriminated by adults. Minute quantities washed into a stream or a we l l , or deposited on the hands or on the breasts, or in some instances carried by f l i e s , can contaminate water, food, cooking vessels, dishes, utensi ls, doorknobs, towels, etc.

A contributing factor of major importance in the etiology of diarrhea is simply the lack of enough water and soap for people to wash their hands, bathe, or wash their cooking vessels and dishes. Mashing with soap, was demonstrated by Kahn (1982), to be essential for the prevention of the secondary spread of shigellosis. Lastly, inadequately constructed shelters may permit the entry of disease-carrying insects.

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Chapter 3

LINKS BETWEEN WATER SUPPLY AND SANITATION (PERSONAL HYGIENE) AND ORAL REHYDRATION THERAPY

As stated at the outset , t h i s report deals wi th two d i f f e r e n t forms of prevention. Oral rehydration therapy i s essent ia l l y a form of secondary prevention, designed to combat dehydration and death, but i t does not prevent diarrhea i t s e l f . There is no doubt, however, as to i t s e f f icacy as a secondary preventive measure. In Bangladesh 50 percent diminutions in mor ta l i t y due to diarrhea and dehydration have been reported for chi ldren treated with oral rehydration solut ion (Rah am an et a l , 1979). Because of the e f f i cacy , re la t i ve s imp l i c i t y , and low cost of oral rehydration programs major agencies such as UNICEF, WHO, and USAID have emphasized them and have funded the manufacture and d i s t r i bu t i on of oral rehydration s a l t s .

There may be another secondary benef i t o f oral rehydration - - the prevention of the nu t r i t i ona l e f fects of d iar rhea. Loss of f l u i d , e l ec t r o l y t es , and nutr ients are caused by diarrhea and vomiting and - - more importantly - - by anorexia as Rohde (1978) and Beisel (1972) repor t , and to some degree by catabolism of body t issues i f there i s fever. Hirschhorn and Denney (1975) have shown that Apache chi ldren who are rehydrated early enough regain the i r appetites sooner and have less weight loss per episode o f diarrhea than chi ldren whose oral rehydration s tar ts l a t e r . The long-term ef fec ts on n u t r i t i o n a l s t a tus may be f u r t h e r m i t i g a t e d by using o ra l r ehyd ra t i on solutions made wi th r i c e , maize, or m i l l e t powder instead of sugar. Such complex carbohydrates provide not only glucose as they are broken down, but starches for storage, which also help to reduce stool volume.

Oral rehydration therapy en ta i l s not simply the administrat ion of oral rehy­drat ion solut ions (ORS) but also the proper n u t r i t i o n of the c h i l d during rehydration and the education of the c h i l d ' s caretakers in how to mix and administer solut ions and in how to prevent diarrhea (Parker et a l , 1984). There are a number o f l i nkages between water supply and s a n i t a t i o n , pa r t i cu la r l y personal hygiene, and oral rehydrat ion. These l i nks can best be elucidated through examining cer ta in issues a f fec t ing both oral rehydration programs and programs to prevent diarrheal disease. In the discussion of each issue, impl icat ions fo r each type of program emerge. Figure 2 presents the issues graph ica l ly .

3.1 Qual i ty of Water Used to Make ORS

Guidelines given by the World Health Organization (WHO) (1976 and 1978) recommend simply the use of the safest water avai lable for mixing the so lu t ion , whether the solut ion contains the f u l l complement of sa l ts and glucose or simply contains s a l t and sugar. Since the safest water supply avai lable may be qui te po l lu ted , some have questioned whether ORS packages should not also contain a d i s in fec tan t . Thus f a r , however, no d is in fec tan t has been found that does not i n te rac t with the sa l ts of ORS. The use of solar energy to d i s i n f ec t ORS may show some promise i f the proper vessels can be obtained and i f the t u r b i d i t y of the solut ion is low, as reported by Acra et a l , (1984). Watkinson et al (1980), however, showed tha t ch i ldren in tfie

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Figure 2

Issues Linking Water Supply and Sanitation with Oral Rehydration Therapy

COMPONENTS OF WATER SUPPLY AND SANITATION

Safe water supply in sufficient quantity

Adequate disposal of human fecal material

Food hygiene

Personal hygiene

Water hygiene

Domestic hygiene

Hygiene education including the pro­motion of commu­nity and women's participation

PRINCIPAL ISSUES

Exposure to fecal matter matter through:

- Water used to mix ORS - Food given to child - Hands or nipples

Prevention of transmis­sion through:

- Washing hands and breasts with soap especially after defecation and before preparing food

- Washing babies' bottom

- Disposal of small children's stools

- Protecting food

Interventions:

- Community parti­cipation

- Women's parti­cipation

• > •

COMPONENTS OF ORAL REHYDRATION

THERAPY

Early administration of oral rehydration solution

Early feeding whether by breast or other foods

Education of mothers concerning ORT and diarrhea prevention

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Gambia treated wi th ORS mixed with contaminated well water recovered from dehydration j u s t as well as those treated wi th a solut ion made wi th clean water. I t i s nonetheless recommended general ly t ha t a so lut ion not be kept longer than 12 hours because of the rapid mu l t i p l i ca t i on of bacter ia in the sugar-r ich so lu t ion . The best standard of water used to mix ORS s t i l l remains that recommended by WHO, the cleanest l o c a l l y ava i lab le .

3.2 Bacterial Qual i ty of the Food and Given During ORT

The major l i n k s between oral rehydration therapy and water supply and sani tat ion have to do wi th the education of the mother in diarrhea prevention as well as in oral rehydration therapy (WHO, 1979). The mother, having been instructed in the pract ice of oral rehydration therapy and seeing her ch i l d on the road to recovery, can also explore questions surrounding her own personal hygiene. Does she wash her hands af ter her own defecation and before handling food? I f she i s breastfeeding, does she wash her nipples as well? Does she have enough water and soap to do so?

Food given to ch i ldren as they recuperate from dehydration should be as free from in tes t ina l pathogens as possible. Dishes must be kept clean and hands washed before preparing food.

Supplemental and weaning foods form excel lent cu l ture media for bacter ia l p r o l i f e r a t i o n . The longer these foods stand around, the greater the bacter ia l po l l u t i on . Beyond 12 hours they can be considered po l lu ted . These issues are of par t icu lar importance because during the weaning period ch i ldren are both in a precarious state o f n u t r i t i o n and especia l ly susceptible to diarrhea because they are ac t ive ly walking about and exploring t he i r surroundings.

The same pr inc ip les apply to bo t t l e feeding. I t seems tha t the e a r l i e r one star ts supplemental bo t t l e feedings, pa r t i cu l a r l y i f they are not given by the mother but by another caretaker while the mother i s working in the f i e l d s , the greater the chance for diarrhea to occur. Vis e t al (1981) provides evidence from a study in eastern Zaire (Kivu Province) that chi ldren of women who must be away in the f i e l ds a l l day have a higher rate of diarrhea and a higher mortal i t y .

3.3 Disposal of Stools of Small Children

As for the disposal of the stools of small ch i l d ren , there are a va r ie ty o f pract ices, but general ly the mother or other caretaker holds the c h i l d over the f loo r while he defecates, and then wipes his anus wi th e i ther a separate c lo th or a section of her wrap-around dress. The important point i s tha t fecal matter should be disposed of promptly and adequately. Washing c lo th ing well in soap and water and burying fecal matter or throwing i t in a l a t r i n e i f one i s avai lable w i l l help prevent contamination.

Toddlers who are no longer carr ied by t h e i r mothers pose an even greater problem, for they tend to defecate ind iscr iminate ly in and around the house. Some of the fecal material i s eaten by pigs or dogs but some contaminates the hands, f ee t , and c lo th ing of other people, pa r t i cu l a r l y ch i l d ren . In Sri Lanka the Sarvodaya movement has developed a special ch i ld -s ize pour f lush l a t r i n e

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with a hole small enough to prevent the fear of fa l l ing i n , that can be placed in the courtyard of the house in f u l l view of the mother. Since there is no superstructure, the fear of a dark enclosed space is also eliminated. The mother is taught to clean the la t r ine with at least a l i t r e of water after each use. Groups of mothers learn how to construct and use these latr ines and how to train their two to three year-old children to use them. Many have also been installed in nursery schools run by Sarvodaya.

3.4 Community and Women's Participation

Community-level organizations that can organize and promote participation in primary health care projects, including water supply and sanitation and oral rehydration, are needed to assure long-term maintenance of f a c i l i t i e s , and permanent changes in group and individual behavior. Participation by various groups of a population helps to provide an organized support network for changes in health-related behavior.

The participation of women in such organizations appears extremely important not only for their education in matters of hygiene and in the use of oral rehydration therapy, but also for so l ic i t ing their opinions on water supply and sanitation improvements (Green 1984). In Togo, for example, there are three to four women among the ten members on most of the health committees. Their primary responsibil i ty is to look after the pump instal led on the bore holes dr i l led by the project. Interestingly, one of the supplemental interests raised by many committees has been oral rehydration. For women struggling to understand and pract ice the prevention of diarrhea and dehydration, participation in such organizations provides an essential support structure without which most behavioral change is not possible.

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Chapter 4

IMPLICATIONS FOR PROGRAMS

4.1 Basic Facts

What are the programmatic implications of all the linkages discussed in Chapter 3? There are several, and they will be discussed in this chapter. But key to all the programmatic implications are a number of basic facts. The first is that it is the mother who is at the very center of both the administration of oral rehydration therapy and the prevention of diarrhea. Rohde (1983) has in fact emphasized this central role of mothers as front-line health care workers.

Another basic fact is that most often the same ministry administers both oral rehydration and sanitation programs, although these programs may be housed in different divisions of the ministry, between which there may be no relations. A correlary is that the same primary health care worker is often responsible for implementing both aspects of this joint program.

4.1.1 The Essential Role of Women

Women's primary role as caretakers of infants and children, carriers of water, and preparers of food, places them in a position to determine in large part the success of programs.

As we have seen in the previous sections, both oral rehydration and sanitation programs depend on women for their implementation. It is women who mix and administer oral rehydration solutions, breastfeed or administer other feedings to children with diarrhea, and are the focus of associated educational programs. Women are charged with carrying and storing water, cleaning the latrines, and training toddlers in defecation habits. By virtue of their role in food preparation, women are the chief transmitters of intestinal pathogens. For these reasons it makes sense to find ways to coordinate both programs, the final focus being the mother.

4.1.2 The Same Ministry Administers Both Programs

Almost without exception, oral rehydration and sanitation programs are under the same ministry, the ministry of health. It should be noted here that water supply has been separated from sanitation in this discussion, because in most countries water supply is the responsibility of one of a number of different ministries. The role of whatever ministry or ministries are responsible for rural water supply will be discussed in Section 4.4.

The responsibility of the ministry of health with respect to water supply is usually limited to disinfection of wells and other sources. Practically speaking, however, health personnel, although they may not have the necessary expertise, are often faced with the maintenance and repair of water supply installations because of their availability and proximity to rural populations. Maintenance and repair of water supply facilities in fact are

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often neglected because the water supply agency is not able to serve rural populations. In Togo during the evaluation of a rural water supply project, it was discovered that for an entire region with over 300 wells there was only one water supply technician.

The association of oral rehydration and sanitation programs in the same ministry has both positive and negative aspects. Oral rehydration programs are usually vested in either the health services division of the ministry of health or in a special diarrheal disease control program set up under the guidance of the WHO, UNICEF, or bilateral agencies. Sanitation, on the other hand, is usually housed in a separate division with its own hierarchy and corps of personnel. Furthermore, sanitation personnel in the field may often be insufficient to cover the population. The sanitation unit of the Ministry of Health in Malawi has attempted to remedy this problem by appointing a group of personnel, originally recruited to work in a cholera control program, as health surveillance assistants, with direct responsibility under the sanitation division of the Ministry of Health.

Relations between the health services division and the sanitation division vary from country to country. In some countries the divisions are completely separate, with sanitation personnel providing technical assistance only as requested. In other countries, sanitation personnel are given clinical roles to play such as in Senegal, where they are expected to substitute for health center chief nurses when the latter are absent from their posts.

4.1.3 The Same People Administer Both Programs in the Field

In almost every developing country responsibility in the field for implementing programs in both oral rehydration therapy (if such a program exists) and sanitation fall upon the same health personnel: nurses, auxiliaries, community health workers, itinerant health agents, and other "front-line" workers. They are responsible for hygiene education, for promoting the construction of latrines, for treating diarrhea, and for a host of other activities.

Sanitarians per se are frequently in short supply. In some countries one sanitarian can be found for a district, and in others whole provinces may be without a sanitarian. Even one sanitarian per district is not enough to carry on all the needed activities. In Sri Lanka, a district sanitarian may have to inspect meat, supervise street cleaning crews, and participate in maternal and child health clinics, leaving only one to two days a week for sanitation work in 150 to 200 villages. It falls then to health personnel at the local level to carry on these activities, whether at a health center or health post, or through visits to villages.

Even if there is enough time for community sanitation activities, the orientation and attitude of sanitarians may be more toward collecting fines for poor hygiene and simply telling people what to do rather than working with people to solve their perceived problems. Training aimed at changing this attitude as well as training in the techniques of mixing and administering 0RS may often be necessary for sanitarians to work effectively with communities. The ability to offer some curative service such as oral rehydration may be essential. If sanitarians can teach mothers to mix oral rehydration solutions

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- - a highly f e l t need - - they may f i nd t h e i r c r e d i b i l i t y s i gn i f i can t l y increased.

4.2 Practical Suggestions for Coordinated Programs

4.2.1 Techniques for Linking ORT and Sanitat ion

A comprehensive oral rehydration therapy program, educates women not only on how to mix and use oral rehydration solut ion and how to maintain the n u t r i t i o n of the ch i ld being rehydrated but also on how to prevent d iarrhea. Therefore, i t makes good sense for the workers who are responsible for oral rehydration therapy programs to be trained in techniques they can employ to communicate e f fec t i ve ly with community members - - especia l ly women. Among these techniques are the fo l lowing:

• Use well-designed visual materials ( f lannel graphs, f l i p c h a r t s , and poster series) to st imulate discussion of personal hygiene, as was done in Niger (Bel loncle and Fournier, 1975), and teach mothers the pr inc ip les and techniques of oral rehydration therapy. In Niger visual aids were designed using local scenes and people that were fami l i a r to women. After showing the f l i p c h a r t or f lannel graph, several questions were asked to provide discussion:

What did you see in the visual aids? Why do you think we showed i t to you? What d id i t say to you?

• Conduct fol low-up of rehydrated in fants to see whether homes are furnished wi th l a t r i nes and water and soap for handwashing and to invest igate the handling of the stools of infants and todd lers . Oral rehydration therapy techniques taught could be reviewed. Latr ine const ruct ion, usual ly a local household respons ib i l i t y , might become a community pro jec t . Community pr ivate enterprises might be started to produce s labs, vent pipes, and vent screens. Water supply improvements and soap-making or cooperative purchase of soap could be undertaken as community pro jec ts .

§ During the same v i s i t , survey water sources and water uses wi th special a t tent ion to quant i t ies consumed by households, how water i s stored, and i t s access ib i l i t y in the kitchen and the l a t r i n e .

® During t h i s or a subsequent v i s i t , t r y to discover how women are involved i n community-wide a c t i v i t i e s , e i ther through a women's organization in the community or through act ive pa r t i c ipa t ion in a health committee. Attempt to meet leaders in order to arrange a series o f meetings about home-based oral rehydration and various hyg ien ic measures needed to prevent d i a r r h e a . Arranging these meetings may involve a confrontat ion with t rad i t i ona l b e l i e f s . In some areas women may par t ic ipa te only i nd i r ec t l y and i t may be customary for them to stay at home or at the periphery of v i l l a g e meetings. Sometimes in such meetings, as was the case of a v i l l a g e in Burkina-Faso (formerly Upper Vol ta) during the evaluation of a

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rural water supply p ro jec t , women may be permitted to speak only i f asked a question d i r e c t l y .

© I f no open par t i c ipa t ion of women is ev ident , then speak to v i l l age leaders about how women in the community can become involved in diarrhea treatment and prevention. Tradi t ional women leaders may be contacted. Satge et al (1970), for example, reports how t rad i t i ona l b i r t h attendants in Senegalese v i l l ages were trained to counsel the younger women in t he i r fami l ies about supplemental feedings and weaning. I f health workers found an undernourished c h i l d , one not r e c e i v i n g supplements or one being weaned too a b r u p t l y , they contacted the trained midwife in that family who immediately began dealing with the young mother. The l a t t e r paid heed to the midwife whose opinion she respected.

• I f no forum for discussing health problems ex is ts already i t may be possible to form a health committee. In many cases, however, where a v i l l age i s composed of mul t ip le castes, socio-economic classes, or ethnic groups, a v i l lage-wide health committee may not be possible; rather one may f ind i t necessary to work wi th several committees or groups.

o I f there is a problem wi th the a v a i l a b i l i t y of soap for handwashing, or sa l t or sugar for mixing the oral rehydration so lu t i on , work through the women's or another community organization to arrange to buy these products cooperat ively.

• I f water supply or technical aspects of sani tat ion are a problem, act as intermediary with the water supply agency.

• Continue meeting with the groups, using visual aids to teach, but most important ly , to st imulate discussion and to give moral and organizational support.

Given the heavy load of respons ib i l i t y already weighing upon f i e l d workers and the i r supervisors, one cannot expect the immediate implementation of a l l these techniques. Each program must be examined ca re fu l l y to determine j u s t what measures are appropriate and po ten t ia l l y use fu l .

4.2.2 The Need for Training

Training of ex is t ing health personnel is great ly needed not only to show health workers how oral rehydration therapy and sani ta t ion are l i n k e d , but also to assure maximum coverage of rural populations with both serv ices. At present neither oral rehydration therapy nor sani tat ion have reached more than a f rac t ion of the rural populations of most developing count r ies . In Togo, rural health workers have been tra ined in a stepwise fashion to form over 400 v i l l age health committees, t r a i n the i r members, and help them plan v i l l age -level pro jec ts . Anong the tasks that health committees took on were handpump maintenance, l a t r i n e bu i l d i ng , education in hygiene, oral rehydrat ion, and malaria control measures. A technique known as success analysis was used to help v i l lages real ize the i r strengths, learn from the i r achievements, and go

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on to other e f f o r t s . No problem was i d e n t i f i e d without a suggested way to solve i t .

Where possible, i t would be a desirable feature of program planning to include as many women as possible in t ra in ing programs in order to promote women's par t ic ipa t ion e f fec t i ve l y through woman-to-woman contact.

Training is not a l l that i s needed. Transport, f u e l , a supply of visual a ids, and release from duties in the hospital or health center are also required. These requirements should be discussed before a t ra in ing program i s begun. I t i s cer ta in ly worthwhile to invest in t r a i n i n g , however, since greater coverage of rural populations with oral rehydration and hygiene services can resu l t in s ign i f i can t reductions in morbidity and mor ta l i t y from diarrhea. In Ind ia , McCord and Kielmann (1978) report no s i gn i f i can t reduction in diarrheal morbidity and mor ta l i ty un t i l v i l l age- leve l workers were trained to administer treatment at home.

4.3 Pract ical Issues Faced in Focusing Programs on Women

4.3.1 Women's Roles

The f i r s t issue to be considered is the ra t i o of public versus pr ivate roles played by women from one society to another. Women's roles vary, and that var ia t ion should influence the design and implementation of diarrhea control programs. In t rad i t i ona l Islamic soc ie t ies , for example, women's roles may be e n t i r e l y p r i v a t e , n e c e s s i t a t i n g i n d i v i d u a l i z e d v i s i t s by female hea l th workers. In other soc ie t ies , even those where Islam is the dominant r e l i g i on (as in sub-Saharan A f r i c a ) , women may have more public roles and can par t ic ipate in e i ther women's or community-wide organizat ions. In Swaziland, Green (1984) found that women's organizations were more numerous and the most act ive of any surveyed among 150 communities. There i s l i t t l e chance that success can be achieved without a great deal of women's p a r t i c i p a t i o n , whether in public or en t i re l y in p r iva te .

4.3.2 Women's Time

Another issue is the amount of time women have for meetings and associated a c t i v i t i e s . Programs must be planned to f i t women's work schedules, especial ly with regard to the demands of seasonal agr icu l tu ra l work.

4.3.3 Women's Autonomy

F ina l l y , an issue that must be addressed is the a t t i t ude of husbands and other re la t ives and community members to women's involvement in programs. In most areas th i s issue w i l l not pose any problem but in others must be deal t with beforehand. Where women do not par t i c ipa te in community-wide organizat ions, such as health committees, t he i r opinions may s t i l l inf luence decisions that a f fec t them, as men have a tendency to discuss such issues wi th t he i r wives (Bay, 1982).

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4.4 Program Coordination Issues

Coordination needs to take place both wi th in and between m in i s t r i es .

4.4.1 Coordination wi th in the Ministry of Health

In order for the d iv i s ion responsible for oral rehydration therapy and the sani tat ion d iv i s ion to begin co l laborat ive t ra in ing of personnel for j o i n t operations, a decision at a policy-making level in the min is t ry of health w i l l probably be necessary. Such a decision w i l l probably come about only i f agencies l i k e the Agency for Internat ional Development (AID) exert some outside pressure. Of course, successful implementation of such j o i n t f i e l d e f fo r t s in the context o f an AID-funded primary health care project would serve to augment the pressure on top min is t ry o f f i c i a l s .

4 .4 .2 . Coordination with the Rural Water Supply Agency

Most rural water supply agencies (whether part of the min is t ry of rura l development, ag r i cu l t u re , or public works, or ex is t ing as a separate water supply min is t ry) do not have enough personnel to cover rural populations. As a resu l t , the only way health personnel can assis t rural communities with water supply problems i s to make special appeals to technicians for help. I f the technician works in a large-scale water supply and sani tat ion pro jec t , one can appeal to him by v i r t ue of his posi t ion in the pro jec t .

4.4.3 Jo in t Planning of Projects

Why not plan r u ra l water supply p r o j e c t s i n c o n s u l t a t i o n w i t h hea l th m in i s t r i es , combining san i ta t ion , health education, and oral rehydration in a coordinated way in areas of the country wi th the highest incidence of diarrheal disease? How could a min is t ry of health and a water supply agency plan such a j o i n t project?

• F i r s t of a l l the water supply should be planned so as to provide water in su f f i c i en t quant i ty (20 to 30 l i t e r s a day per person) to have an e f fec t on heal th.

• Secondly the health min is t ry should begin the process of organizing community groups to work on san i ta t i on , water supply maintenance, and other diarrhea control measures before the water supply i s i n s t a l l e d .

• Where poss ib le women's concerns for convenience, t a s t e , and r e l i a b i l i t y of water should be given serious consideration in i n s t a l l i n g water supply systems, and women should play key roles in whatever community-level organization i s establ ished.

® In communities where ora l r ehyd ra t i on therapy has not been introduced as a diarrhea control measure i t should be as soon as possible.

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The in te rmin is te r ia l coordination needed to assure a successful program i s d i f f i c u l t to achieve. Coordinating the a c t i v i t i e s of the min is t ry of health with those of the agency responsible for rura l water supply is pa r t i cu la r l y d i f f i c u l t . In Togo, i t was two years before the Min is t ry of Public Works openly admitted the value of the cont r ibut ions made by the Health Minist ry in organizing local communities to maintain and repair wel ls and pumps. In Burkina-Faso such coordination has hardly begun, although both m in is t r i es recognize i t s d e s i r a b i l i t y . In Sri Lanka, where a new water supply project is being planned, an e f fec t i ve l i n k between the Min is t ry of Health and the water supply agency has been established in pro ject plans. Only time w i l l t e l l , however, how well such pre-planned coordination w i l l func t ion .

In summary, coordination of oral rehydration therapy with sani tat ion and with water supply can take place in a p i l o t fashion in the f i e l d , but such coo rd i na t i on w i l l not be widespread in the count ry unless top l e v e l decision-makers in the min is t ry of health and in other m in is t r ies establ ish e f fec t ive l i n k s .

4.4.4 Coordination w i th in AID

Although some water supply i ns ta l l a t i ons are cos t ly in terms of capi ta l i n p u t s , most r u r a l i n s t a l l a t i o n s are of moderate cos t g iven community contr ibut ions of labor and mater ials and in some cases par t ia l or to ta l f inancing of operations and maintenance. Sanitat ion has an int imate re la t i on to diarrheal disease control and thus to oral rehydrat ion, but most sani tat ion measures (handwashing, bathing, and food preparation) depend quite simply on the a v a i l a b i l i t y of a safe, r e l i a b l e , and convenient source of water. Combining water supply and sani tat ion and oral rehydration therapy programs resul ts in both primary and secondary measures to prevent diarrhea and dehydration. Thus, one can argue fo rce fu l l y for a close association of these programs in the agenda of AID Missions.

In one country, for example, where a water supply and sani tat ion pro ject was being planned, the health o f f i c e r urged project planners to give p r i o r i t y to areas of the country with high morbidity and mor ta l i t y from diarrheal disease. Later mission e f f o r t s to promote oral rehydration in the same areas would mul t ip ly the benef ic ia l e f f ec t s . In other areas where oral rehydration programs are already in progress, water supply and sani ta t ion p ro jec ts , whether funded from health or other accounts, could be planned.

E f f e c t i n g t h i s c o o r d i n a t i o n w i t h i n a m iss ion o f t e n requ i res c lose col laborat ion between hea l th , engineering, and rural development o f f i c e r s , often not possible without the support of the mission d i r ec to r . I t i s , in f a c t , possible for a health o f f i ce r to be promoting oral rehydrat ion, while the engineering o f f i c e r i s planning a rura l water supply and sani ta t ion program, without one knowing about the program of the other. These programs should be developed together so t h a t water supp l ies are i n s t a l l e d i n communities where health personnel can be t ra ined to promote both oral rehydration therapy and san i ta t ion .

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Chapter 5

SUMMARY AND CONCLUSIONS

Diarrhea incidence is c losely related to both the qua l i t y and quant i ty of water ava i lab le . E t i o l og i ca l l y , the primary source of diarrhea is human fecal matter. Intermediate sources are contaminated water suppl ies, hands, n ipp les, household items, and pa r t i cu la r l y food.

A complete program of diarrhea control therefore includes education of the mother in diarrhea prevention. While promoting oral rehydration therapy, health personnel can work e f fec t i ve l y wi th populations ( i f possible with women's groups), in the promotion of home-based oral rehydration therapy and personal, food, and domestic hygiene. Training health workers to carry out these tasks, of course, requires careful planning, sound implementation by experienced t r a i n e r s , and fo l l ow-up to assure t r a n s p o r t and superv isory support. In order to be implemented na t iona l l y , there must be coordinat ion at three level s:

9 Within the min is t ry of health involv ing the sani tat ion uni t and the un i t responsible for diarrheal disease control

G Between the min is t ry of health and the water supply agency (or agencies) of the country.

t Within AID, where programs for oral rehydration and water supply and sani tat ion are usually managed separately.

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REFERENCES

Acra, A., Z. Raf foul , and Y. Karahagopian 1984. Solar D is in fec t ion of Drinking Water and Oral Rehydration Solut ions: Guidelines for Household Appl icat ion in Developing countr ies. Heirut: i l l u s t r a t e d Publications S . A . L .

Bay, E.G. 1982. Women and Work in A f r i c a . Boulder, Colorado: Westview Press, p. 202.

Beisel, W.R. 1972. "Nutr ient wastage during i n f e c t i o n . " Proceedings of the 9th Internat ional Congress of Nut r i t i on 2:160.

Bel loncle, G., and G. Fournier. 1975. Sante et Developpement en Mil ieu Rural A f r i c a i n . Co l lec t ion : Developpement et C i v i l i s a t i o n s . Paris: Edit ions Economiques et Humanisme, Les Edit ions Ouvrieres, p. 229.

Black, R.E., K.H. Brown, S. Becker, A.R.M.A. Al im, and M.H. Merson. 1982. "Contaminat ion o f weaning foods and t ransmiss ion o f en te ro tox igen i c Escherchia co l i diarrhea in chi ldren in rura l Bangladesh." Transactions of the Royal Society of Tropical Medicine and Hygiene 76(2):2b9-64.

Briscoe, J . 1979. "The quant i ta t ive e f fec t o f in fec t ion on the use of food by young chi ldren in poor countr ies." American Journal of C l in ica l N u t r i t i o n . 32(31:648-676.

Cappare l l i , E., and J . Mata. 1975. "Microf lora of maize prepared as t o r t i l ­l a s . " Applied Microbiology, 29:802.

Feachem, R.G., D.J. Bradley, H. Garel ick, and D. Mara. 1983. Sanitat ion and Disease: Health Aspects of Excreta and Wastewater Management" New York: Wiley, p. 288.

Green, E.C. 1985. "Swazi be l ie fs and pract ices re la t ing to diarrheal disease of chi ldhood." Social Sciences and Medicine 19.

. 1984. Tradi t ional Leadership, Community Par t i c ipa t ion and Develop­ment Educat ion : Resul ts and I m p l i c a t i o n s of Two Surveys in Swaziland. Washington, D.C.: Academy for Educational Development.

Hirschhorn, N., and K.M. Denney. 1975. "Oral g lucose-electro lyte therapy for d iarrhea: a means to maintain or improve n u t r i t i o n . " American Journal of C l in ica l Nu t r i t i on 28:189-192.

H o l l i s t e r , A . C . , M.D. Buck, A.M. G i t t e l s o h n , and E.C. Hemph i l l . 1955. "Inf luence of water a v a i l a b i l i t y on Shigel la Prevalence in ch i ld ren of farm labor fam i l i es . " American Journal of Public Health 45:354-362.

Khan, M.U. 1982. " In te r rup t ion of sh ige l los is by hand washing," Transactions of the Royal Society of Tropical Medicine and Hygiene 76(2):164-8.

Mata, L . J . , C. C a r r i l l o , and V i l l a t o r o . 1969. "Fecal microf lora in healthy persons in a pre industr ia l ized region." Applied Microbiology 17:596-602.

McCord, C , and A.A. Kielmann. 1978. "A successful programme fo r medical aux i l i a r i es t rea t ing childhood diarrhoea and pneumonia." Tropical Doctor 8:220-225.

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Merson, M. 1983. "The WHO Diarrhoeal Diseases Control Program: The pract ical appl icat ion of oral rehydration therapy." Proceedings of the Internat ional Conference on Oral Rehydration Therapy, Wasmngton, A I D , p. z'i.

Parker , R .L . , W. R ineha r t , T. P ie t row, and L. Doucet te . 1984. , "Oral rehydration (ORT) for childhood d iar rhea." Series L. No. 2 ( rev ised) . Population Reports 12(4).

Rahaman, M.M., Y. Patwari, K.M.S. Aziz, and M.H. Munshi. 1979. "Diarrhoeal mor ta l i t y in two Bangladeshi v i l l a g e s : w i th and without community-based oral rehydration therapy." Lancet, October 20:809-812.

Rahaman, M.M., M.U. Khan, M.S. Assiz, S. Islam, and A.K.M.G. K ib r iya . 1975. "An outbreak of dysentery caused by Shigel la dysenterae on Coral Island in the Bay of Bengal." Journal of In fect ious uiseases u z : i 5 - 1 9 .

Rohde, J .E. 1978. "Preparing for the next round: convalescent care a f te r acute i n f e c t i o n . " American Journal of C l in i ca l N u t r i t i o n 32:2258.

. 1983. "Mothers: Front - l ine Health WorkerSc" Salubri tas 7 ( l ) : l - 2 .

Rowland, M.G.M., R.A.E. B a r r e l l , and R.G. Whitehead. 1978. " B a c t e r i a l contamination in t rad i t i ona l Gambian weaning foods." Lancet, January 21:136-138.

Satge, P., V. Dan, A. Debroise, N. Raybaud and A. Ko i te . 1970. "Une experience de sante pub l ique appl iquee a 1'enfance en m i leu r u r a l (Khombole Senegal)." Carnets de 1'Enfance 12:31-44.

Schliessman, D.J. 1959. "Diarrheal diseases and the environment." Bu l le t in of the World Health Organization 21(3):381.

Vis, H.L., P. Hennart, and M. Ruchababisha. 1981. "L1Allai tement en zone rurale pauvre: 1'al imentation maternelle e t 1 ' al 1 aitement au Kivu, Zaire." Carnets de 1'Enfance 55/56:172-189.

Watkinson, M., N. Lloyd-Evans, and A.M. Watkinson. 1980. "The use of oral g lucose-electrolyte solut ion prepared wi th untreated well water in acute nonspecific diarrhea." Transactions of the Royal Society of Tropical Medi­cine and Hygiene 74(5):657-662.

World Health Organization. 1976. Treatment and Prevention of Dehydration in Diarrheal Disease: A Guide fo r uTe at the Primary Level . Geneva: Won a Health Organization.

1978. C l in ica l Management of Acute Diarrhea. Report of a Sc ien t i f i c Working Group, New Delh i , October 30 - November 2, 1978. Geneva: World Health Organization.

. 1979. Child Care Practices Related to Diarrhoeal uiseases. Report o t a Sc ien t i f i c working liroup, Apr i l i / - z u , i y / y . lieneva: World Heal th Organization.

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