IJPHCS International Journal of Public Health and Clinical Sciences

Open Access: e-Journal e-ISSN : 2289-7577. Vol. 4:No. 3

May/June 2017

ORS usage in the management of diarrhea among children under

age of 5 years old in Balikpapan, Indonesia

Tri Murti Tugiman1, Muhamad Hanafiah Juni2*, Hejar A.R2

1
Faculty of Public Health, Mulawarman University, Samarinda, East Kalimantan Indonesia
2
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti
Putra Malaysia

*Corresponding author: Associate Professor Dr. Muhamad Hanafiah Juni

Email: hanafiah_juni@upm.edu.my

ABSTRACT
Introduction: Diarrhea is a preventable disease, but it remains the second leading cause of
death (after pneumonia) among children aged under-five years worldwide. Diarrhea diseases
are caused by viruses, bacteria or protozoa and transmitted through faecal-oral transmission.
In Indonesia, diarrhea has been a public health problem, as reflected in the high rates of
morbidity due to diarrhea, whereby in 2012, the morbidity of diarrhea among children under 5
years old was 900 per 1000 population. ORS is simple and effective treatment for diarrhea
among children. The aims of the study are to determine the practices among mothers and
factors influencing use of ORS in management of diarrhea at Balikpapan, Indonesia.

Methodology: A cross-sectional study was conducted in South Balikpapan District of East

Kalimantan. A total of 450 children under-five years of age attending health clinics in South
Balikpapan District were randomly selected for the study. All children had history of diarrhea
for last two weeks. Mothers accompanying the child were interviewed as respondents of the
study using questionnaire developed for the study. The Statistical Package for Social Science
(SPSS) version 22 was used for data analyses.

Results: 403 or 90% mothers completed the questionnaires. 278 (69%) of the mothers
reported gave ORS treatment for their children who having diarrhea, while 125 (31%) were
not used the ORS. All mothers reported gave home remedies such as black tea (32%), guava
leaf water (21%), plain mineral water (20%), rice water (18%), coconut water (7%), and fruit
juice (2%) to children having diarrhea. The study also showed mothers had good knowledge
on diarrhea among children and about the usage of ORS. Majority mothers showed negative
belief on ORS; 54.6% mothers belief ORS cause diarrhea and 60.1% belief ORS only for
mild diarrhea. Health service factors such as distance and waiting time, and cost of ORS
among others factor influencing use of ORS among under-five years of age attending health
clinics in South Balikpapan District of Kalimantan.

Conclusion: The usage of ORS was found to be satisfactory (69%) for children under 5 years
old in Balikpapan, Indonesia. The proportion of mothers not using ORS also still high (31%)
most likely due to negative belief on ORS.

Keywords: ORS usage, diarrhea, children, Balikpapan Indonesia

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1.0 Introduction
Diarrhea diseases are caused by viruses, bacteria or protozoa. Most pathogens that cause
diarrhea mostly transmit from the stool of one person to the mouth of another via
contaminated food or water, which is known as faecal-oral transmission and the number of
organisms needed to cause clinical illness, varies amongst pathogens (UNICEF/WHO, 2009).
These are normally caused by poor personal hygiene or consuming contaminated drinking
water and food. Diarrhea is a disease characterized by having watery stool more than thrice a
day with liquid feces consistency sign (UNICEF/WHO, 2009 & Walker et al. 2012). Among
children the most important indicator of diarrhea is the consistency of stools. Passing more
than thrice with well-formed stool is not considered as diarrhea, as well as babies fed only
with breast milk, who often pass loose stools (World Health Organization, 2005). Diarrhea
has been classified as mild, moderate, and severe diarrhea. Mild acute diarrhea is defined as
having a few diarrhea stools in a day, whereas moderate acute diarrhea is defined as having
more than a few but not more than ten times diarrhea stools in a day. Meanwhile, severe acute
diarrhea is defined as having more than ten times loose and watery stools in a day.

Diarrhea is a preventable disease, but it remains the second leading cause of death (after
pneumonia) among children aged under five years worldwide, and it is estimated that in 2010,
diarrheal diseases accounted for 60.1 million disability-adjusted life years (DALYs) and for
666 000 deaths among children aged under five years - down from 70.6 million DALYs and
782 000 deaths in 2005 (GBD, 2010). In developing countries and less developed countries,
diarrhea is a common cause of death among under five children, it is accounting for 9 per cent
of all deaths among children under five of age. In 2013 estimated that about 1,600 children
died each day, or about 580,000 a year due to diarrhea (WHO, 2013). It killed more young
children than AIDS, malaria, and measles (Liu et al., 2012). In study by Liu et al (2015) it
was found that diarrhea mortality among children had been concentrated in a few countries.
Children less than 5 years old who died due to diarrhea in 15 countries , namely Indonesia,
Kenya, Sudan, Chad, Uganda, Ethiopia, Pakistan, Nigeria, Democratic Republic of the
Congo, India, Niger, Bangladesh, Angola, China, and Afghanistan (Liu et al, 2015). WHO
and UNICEF reported that used of ORS was very low in these countries (WHO & UNICEF,
2013).

The most important treatment of diarrhea in children is by replacing fluids losses through oral
rehydration therapy. These interventions have been proven to be cost-effective, affordable,
and relatively straightforward to be implemented. However, only about 39% of children under
the age of five years with diarrhea received oral rehydration therapy for treatment of diarrhea
(UNICEF & WHO, 2009). From 2000 to 2013, the annual total number of deaths from
diarrhea among children under 5 decreased from over 1.2 million to fewer than 0.6 million.
This was because many children were saved through appropriate and simple management of
diarrhea in children with the use of oral rehydration salts (ORS) and zinc supplementation
(UNICEF, 2012). Coverage of ORS usage was the lowest in sub-Saharan Africa and South
Asia Regions (36 per cent and 38 per cent, respectively), where most deaths from diarrhea
occurred among children (UNICEF, 2014).

Indonesia with estimated 27% of the population over 250 million is under the national poverty
line, and accessibility to clean water is still the main health problem. The country is still
suffering from water-borne diarrhea-causing diseases, and diarrhea is considered among the
ten leading causes of mortality (WHO/UNICEF, 2000). In Indonesia, diarrhea has been a
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public health problem, as reflected in the high rates of morbidity due to diarrhea, whereby in
2012, the morbidity of diarrhea among children under 5 years old was 900 per 1000
population (Indonesian Ministry of Health, 2012). In the study investigated diarrheal cases as
a result of chronic infectivity over a 6-year-period duration found that the infectivity was
attributed to bacterial and protozoan causes and chronic infective diarrhea was detected in
66.7% (Simadibrata et al. 2004).

The Ministry of Health Republic of Indonesia reported that diarrhea is an endemic with a
potential disease outbreak, often accompanied by death. Diarrhea had been the number one
cause of death (25.2%) among children under five years old in 2007, and in the year of 2013,
it cause 6.7% of death among children under five years old (Ministry of Health of Republic of
Indonesia, 2014). The prevalence of diarrhea among 12 - 23 months old infants in rural
Balikpapan City of Indonesia was 5.7%. It had been discovered that only 33% of children
with diarrhea received ORS and usage of ORS among children less than 5 years old with
diarrhea in Balikpapan city was also found very low (Ministry of Health Republic of
Indonesia, 2013).

1.1 Oral rehydration salts (ORS)

Researches have proven the effectiveness of ORS in dealing with diarrhea among children
(Munos et al., 2010; Pham et al., 2013; Walker et al., 2013; Walker & Walker, 2014).
Untreated diarrheal episodes in children can lead to severe dehydration, as well as contribute
to high morbidity and mortality rates. The usage of low-osmolality ORS in the management
of diarrhea at the facility and community levels had gone a long way in preventing
unnecessary deaths due to diarrhea among children under five years old. However, this is not
easy to be achieved due to some obstacles, such as lack in stock, long distances required to
reach the nearest health facilities, lack of knowledge about ORS and its appropriate use. Low-
osmolality ORS had been shown to reduce stool volume output and vomiting by 25% and
30% respectively compared to the original formula of ORS (WHO & UNICEF, 2004). Low-
osmolality ORS also reduced the need for unscheduled intravenous (IV) fluids in young
children and the duration of diarrhea by 33%. The usage of I.V. fluids implied the need for
hospitalization with all its increased costs to the health care system, as well as the potential
risks to patients (WHO & UNICEF, 2004).

The Indonesia Demographic and Health Survey (IDHS, 2007) reported that family practice of
using ORS in the treatment of diarrhea was still low as shown in Table 1 below. The possible
explanation of lower usage of ORS in treatment of diarrhea among children is lack of
knowledge and awareness among mothers on the important of ORS in treatment of diarrhea
among children.

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Table 1: Family practice in treating diarrhea among children

Aged Attend Given fluid for Given No Total children
(Months) Health diarrhea ORS treatment with diarrhea
Facility % % given
% %
<6 31.3 7.3 6.6 50.1 187
6 - 11 59.1 15.4 28.0 23.0 302
12 - 23 57.1 25.2 40.2 9.2 640
24 - 35 52.0 25.1 37.7 14.0 482
36 - 47 39.7 29.3 35.1 16.3 306
45 - 59 52.3 21.4 42.7 11.3 261

1.2 Guideline for policy in controlling diarrhea and implementation of policy for
usage of ORS in Indonesia

Diarrhea is categorized as one of easily preventable and treatable diseases, yet it is the cause
of estimated 1.5 million deaths of children under 5 years old every year. Reducing the number
of deaths depends largely on delivering of life-saving treatment by using low – osmolality
ORS solution and Zinc tablet to those children in need (UNICEF, 2014b). WHO
recommended ORS with low osmolality oral rehydration salts. Usage of ORS can reduce the
use of intravenous rehydration, the amount of faeces, as well as the frequency of vomiting
when compared with the use of old ORS (Hahn et al., 2001).

Although UNICEF and WHO have recommended the usage of low-osmolality ORS solution
in treating childhood diarrhea, only 66 countries around the world, including Indonesia, had
explicit national policies to the recommendation. Indeed, an important first step to increase
the coverage of this intervention is to ensure that national guidelines promoting their usage
are established. However, policies need to be further coupled with strengthened distribution
systems and new delivery strategies to make a real difference in the availability of the new
formula to children with diarrhea (WHO & UNICEF, 2009).

In Indonesia the policies set by the government to reduce morbidity and mortality due to
diarrhea are:
a) Managing patients with diarrhea standards, both at health facilities and community /
household.
b) Implement Surveillance Countermeasures epidemiology and Extraordinary Events.
c) Develop guidelines for diarrheal disease control.
d) Improve knowledge and skills of personnel in the management of the program,
including managerial and technical aspects of medical.
e) Develop networking across programs and sectors.
f) Technical guidance and monitoring implementation of diarrheal disease control.
g) Carry out evaluations as a basis for planning the next

(Source: Indonesian Ministry of Health, 2010).

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1.3 Factors influencing ORS uses in children with diarrhea

To investigate the prevalence of ORS in diarrhea treatment, a study among 140 children under
5 years old suffered with diarrhea for a duration of approximately two weeks had revealed
that; of the 140 cases, 35 children (about 25%) were self-treated, 72 were aided by health
workers, and 60.7% of them received treatment from nurses in private practice. The decoction
was the main medicine used by the family and traditional healer. Most of the health workers
gave injections using prescribed drugs, while 49.2% of them practiced oral rehydration
therapy (ORT) (Indonesian Ministry of Health, 2012). The mothers who knew about ORS
accounted for 35.6% of mothers, and 26.5% of them had previously used ORS. Among the 35
self-treated cases, only 17.1% were given ORS. Gradual semi-starvation was not the common
practice in the area. Breastfeeding was stopped during the diarrheal attack in 14.1% of the
cases, while 37.6% stopped formula feeding, and 9.1% stopped the weaning diet. Meanwhile,
the appreciation of the health worker towards ORT was satisfactory, however, the
appreciation only applied to the workers who were adamant on curing the disease as soon as
possible. Thus, they were more likely to overuse drugs and the diet regimen. From these
cases, it was clear that there was a great need to train health workers, especially nurses, to
understand the more comprehensive management of diarrheal diseases (Indonesian Ministry
of Health, 2012), especially on the usage of ORS.

Study showed that the used of ORS in treatment of diarrhea among under-five year’s old
children were low in rural area of Indonesia. Majority mothers still used traditional methods,
while health workers more frequently used prescribe medicine rather than ORS to treat
diarrhea. It is important to investigate further the mother’s knowledge, attitude and practices
toward the used of ORS for treatment of diarrhea among children in rural Indonesia.

2.0 Methodology
A cross-sectional study was conducted in South Balikpapan District of East Kalimantan. The
South Balikpapan District selected because the district recorded highest incidence of diarrhea
(Dinkes Balikpapan, 2013). A proportionate systematic random sampling among children less
than 5 years old and having diarrhea during last 2 weeks attending clinics in South
Balikpapan District was used as sampling methods. A total of 450 children under-five years
of age were included into the study. The mothers accompanying the child were interviewed as
respondents of the study using questionnaire developed for the study. The interviewed carried
out by trained health workers (nurses) in the respective health clinics. The health workers
were trained by the researcher to secured data collection.

The Statistical Package for Social Science (SPSS) version 22 was used for data entry and data
analyses. Data screening and exploration had been done on all variables in order to obtain an
overview of the sample and to ensure that there was no error with data entry before data
analysis was carried out. Errors in data entry and missing values were corrected accordingly
by checking the original questionnaire.

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3.0 Results and discussion

A total of 450 mothers who had reported their child age under 5 years old having diarrhea for
last 2 weeks were invited to participate in the study. However, only 403 mothers completed
the questionnaires with a total response rate of 90%.

3.1 Usage of ORS for children under 5 years old

The study revealed that only 278 (69%) of the mothers gave ORS treatment for their children
who having diarrhea, while 125 (31%) were not used the ORS.

Figure 1: Distribution of traditional remedies used by mothers during episode of diarrhea

among children under 5 years old (n = 403)

In developing countries, mothers usually manage diarrhea at home with the pattern of
management depending on perceived disease severity and beliefs (Ansari et al, 2012).
Interesting to noted that, in our study showed all the mothers (403) had given their child
traditional home remedies to their under 5 children having diarrhea. Figure 1 below showed
the frequency of traditional remedies used by the mothers. The common remedies used are
black tea (32%), guava leaf water (21%), plain mineral water (20%), rice water (18%),
coconut water (7%), and fruit juice (2%). While in study Iván Sarmiento et al (2016) reported
that traditional remedies practices by 11.3% (615/5416) of mothers for childhood diarrhea.
Use of traditional medicine is associated with several factors related to cultural transition and
to health status, with formal education playing a prominent role. Any assessment of the
effectiveness of traditional medicine should anticipate confounding by these factors, which
are widely recognised to affect health in their own right.

3.2 Knowledge of mothers regarding diarrhea in children

Table 2 below represents the distribution of knowledge of mothers regarding diarrhea in

children under 5 years old. The study showed the mothers had good knowledge regarding
signs of danger of diarrhea (score range between 46.2% to 65.3%), causes of diarrhea (score
range between 66.7% to 81.4%) and knowledge on possible action taken (score range
between 53.3% to 65.8%).

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Table 2: Distribution of knowledge of mothers about diarrhea in children under 5 years old
(n = 403)

Yes No Don't
Items
(%) (%) Know (%)
Knowledge on signs of danger of diarrhea
Starts to pass many watery stools 263 (65.3) 131 (32.5) 9 (2.2)
Has repeated vomiting 244 (60.6) 144 (35.7) 15 (3.7)
Becomes very thirsty 216 (53.6) 174 (43.2) 13 (3.2)
Is eating or drinking poorly 248 (61.6) 144 (35.7) 11 (2.7)
Develops fever 190 (47.2) 200 (49.6) 13 (3.2)
Has blood in the stools 210 (52.1) 184 (45.7) 9 (2.2)
Does not get better in three days 186 (46.2) 210 (52.1) 7 (1.7)
Knowledge on the causes of diarrhea
Contaminated food 281 (69.7) 113 (28.1) 9 (2.2)
Germs 269 (66.7) 128 (31.8) 6 (1.5)
Dirty hands 95 (23.5) 288 (71.5) 20 (5.0)
Cultural Practices 328 (81.4) 69 (17.1) 6 (1.5)
Knowledge of mothers possible action
combatting diarrhea among children
Get an early treatment as soon possible 265 (65.8) 81 (20.1) 57 (14.1)
Wait and see if it gets worse 66 (16.4) 215 (53.3) 122 (30.3)
Need not do anything at all 72 (17.9) 250 (62.1) 81 (20.0)

Several study showed significant relationship between knowledge and usage of ORS. A study
by Jamison et al. (2006) also reported that there was slight but significant relationship
between knowledge and usage of ORS solution. In addition, MacDonald et al. (2007) showed
the association between current maternal knowledge on correct signs of dehydration and
usage of ORS. Besides, there was a significant difference in mothers’ good knowledge
towards diarrhea and the management of diarrhea disease for children under 5 years old with
the usage of ORS (Amare et al., 2014).

Table 3: Distribution of knowledge among mothers on the usage of ORS (n= 403)

Don't Know
Items Correct (%) I Incorrect (%)
(%)
Knowledge of mothers on treatment of diarrhea 311 (77.2) 80 (19.8) 12 (3.0)
with ORS
Knowledge on mixing ORS 272 (67.5) 80 (19.9) 51 (12.7)
Knowledge on frequency of ORS administration 230 (57.1) 105 (26.1) 68 (16.9)
Knowledge on quantity of ORS administration 272 (67.5) 125 (31.0) 6 (1.5)
Knowledge on ORS storage 280 (69.5) 117 (29.0) 6 (1.5)

In our study on knowledge regarding usage of ORS covering general knowledge on treatment
of diarrhea using ORS, mixing ORS, frequency and quantity of administration and storage of
ORS showed that the mothers had scored higher proportion of correct answer indicating their
good knowledge on ORS usage. The findings of the study as shown in Table 3 above showed

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that the mothers had good knowledge regarding usage of ORS with score on the questions
regarding usage of ORS were ranging from 57.1% to 77.2%.

3.3 Belief of mothers on the usage of ORS

As shown in Table 4, majority of mother indicating negative belief on ORS, as 220 (54.6%:
20.6% strongly agreed, 20.8% agreed and 13.2% undecided) mother’s belief ORS cause
diarrhea among under 5 years old children and ORS only for used in mild diarrhea in children
(60.1%). Similar finding on traditional remedies use by mothers is good for diarrhea replacing
ORS (86.4%), children to be given prescribe injection first before taking ORS (73.1%), and
ORS should be given after diarrhea worsen ie more than thrice a day (41.5%).

Table 4: Distribution of belief of mothers of the usage of ORS (n=403)

Strongly Strongly
Agree Undecided Disagree
Items Agree Disagree
(%) (%) (%)
(%) (%)
ORS cause of diarrhea 83 (20.6) 84 (20.8) 53 (13.2) 79 (19.6) 104 (25.8)
ORS only for mild diarrhea 52 (12.9) 64 (15.9) 126 (31.3) 105 (26.1) 56 (13.9)
Traditional remedies good for 103 (25.6) 160 (39.7) 85 (21.1) 33 (8.2) 22 (5.5)
diarrhea replacing ORS
Before the children were given 115 (28.5) 119 (29.5) 61 (15.1) 70 (17.4) 38 (9.4)
ORS, they should be injected
with prescribe medicine first
Treatment of diarrhea with ORS 56 (13.9) 31 (7.7) 80 (19.9) 88 (21.8) 148 (36.7)
should begin after the episodes of
diarrhea occur more than thrice a
day

In developing countries there were varied beliefs among the mothers about the types, causes
and severity of diarrhea, classification of foods/fluids and beliefs and barriers about
preventing or treating diarrhea, and also traditional or home remedies in treatment of diarrhea.
Ansari et al. (2012) in his study showed that mothers’ belief on diarrhea prevented treating
diarrhea with perceived causes, management approaches, severity, and classified foods/fluids
during diarrhea - the study also found that there were differences in traditional beliefs by
different communities about management of diarrhea at local level as perceived and
childhood illnesses (Ansari et al., 2009).

3.4 The health service factors and usage of ORS

The travel distance between respondents house and health facilities play important role for
ORS utilization among the respondents. Table 5 shows that 46.9% mothers who had to travel
less than 5 km to health facilities will use ORS more frequent than if they have to travel more;
and only 23.6% and 29.5% mothers if they have to travel between 5 – 10 km and more than
10 km will use ORS respectively

The percentage of mother uses ORS also more if the waiting time in health facilities is
shorted. 63.5% mothers will not use ORS if they had to wait too long to get ORS in the health
facilities. Larson et al. (2006) reported that increased likelihood of seeking service from
health clinics by mothers displayed significant difference with usage of ORS for children with

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diarrhea. As shown the finding of this study revealed that 45.7%, 37.2% and 17.1% of
mothers will use ORS for their diarrhea child if the waiting times less than 30 minutes, 30 –
60 minutes and more than 60 minutes respectively.

Table 5: Distribution of health service factors on the usage of ORS (n=403)

Yes No
Items
(%) (%)
Distance to source of ORS
Less than 5 km 189 (46.9) 214 (53.1)
5-10 km 95 (23.6) 308 (76.4)
More than 10 km 119 (29.5) 284 (70.5)
The time required to receive the treatment
for diarrhea with ORS
Less than 30 minutes 184 (45.7) 219 (54.3)
30-60 minutes 150 (37.2) 253 (62.8)
More than 1 hour 69 (17.1) 334 (82.9)

3.5 Cost of usage of ORS

As shown in Table 6 more mothers in this study will use ORS if they get its free from health
clinic. The willingness of mothers to pay for ORS are 49.1%, 41.1% and 9.7% of mothers will
use ORS for their diarrhea child if the ORS is free, pay less than IDR 5000 and pay more than
IRD 5000 respectively for the ORS.

Table 6: Cost of ORS andr the usage of ORS (n=403)

Yes No
Items (%) (%)
Mothers to pay ORS
Free (in health facility) 198 (49.1) 205 (50.9)
Less than IDR 5000 166 (41.1) 237 (58.9)
More than IRD 5000 39 (9.7) 364 (90.3)

Although affordability has been recognized as an important factor associated with traditional
medicine, in Nigeria treatment choice involves cultural factors as well as cost of services
(Chukwuneke FN, 2012). Larson et al. (2006) showed that household income was associated
to usage of ORS for diarrhea in children. But another study by Mahalanabis et al., (1996)
showed that family income was not associated with usage of ORS for children under 5 years
old with diarrhea. The findings of the study indicate that cost of ORS or family income
doesn’t exclusive factor deciding usage of ORS for diarrhea in children. The findings of the
study are compatible with a ‘transitional society where both traditional and modern medicine
is employed and where the choice between them is determined by multifactor including belief
systems which are they in the process of change.

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Conclusion
The usage of ORS was found to be satisfactory for children under 5 years old in South
Balikpapan District of Kalimantan, but traditional home remedies still play important roles in
treatment of childhood diarrhea in South Balikpapan District of Kalimantan. Among the
factors that influencing the usage of ORS knowledge among mothers regarding diarrhea
among children and usage of ORS, belief among mothers regarding, health services factors
such as distance and waiting time, and cost of ORS.

Acknowledgement
This manuscript is part of the research finding for Master of Science by Ms Tri Murti
Tugiman title: Diarrhoea management practice in children under five years old and
its associated factors among mothers attending health clinic in Daerah Balikpapan
Selatan, Kalimantan Timur, Indonesia, as part of fulfilment for Master of Science
(Community Health) at the Universiti Putra Malaysia.

Declaration
The authors declare no conflict of interest in publication of the manuscript.

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