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Promotion of oral rehydration therapy comparing a home-made rice-powder gruel and oral rehydration salts
Homero Martínez, Rossana Bojalil, and Héctor Guiscafré
Characteristics of the use of two oral rehydration solutions [rice-based gruel (RBG) or oral rehydration salts (ORS)] were assessed in 162 mothers of children under five years of age who presented a first episode of diarrhoea during the study period, in 12 rural villages of Central Mexico. Eighty-six mothers lived in six villages randomly assigned to receive the RBG promotion and 76 lived in six villages assigned to receive the ORS promotion. The intervention strategy, relying on face-to face contact by health auxiliaries who teach mothers about the dangers of dehydration, how to recognize it, and how to prepare and feed an oral rehydration solution, closely resembled that used by the National Program for the Control of Diarrheal Diseases. Before the intervention, 42% of all mothers used RBG and 58% used ORS; 8% of mothers who used RBG and 18% of those who used ORS used the beverage for rehydration purposes. After the intervention, in the villages where RBG was promoted, 57 (66%) of the mothers used RBG and 14 (16%) used ORS. In the villages where ORS was promoted, 9 (12%) of the mothers used RBG and 58 (76%) used ORS. In both groups, all mothers used at least one other beverage (usually herbal tea) during diarrhoea. but the promoted beverages were used first The use of the promoted beverage was higher when mothers had used it before the intervention. Eighty-six percent of mothers who prepared RBG used the promoted concentration of ingredients, whereas all mothers who prepared ORS correctly diluted one package in 1 L of water. After the intervention, 54% and 67% of mothers said they used RBG and ORS specifically to prevent dehydration.
Oral rehydration therapy is the most effective way to treat dehydration secondary to acute diarrhoea . Although several beverages are effective for this purpose, the choice of the most suitable one has been a subject of considerable debate. Early discussions dealt with the optimum composition of a carbohydrate-electrolyte solution [2-4], whereas later the focus was on cereal based solutions , which may be as effective in reestablishing hydration and preventing dehydration as the previous glucose-based solutions and may have greater acceptability at the home level [5-9]. Since the late 1980s and early 1990s, attention has been increasingly drawn to rice-based beverages, as they seem to decrease diarrhoeal output and shorten the time to rehydration [10-15].
Before the present study, rice-based gruel (RBG) and pre-packaged oral rehydration salts (ORS) were assessed in the study area in Mexico by direct observation of mothers' practices during actual episodes of diarrhoea . The use of RBG and ORS was 38% and 9%, respectively. At the same time, a national representative survey carried out by the Mexican Ministry of Health showed that the average use of ORS in the country was 9% , and the use of home-made fluids during acute diarrhoea, among which rice-based fluids are preponderant [18, 19], was estimated to be 35% . Mothers in rural Mexico commonly give rice-based beverages (rice water, rice gruel) to their children with diarrhoea. but their main purpose is not to rehydrate, but to help settle the child's upset stomach and sustain nutrition . After that study, we tested the RBG prepared the way mothers do in a rural area, and showed that it was effective in rehydrating children with acute diarrhoea .
In the period between the study identifying RBG as a potential rehydration fluid (which took place in 1987) and the beginning of the study reported here, two crucial events occurred in the country that significantly increased the use of oral rehydration therapy. First, the Ministry of Health responded to Mexico's commitments made in 1990 with UNICEF's World Summit for Children, in which one of the goals was to reduce mortality due to diarrhoeal disease by 50%, with an extensive national programme for controlling the diseases [23, 24]. As part of this programme, a nationwide campaign was launched to promote the use of pre-packaged ORS . Second, shortly thereafter, in June 1991, a cholera epidemic reached Mexico. This further increased the government's efforts to promote ORS through mass media (radio, television) and printed materials in health facilities .
At the same time, a change in policy took place in the Mexican Ministry of Health in relation to oral rehydration therapy. The initial resistance to promoting home-made beverages  was based on published literature showing that preparing oral rehydration solutions at home was difficult and time-consuming ; that based on experience in the country, mothers preferred the prepackaged salts ; and that the promotion of prepackaged salts would be a more effective way to incorporate medical personnel into oral rehydration therapy than the promotion of home-made solutions. This slowly changed, however, to recognition that some solutions available at home, such as rice water, could be helpful in preventing dehydration . Eventually, it was recognized that RBG not only was effective as a rehydration solution but actually decreased stool output, making it especially effective in children with high purging rates .
Having proved the clinical efficacy of the RBG in a previous stage of the programme, the present study was planned to promote its field use as an oral hydration solution, describing characteristics of its acceptability compared with a pre-packaged ORS currently promoted by the Ministry of Health .
The study took place in the same rural area in which the preparation of RBG was originally studied . Eight communities participated, four of which were randomly assigned to the promotion of RBG and four to the promotion of ORS; seven of these communities had been part of the baseline study. The general strategy for promoting the beverages was similar to the one used by the public health system in the country; that is, it relied strongly on face-to-face contact by health auxiliaries, who were usually women from the same community in which they worked, who had elementary school training, and who could talk to mothers using local, colloquial language. These auxiliaries were usually supervised by a field primary care physician. The ORS was made available to the community through local stores .
Four months before data collection was begun, community health workers visited mothers of children under five years of age to show them how to prepare the assigned solution, recommending as well the practice of sustained feeding with locally available and culturally acceptable foods . At this stage, health workers visited on average 10 houses per day. During data collection, all the houses with target children were visited weekly by the health worker to identify those with acute diarrhoea. The number of houses visited by each health worker varied, depending on the number of children under five years of age in each community; this number was distributed evenly among the days of the week for each health worker.
Previous studies in the same area showed that mothers' definition of diarrhoea corresponded closely to clinical criteria, consisting primarily of watery content (84%), increased number of stools (68%), or both symptoms (99%); therefore, in this study we relied on mothers' accounts of the presence of diarrhoea [16, 32]. Mothers were instructed to recognize alarm signs for dehydration, following the criteria established by the National Diarrhea Control Program (increased number of liquid stools; frequent vomiting; intense thirst; diminished urine, with concentrated colour; very little intake of fluids and foods; fever; blood in stools) [27, 33], and were encouraged to take their children to the project's clinic if such signs appeared . Only first episodes of diarrhoea during the study period were included in the analysis, although the same dynamics of home visits and reinforcement of education took place with all episodes identified throughout the duration of the study.
The day after a child was identified with diarrhoea, a physician visited the house to assess the administration of hydration solutions. The object of the visit was to ensure that proper action could be taken if it appeared that the child's general status was deteriorating. The physician applied a questionnaire to identify the type of beverage given to the child by the mother, and other characteristics such as its method of preparation, the time at which it was started and stopped, the mother's opinion about its effectiveness, reasons for giving or withholding it, and other home-made beverages offered to the child. The physician also performed a physical examination to assess the child's hydration status, reinforcing the mother in recognizing the alarm signs that should prompt her to seek help. The health auxiliaries made a last visit to the home once the diarrhoeal episode was over, to ask about the time when the oral hydration solution was stopped. All procedures were approved by the institution's ethical review committee.
A deliberate effort was made to ensure that ORS packages were available at local stores as well as in the public health clinics, where mothers could get them free of charge. Also, health auxiliaries checked periodically at local stores to ascertain whether the rice powder required to prepare rice gruel was available, although no specific action was taken to ensure this supply.
Data analysis included descriptive statistics of the administration of oral hydration solutions and the characteristics listed above. Comparison of these characteristics between both intervention groups was done by a c 2 statistic.
Morbidity surveillance identified 162 children under five years of age who experienced one episode of diarrhoea to be studied during the intervention period; 86 lived in the communities where the use of RBG was promoted, and 76 in the communities where ORS was promoted. All the mothers had received education on the use of home fluids and foods, and all of them agreed to the follow-up visits.
The mean age (± SD) of children in the RBG communities was 24.3 ± 13.5 months (range 4-60 mo), which was not significantly different from that of children in the ORS communities, 21.4 ± 12.9 months (range 2-53 mo).
The basal determination of previous use of the beverages was 42% for RBG and 58% for ORS. Before the intervention, the concept of dehydration was not widespread in this population; less than 40% of the mothers mentioned at least one clinical sign of dehydration when asked to do so, and nearly 30% mentioned none. Only 8% of the mothers who gave RBG did so for hydration, compared with 18% of those who gave ORS.
During the study period, all mothers except one in each group reported giving a child at least one beverage during the episode of diarrhoea. In the villages where RBG was promoted, 57 (66%) of the mothers used RBG and 14 (16%) used ORS. In the villages where ORS was promoted, 9 (12%) of the mothers used RBG and 58 (76%) used ORS.
In addition to the promoted beverages, mothers gave other home-made fluids. However, the promoted beverage was usually the first fluid given to the child (table 1). In both groups, herbal teas were the second most frequently given beverages.
TABLE 1. Beverages used by mothers during diarrhoeal episodes in their children, according to the group in which the beverage was promoted and the order in which they were fed during the episode
|Beverage used and first introduction of beveragea||Promotion of|
|later during the episode||17||20||3||4|
|later during the episode||6||7||20||26|
|later during the episode||15||17||14||18|
|Other recommended beveragec|
|later during the episode||12||15||11||14|
|Other non-recommended beveraged|
|later during the episode||1||1||1||1|
Mothers were more likely to use the promoted beverage if they were familiar with that beverage be fore the intervention: 85% (23) of the mothers who were familiar with RBG gave it during the diarrhoeal episode, as did 97% (36) of the mothers who were familiar with ORS (table 2).
Eighty-six percent of the mothers who prepared RBG used the promoted concentration of rice (50 g rice powder/L water); the mean concentration was 57.9 g/L (95% confidence interval 51.4 to 64.5; minimum 25.5, maximum 94.2 g/L). The mean concentration of sugar was 52.3 g/L (95% CI 46.4 to 58.1; minimum 21.1, maximum 89.5 g/L). The correlation between the amount of rice and the amount of sugar was 0.65 (p < .0001). The mean measure of 1 L water was 970 ml; three mothers prepared the gruel with half a litre (measured 500 ml), but they also used half the concentration of the other ingredients. All mothers who prepared ORS made the correct dilution of one package in 1 L water (the mean measure of 1 L was 1,000 ml).
The median time in which RBG feeding was begun was 6 hours (range 0-96 hours, mode 2 hours), significantly different (p < .001) from the median time of 12 hours in which ORS feeding was begun (range 1-96 hours, mode 24 hours). The median time that RBG was fed was 6.5 hours (range 1-48 hours), and that of ORS was 8 hours (range 1-66 hours; not significant).
After the intervention, 54% and 67% of the mothers, respectively, said that they gave RBG and ORS specifically to prevent dehydration in the villages where these two fluids were promoted (table 3). Among the reasons they stopped giving the beverage, the most common was that the child did not like it (9% in each group); 1% and 8% of the mothers in the RBG and ORS groups, respectively, said that they ran out of the beverage, and 1% in each group cited the child's continued vomiting. The main reason for not using the promoted beverage was not having the necessary ingredients at home, 9% and 14% for RBG and ORS, respectively.
One objective of the present intervention was to teach mothers to give their children the promoted liquids with the specific purpose of preventing or treating dehydration. Over half the mothers in both groups thought that the beverage had been helpful in preventing dehydration. Thus, compared with baseline values, the awareness of the effectiveness of these beverages for this purpose increased by 46% and 49% in the RBG and ORS villages, respectively.
The initial usage rate of RBG and ORS in the study area in 1987 was similar to the rate in a representative national sample of mothers, which strengthens the external validity of our findings. Our study showed that the administration of oral rehydration therapy can be substantially increased, even in the face of the present high levels of use in the country. The use of ORS had been previously boosted by the national campaigns promoting pre-packaged salts, from 9% at the beginning of the overall programme presented here to 22% just after the cholera epidemics , and to 42% two years later nationwide . The local promotion increased it by another 34% in the study villages. In contrast, the use of RBG was supported only by this study, and increased 24% from 42% to 66%.
TABLE 2. Percentage of mothers who used the promoted beverages according to their custom of using that beverage before the intervention
|Were used to||Used|
(n = 28)
(n = 36)
(n = 39)
(n = 25)
|yes (n = 27)||85||14a||11||97a|
|no (n = 37)||15||87||89||3|
|yes (n = 37)||14||85a||97||11a|
|no (n = 27)||86||15||3||89|
a. p < .001.
The availability of rice powder was greater than that of ORS, as only 9% of mothers did not have it at home when needed, and only 1% said that they discontinued giving it because they ran out of it. In contrast, 14% did not find ORS and 8% discontinued its use because they ran out of it. These findings are especially important because no special strategy was followed to make rice powder available in local stores, whereas a specific effort was made to have prepackaged ORS in these stores. In the absence of the latter strategy, it is clear that the use of RBG has a greater chance of sustainability at the community level.
TABLE 3. Main reasons given by mothers for using the selected beverages
|Support child's nutrition||3||5||2||4|
|Settle child's stomach||3||5||l||2|
|No special use||3||5||2||4|
RBG was fed to children significantly earlier during the diarrhoeal episode than ORS, probably also due to wider availability of the rice powder in the home.
The proportion of mothers who prepared the solutions according to instructions was high, 86% and 100% for RBG and ORS, respectively. Actually, the preparation of RBG in the present study was remarkably similar to what we found in the original ethnographic study (52.3 vs 57.8 g/L rice powder, and 52.3 vs 66.4 g/L sugar) .
Even though some mothers did not prepare RBG exactly according to instructions, they still prepared it with a concentration of rice powder and sugar adequate for hydration purposes, without adding any risk to the child in terms of osmolar load. Osmolar load is a major concern of clinicians when dealing with oral rehydration solutions  according to evidence from both the present series of studies  and other clinical trials [6, 38-41]. Several authors determined that the osmolar load of rice powder is very low [10, 42, 43], and we previously showed that the concentration of sugar is the largest contributor to the osmolarity of the RBG . The calculated osmolarity of the rice gruel with the largest concentration of sugar in the present study was 247 mOsm/L.
The proportion of mothers who thought that the beverage had been helpful in stopping diarrhoea was significantly higher for those who used RBG (25%) than for those who used ORS (14%, p < .05). This is an important finding, as the mothers received no specific message in this respect. Actually, their perceptions about the usefulness of RBG agree with findings from several studies, including our own clinical trial , showing that rice-based ORS diminishes diarrhoeal output on average by 30% [10, 13, 44].
Summary and conclusion for the overall programme
When we designed the programme, we were looking for a second-best alternative to pre-packaged ORS. We were willing to sacrifice efficacy to increase coverage to improve the overall public health effectivess of an oral hydration intervention. During the course of the programme, however, we found that RBG was not only as good as ORS, but was actually better, for the following reasons:
It is culturally acceptable to a high proportion of mothers, not only in the study area but also throughout Mexico [17, 21, 35, 36].
It is clinically safer because it is not a hyperosmolar solution that may worsen diarrhoea, and it will not cause hypernatraemia .
It reduces faecal output by increasing the uptake of endogenous sodium and water present in the intestinal lumen [14,15].
Mothers perceive it as a beverage that will help to stop diarrhoea, and they can also learn that it is meant to prevent and treat dehydration.
The wide household availability of the rice powder required to prepare the gruel makes it a solution that is fed earlier to the diarrhoea-affected child, facilitates its use long enough during the episode, and guarantees sustainability of the intervention at the community level.
It was possible to teach the mothers to prepare the beverage with an acceptable variability, using an intervention that closely resembles the present strategy of the control of diarrhoeal diseases programme.
In summary, the promotion of oral hydration therapy relying on rice gruel is a sound intervention for preventing and treating dehydration due to acute diarrhoea in Mexico and should be preferred over the promotion of prepackaged ORS at the home level.
Because we undertook these studies in close collaboration with the Mexican health authorities responsible for diarrhoea control, the results of our programme were more widely accepted, as shown by the mentioned change in national policy. In 1984, when the National Program for Oral Hydration Therapy (NPOHT) was established, the policy was to promote the use of prepackaged ORS exclusively, and to discourage the use of other solutions prepared at home from local ingredients . A few years later, due in part to the results of our study  as well as others conducted in the oral hydration ward of the Children's Hospital [30, 33], the official research and training centre for the NPOHT, rice-based beverages were accepted as effective alternatives at the hospital level to reduce diarrhoeal output, particularly in patients with high purging rates [25, 30]. At present, rice water is among the preferred beverages promoted in Mexico by the NPOHT, and the most recent edition of the training manual for the control of diarrhoeal diseases in the country now refers to our clinical study to support the administration of rice gruel in the home management of dehydration .
A similar evolution in the management of diarrhoea has also occurred worldwide. From initial emphasis on prepackaged salts as the basis for oral rehydration therapy, the World Health Organization now recommends that home-made beverages , which may have higher cultural acceptability, be used, provided their content is adequate to promote fluid and salt absorption . These beverages usually are based on cereals or other foods such as soups or broths  containing starch and other polymeric substances that enhance active transport of water and salt across the intestinal mucosa [10, 11, 13, 15]. We expect that the present study and other studies will increase this movement from prepackaged salts to food-based fluids in the management of diarrhoea at home.
Dr. H. Reyes' comments on a previous version of this paper are sincerely acknowledged. Financial support for this research was provided in part by the Applied Diarrheal Disease Project at Harvard University by means of a cooperative agreement with the US Agency for International Development. Financial and logistical support was also received from the Instituto Nacional de la Nutrición, Mexico.
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