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Promoting Better Home Care of Young Children withDiarrhea through Workshops at Preschool and DaycareSettingsDr. Lynn Artz a , Scott Winnail b , Rebecca Bailey c , Brian F. Geiger b , Cynthia Petri b & J.Walter Mason aa School of Public Health , University of Alabama at Birmingham , USAb School of Education , University of Alabama at Birmingham , USAc World Health Organization in Geneva , SwitzerlandPublished online: 25 Feb 2013.

To cite this article: Dr. Lynn Artz , Scott Winnail , Rebecca Bailey , Brian F. Geiger , Cynthia Petri & J. Walter Mason (2000)Promoting Better Home Care of Young Children with Diarrhea through Workshops at Preschool and Daycare Settings, Journal ofHealth Education, 31:1, 42-49, DOI: 10.1080/10556699.2000.10608647

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Promoting Better Home Care of Young Children With Diarrhea Through Workshops at Preschool

and Daycare Settings Lynn Artz, Scott Winnail, Rebecca Bailey, Brian E Geiger, Cynthia Petri, and J. Walter Mason

ABSTRACT

Diarrhea is a common and sometimes deadly illness of young children. Proper early care by parents can prevent serious complications. Recommended approaches to fluid replacement and feeding during diarrhea are not widely practiced, however. More education of parents is needed. The present study evaluated the feasibility and effectiveness of a n educa- tional intervention designed to reach parents through early childhood settings. Daycare and preschool facilities in Wilcox County, Ala., were receptive to in-service training forparents, teachers, and staff on how to care for young children wi th diarrhea. A knowledge pretest confirmed that recommendations for the early care of diarrhea were largely unfamiliar and not routinely practiced. Knowledge levels increased substantially after a practical workshop that can be easily repli- cated. Among participants who completed knowledge tests before and after the workshop, the median test score increased f rom 32 to 84%. Distribution of information packets by daycare and preschool staff m a y be an effective way to dissemi- nate information on diarrhea care to parents unable to attend the workshop.

Diarrhea is one of the most common ill- nesses of young children. In the United States young children typically experience two to three episodes of diarrhea annually, accruing 7 to 15 episodes by age five (CDC, 1992). The illness burden nationally totals 20-35 million episodes of diarrhea per year. Diarrhea also can be a life-threatening illness. Each year among children under 5, there are 2-3.5 mil- lion doctor visits, more than 200,000 hospi- talizations, and about 400 deaths due to diar- rhea (CDC, 1992). Diarrhea is responsible for 10% of all hospitalizations of children under 5 and 10% of preventable postneonatal deaths (Glass, Lew, Gangarosa, LeBaron, & Ho, 1991). Most of this morbidity and mortality is due to dehydration associated with acute watery diarrhea.

Effective early care by parents can reduce the complications of diarrhea and prevent

hospitalizations and death. Guidelines for the care of children with diarrhea have been published by the American Academy of Pe- diatrics (AAP, 1985) and the Centers for Dis- ease Control and Prevention (CDC, 1992). These guidelines recognize that the manage- ment of acute diarrhea should begin at home. Recommended care includes the immediate, in-home administration of an appropriate oral rehydration solution (ORS) to prevent dehydration, continued feeding, and appro- priate seeking of health care.

Oral rehydration solutions have proven effective both as an alternative to intrave- nous fluids for rehydration and also for maintaining hydration and preventing de- hydration (CDC, 1992). Commercial oral rehydration solutions, typically glucose- electrolyte solutions, are readily available under brand names such as Pedialyte'".

They usually cost $ 5 to $7 per liter bottle. Sucrose-based solutions (composed of wa- ter, table sugar, and salt) and cereal-based solutions (such as those made from baby

Lynn Artz and I. Walter Mason are with the School of PublicHealth at the University ofAla- bama at Birmingham. Scott Winnail, Brian F. Geiger, and Cynthia Petri are with the School of Education at the University of Alabama at Birmingham. Rebecca Bailey is with the World Health Organization in Geneva, Switzerland. Correspondence to: Dr. Lynn Artz, MJH 108, UAB Station, Birmingham, Alabama 35294- 2010; E-mai l : lartz@ms.soph.uab.edu.

This project was funded through a cooperative agreement between the Centers for Disease Con- trol and Prevention and the Association for Schools of Public Health (S-150/14/14).

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rice cereal) can be prepared at home for considerably less cost. Homemade ORS is, however, vulnerable to mixing errors (Fontana, Zuin, Paccagnini, Palmieri, Beretta, 81 Principi, 1991; Hutchins, Wilson, Manly, & Walker-Smith, 1980; Levine et al., 1980; Snyder, Molla, & Cash, 1996). All of these solutions, when prepared and admin- istered correctly, can prevent dehydration if initiated when diarrhea first occurs (Brown, 1996; CDC, 1992).

Proper nutrition management also helps to prevent diarrheal complications (CDC, 1992). Continued feeding has proven supe- rior to the tradition of initial fasting that is widely practiced. Fasting reduces enterocyte renewal and increases intestinal permeabil- ity. Early feeding provides energy and nutrients that prevent nlalnutrition, help to repair the intestinal lining, and may reduce the severity and durat ion of diarrhea (Jelliffe & Jelliffe, 1990). Several clinical trials have demonstrated that full-strength lactose-free formulas can improve nutri- tional outcomes and reduce stool output for infants (CDC, 1992) . Cont inued breastfeeding or bottle feeding with milk- based formulas is also well-tolerated aiid beneficial (CDC, 1992). Infants who are breastfed should be allowed to feed as of- ten and as long as they want throughout an episode of diarrhea (Richards, Claeson, & Pierce, 1993). Older children should coil- tinue to receive table foods high in complex carbohydrates, particularly starches. Foods high in simple sugars and fats should be avoided. Neither antibiotics nor nonspecific antidiarrheal medications (e.g., Lomotilg, Pepto Bismolu, KaopectateB, Imodium- AD@) are usually indicated for acute diar- rhea. Other treatments and inappropriate home remedies also should be avoided.

Unfortunately, many parents of young children do not follow current national rec- ommendations for the home management of diarrhea. Parents continue to give a vari- ety of “clear 1iquids”such as carbonated soft drinks and apple juice to young children with diarrhea instead of an appropriately composed ORS. Carbonated beverages, commercial fruit juices, aiid sports drinks have no physiologic basis for use and can

cause osmotic diarrhea and electrolyte im- balance (Snyder, 1991). Many parents ad- here to the harmful practice of withhold- ing food for 24 hours after diarrhea begins. Use of over-the-counter antidiarrheal medi- cations is also common practice.

Lack of information seems to be the main reason for the discrepancy between current recommendations and current pa- rental practices. More education of parents during well-infant visits is one solution that has been recommended (Kleinman, Sack, & Dale, 1994) but this approach requires that physicians themselves be familiar with current recommendations, which is often not the case (Snyder, 1991). Educational activities in daycare and preschool settings may be an important way to disseminate information on diarrhea care to the parents of young children. The present study was undertaken to assess the feasibility and the effectiveness of an educational intervention to promote recommended diarrhea care practices to parents through early child- hood settings.

Methods

Subjects and Setting The workshops described here were con-

ducted in Wilcox County, Alabama. Located southwest of Montgomery, Wilcox is a large rural county with approximately 13,500

residents. The majority of the population (69%) is African-American. Wilcox is one of the poorest counties in Alabama. In 1990 per capita income was only $6,552, and 39% of families were below the poverty level.

In Wilcox County in 1990 there were 249 live births, 1,075 children younger than age 5, and 832 families with children under 5. At the time of the intervention this popu- lation was served by 11 preschool and daycare facilities, not counting private homes licensed to provide daycare. There were 7 preschools, including 4 Head Start programs, and 4 daycare facilities. Approxi- mately 40 teachers, teachers’ aides, admin- istrators, and other staff worked at these sites. Approximately 260 children attended these sites. Assuming 1.3 children per household (1,075 children under 5 in the county/832 households with children un- der 5), approximately 200 households (and at least 200 parents) were served by these sites.

Young children in the county experience diarrhea at increased frequency. On aver- age, children in Wilcox County experience diarrhea five to six times a year, approxi- mately twice the national average. In some of the poorest areas of this rural county where sanitation problems are prevalent, children are eight times more likely to suf- fer diarrhea than children in a neighboring

I Figure 1. Contents of Diarrhea Care Packet I

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county served by a public sewer system (Mason et al., 1993).

Intervention Methods Every preschool and daycare facility in

the county was contacted and offered a free 45-minute workshop for parents and/or staff on “How to Care for a Child With Di- arrhea.” Workshops were scheduled at times that were either most convenient for staff or when parents would be most likely to attend.Although parents were the intended audience, teachers and staff were included because of their ability to reach and edu- cate parents. In addition, many preschool and daycare providers are themselves par- ents of young children.

The workshops were conducted in the spring and summer of 1997 by a public health educator with the assistance of a graduate student in health education. The workshop consisted of an interactive pre- sentation, an opportunity to practice mix- ing and tasting ORS, and a short videotape. During the presentation the seriousness of diarrhea and the danger of dehydration were briefly discussed. Important ways to prevent diarrhea were reviewed. Then cur- rent guidelines for caring for a child with diarrhea were presented. Participants were advised to (1) give ORS, (2) continue feed- ing, and (3) watch for danger signs of de- hydration and infection. They were also advised to refrain from giving any medicine to a child with diarrhea unless instructed to do so by a doctor.

The workshop instructor discussed each of these recommendations in detail. Partici- pants were advised to give oral rehydration solutions such as Pedialyte or homemade ORS instead of sugary sodas and fruit juices or salty broths and soups. The instructor told participants to give ORS after each di- arrheal stool, as soon as the diarrhea starts and continuing until the diarrhea stops. Participants were taught how much ORS to give based on the child’s age. They were told to spoon feed ORS to infants and young children and to continue to give ORS even if a child vomits.

The common practice of initially with- holding food was discouraged. Parents were urged to continue to feed children with di- arrhea. They were told that infants with di- arrhea should continue to receive breast milk or undiluted formula, and children who eat table foods should be fed frequent small meals of bland starchy foods such as dry toast, crackers, unsweetened cereal, rice, pasta, potatoes, and bananas. Giving soft bu t sugary foods such as Jell-0’” and applesauce was discouraged.

The instructor taught participants the danger signs of dehydration (e.g., sunken eyes, a skin pinch that flattens slowly) and infection (e.g., fever). Additional danger signs such as recurrent vomiting, refusal to eat for more than 24 hours, and failure to improve within 2 to 3 days were also taught. The instructor advised participants to take the child to a doctor, nurse, clinic, or hos-

Figure 2. Mean and Median Knowledge Test Scores Before and After the Workshop (for Participants Who Completed Both Tests] I

Mean Scores Parents TeachersIStaff All Participants

( n = l l ] (n=18)

80

Q 70

;; 60

$ 50

% 40

S 30

r 20

10

0

?

2

% s 8

I Before After Before After Before Affei

All Participants ln:181

Before Afrei

pita1 immediately if any danger signs were observed.

After the presentation, participants were given a chance to practice mixing and tast- ing homemade ORS. Nearly every partici- pant took advantage of the practice oppor- tunity, usually preparing ORS in pairs. ORS preparation was watched closely by the workshop instructors and all observed er- rors were corrected immediately during the mixing practice. The importance of follow- ing the recipe exactly was emphasized.

At the end of the workshop, participants watched a 5-minute videotape titled Orul Rehydration Therapy: ORT (National ORT Project, 1991 j . Produced for parents, the videotape featured two mothers of young children, one African American and one Caucasian. The mothers in the video dis- cussed their children’s recent bouts of diar- rhea and what they had learned about ORT from their children’s health care providers. Although the video mentioned only com- mercially available oral electrolyte solutions, the video otherwise reviewed many key points from the presentation (e.g., do not give sugary drinks such a s sodas and fruit juices). The video also provided a second credible source for recommendations par- ticipants may have been reluctant to accept (e.g., to continue feeding).

Every parent who attended the work- shop received a packet to take home (see Figure 1). The packet contained a brochure, an educational coloring book, and an ORS recipe set. The reading level of these items was grade eight. The brochure reviewed important information from the workshop and included two recipes for ORS, includ- ing a cereal-based recipe. The illustrated coloring book, titled OILS to the Rescue, was designed to communicate important con- cepts of diarrhea care to children and adults with low- literacy. The ORS recipe set con- sisted of a refrigerator magnet, a recipe card for homemade ORS, and a double-ended ORS measuring spoon. Double-ended mea- suring spoons have been shown to reduce mixing errors and consistently yield physi- o 1 o g i c a1 1 y sound homemade solutions (Levine et al., 1980). A I-liter plastic con- tainer for mixing and storing homemade

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ORS also was given to parents of children under 5.

Daycare and preschool staff were given extra packets to distribute to parents who were unable to attend a workshop. They were encouraged to promote the recom- mendations of the workshop to parents whenever possible. Staff also received a poster to display promoting ORS. Evaluation Methods

The workshops were evaluated using a nonexperimental pretest-posttest design. Pre- and postintervention knowledge tests were developed by the research team to as- sess participant’s knowledge of correct di- arrhea care. To assure content validity, the knowledge tests were based on care guide- lines issued by CDC (1992), AAP (1985), and the World Health Organization (WHO, 1993). Review of the instruments by an ex- pert with WHO confirmed the content va- lidity of the instruments. The reading level of the knowledge tests, as assessed by the SMOG readability formula, was grade eight (due mainly to numerous repetitions of the word “diarrhea”). The instruments were pilot tested at a large preschool in another Alabama county to assure that the questions were understandable and would perform as expected when administered before and af- ter a workshop.

Workshop participants completed the knowledge pretest at the beginning of the workshop. Researchers were present to as- sist participants who had difficulty reading or understanding test questions. The pretest consisted of 15 questions, for which there were a total of 25 correct responses. The pre- test included three fill-in-the-blank ques- tions (six correct responses), three true/false questions, seven multiple choice questions, and two matching questions (nine correct responses). Parents of children under 5 also were asked three questions about their past and current diarrhea care practices.

At the end of the workshop, participants completed the knowledge posttest. The 15 questions on the posttest were identical to the 15 knowledge questions on the pretest. The three questions about diarrhea care practices were not repeated on the posttest.

Pretest and posttest data were to be col-

lected at every workshop and for every workshop participant. Because of time con- straints, however, the posttest alone was administered at one workshop. At other workshops where both the pretest and posttest were administered, some individu- als who arrived late completed only the posttest. Participants who completed only the posttest also were asked to answer the questions about past and current diarrhea care practices from the pretest. Data Analysis

The knowledge tests were scored by one researcher and checked by another. To com- pute a knowledge test score, the number of correct responses on each test was multi- plied by four to yield a score based on 100%.

The effect of the intervention on knowl- edge test scores was evaluated by compar- ing the overall distribution of scores before and after the intervention, and by examin- ing the score changes for individual partici- pants. Statistical inference about the distri- bution of score changes was done using a t- test for paired samples. A paired t-test was used to test the null hypothesis that there was, on average, no change in each participant’s knowledge score after partici- pating in the workshop (Glantz, 1981).

The effect of the intervention on each knowledge test item was evaluated by com- paring the overall distribution of responses before and after the intervention, and by examining the distribution of response changes for individual participants. Statis- tical inference about the distribution of changes in a single item was done using a sign test. Participants whose response did not change were considered uninformative. Participants whose response changed in the direction intended by the intervention were considered positive changes, and partici- pants whose response changed in the op- posite direction were considered negative changes. If the intervention had no effect, the changes would be randomly distributed in both directions. If the intervention had the intended effect, the number of positive responses should exceed the number of negative changes. An excess of negative changes would indicate that the interven- tion had a detrimental effect. McNemar’s

chi-square test for paired count data was used to test the null hypothesis that changes were evenly distributed in both directions (Fleiss, 1981).

Results Participation

Five of the 11 preschool and daycare fa- cilities in Wilcox County agreed to host a workshop. A sixth site was given packets to distribute in the absence of a workshop. These six sites served approximately 186 preschool children. The five workshops were attended by a total of 3 1 participants: 15 parents and 16 teachers and staff. Ap- proximately 250 information packets on diarrhea care were given to workshop par- ticipants or left with staff to distribute to parents unable to attend the workshop.

Only 2 of 11 preschool and daycare fa- cilities in the county declined to participate due to lack of interest. Three sites declined to participate because some parents or staff had already received the information. (One site had previously hosted a four-session parenting course that included this topic. Several staff from two other sites had par- ticipated in a six-session community volun- teer training course that included this topic.) Knowledge Levels Before the Workshop

Eighteen of the 31 workshop partici- pants completed the knowledge pretest prior to a workshop. Scores on the knowl- edge pretest averaged 36% (range: 4-68%). The median score was 32%. Preschool and daycare teachers and staff (n=11) correctly answered 40% of the pretest questions. Par- ents (n=7) correctly answered 28%.

Participants had considerable difficulty answering the fill-in-the-blank and match- ing questions before the workshop. Most participants (78%) could not correctly list even one way to keep a child from getting diarrhea. None of the participants knew what the letters “ORS” stood for. However, 56% of the participants were aware that di- arrhea is dangerous for young children be- cause it causes water loss, fluid loss, or de- hydration. Forty-four percent specifically mentioned the word “dehydration.” Partici- pants also recognized four of nine danger signs of dehydration or infection.

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Responses to the three true/false ques- tions were correct 52% of the time, or the equivalent of chance (i.e., guessing). Fifty-

(range: 38-92%).The median score was 84YiTeachei-s and staff (n=l6) correctlyan- swered 83% of the posttest questions. Par-

ents (n=15) correctly answered 72%. Only 26 of the 31 participants who completed a posttest were present for the entire work-

six percent of the participants an- swered incorrectly that a young child with diarrhea should be taken to a doctor immediately. Fifty per- cent thought erroneously that it was a good idea to give a child some medicine (such as Pepto Bismol, Kaopectate, or Imodium-AD) to stop the diarrhea.

Responses to the seven multiple choice questions averaged 33% cor- rect, or only slightly better than chance. Only 33% of the partici- pants knew that a child with diar- rhea should not be given sodas, fruit juices, or sports drinks. Nearly 40% thought food should be with- held for the first 24 hours. Only 1 I % correctly identified the kind of food that is recommended for chil- dren with diarrhea (i.e., bland, starchy food). Most chose salty broths and soups or sugary soft foods such as Jell-0 and applesauce. Diarrhea Care Practices Before the Workshop

Nineteen of the 31 participants responded to the questions on di- arrhea care practices that were to be answered only by parents with a child younger than age 5. One of these individuals said the questions were not applicable because her child had never had diarrhea. Most of the others (72%) said they had given Pedialyte/ORS to their child on at least one occasion. However, only 44% had used PedialytdORS the last time their child had diar- rhea. Thus, 10 of 18 mothers (56%) had put their children at risk by not administering Pedialyte/ORS when needed most recently. Knowledge Levels After the Workshop

All 31 participants completed the knowledge posttest after attend- ing a workshop. Scores on the knowledge posttest averaged 78%

Ta

ItemA Before After workshop I%) workshop 1%) x2 P

When a young child gets diarrhea, it’s a good idea to .. .

Take the child to the doctor immediately.

Stop feeding the child for 24 hours.

Give the child some medicine (such as Pepto Bismol, Kaopectate, or lmodium A-D) to stop the diarrhea.

False

False

False

What liquids should NOT be given to a child

a. Sodas such as 7-Up, Ginger Ale, and Sprite. b. Fruit Juices such as apple juice. c . Sports drinks such as Gatorade. d. All of the above.

What does ORS do? a. ORS stops the diarrhea completely. b. ORS slows down the diarrhea. c. ORS replaces the water the child is losing

and prevents dehydration.

When should OR8 be given? a. As soon as the diarrhea starts. b If the diarrhea does not improve in 24-48 hours. c. If the child shows signs of becoming dry

How much ORS should a mother give to a

a. 1/Z cup (after each diarrheal stool). b. 3/4 cup (after each diarrheal stool). c. I cup (after each diarrheal stool).

When a child with diarrhea is also vomiting, OR8 . . .

a. Should not be given. b Should be given after the vomiting stops. c. Should be given in small amounts.

What should a mother feed to a young child with diarrhea? a. Broths and soups. b. Soft foods such as Jell-0, pudding, and applesauce c. Bland, starchy foods such as crackers,

toast, cereal, potatoes, spaghetti, and rice. d. All of the above.

with diarrhea?

or dehydrated.

6-month old child?

44 72

61 100

50 94

33 83

56 83

33 89

33 89

33 72

1 1 100

2.8

7.0

8.0

7.4

5.0

11.0

10.0

5.4

16.0

ns

,008

,004

,007

,025

,0009

,002

.02

<.ooo 1

A Correct responses in boldface

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shop. Five parents arrived late and missed some or nearly all of the presentation. Posttest scores for those attending the en- tire workshop averaged 81%. Posttest scores for those who missed part of the workshop averaged 62%. Two posttest questions were answered correctly by 100% of the partici- pants who attended the workshop in its entirety (n=26). Both questions pertained to correct feeding practices.

Correct responses to the fill-in-the- blank and matching questions were much more frequent after the workshop. Fully 84% of the participants knew that diarrhea is dangerous because it causes dehydration and 58% could state what the letters “ORS” represent. On average, participants could list two of four ways to prevent diarrhea and could identify eight of nine danger signs of dehydration or infection.

Correct responses for the three trudfalse questions averaged 89%. After the work- shop, 97% of participants did not think it was a good idea to withhold food for the first 24 hours and 94% disagreed that a young child with diarrhea should be given antidiarrheal medications. However, 23% still believed incorrectly that a young child with diarrhea should be taken to a doctor immediately.

Correct responses for the seven multiple choice questions averaged 82% after the workshop. More than 80% of the partici- pants knew what ORS does (and does not do), when ORS should be given, how much ORS to give, and whether to continue ORS if a child is vomiting. Seventy-seven percent knew to avoid sugary sodas, fruit juices, and sports drinks, and 87% knew to offer bland starchy foods.

Changes in Knowledge A total of 18 workshop participants

completed both a knowledge pretest and a knowledge posttest. The pretest and posttest scores for these 18 individuals were com- pared and test scores increased significantly after the workshop ( t = 11.0; p < .0001). Median scores for the group increased from 32% on the pretest to 86% on the posttest (see Figure 2). The average test score in- creased from 36% (range: 4-68%) to 81% (range: 38-92%). If two exceptional indi-

viduals are excluded from the comparison, the average test score increased from 34% (range: 4-60%) to 83% (range: 52-92Yo).

All 18 participants increased their indi- vidual scores. The greatest improvement was from a pretest score of 12% to a posttest score of 88%. The least improvement was from a pretest score of 24% to a posttest score of 38%. However, the individual showing the least improvement appeared to have a learning disability.

For each test question, the percentage of correct responses was considerably higher after the workshop, and most of the in- creases were statistically significant (see Table 1). Correct responses to the 15 ques- tions on the pretest ranged from 0 to 61% correct. Correct responses to the same 15 questions after the workshop ranged from 17 to 100% correct. The greatest improve- ment was noted for a multiple choice ques- tion pertaining to proper feeding practices. Before the workshop, only 11% answered this question correctly. After the workshop, 100% responded correctly. The least im- provement was observed for a true/false question concerning whether to seek medi- cal care immediately (pretest: 44%; posttest: 72%). One of the fill-in-the-blank questions also showed limited improvement. Al- though the proportion unable to identify any ways to prevent diarrhea decreased from 78 to 11% and the average number of prevention strategies mentioned increased from 0 to 2.5, the proportion able to iden- tify all four strategies outlined in the work- shop increased only from 0 to17%.

Discussion The parents, teachers, and staff in our

sample from early childhood settings were generally unfamiliar with current recom- mendations regarding the proper care of young children with diarrhea. Although many parents were aware of and had previ- ously used Pedialyte, ORS was not routinely used for every bout of diarrhea. Homemade ORS was virtually unknown and unused. Recommendations regarding feeding prac- tices and antidiarrheal medications were not well known. Participants also were un- able to recognize many serious signs of dan-

ger that should prompt parents to seek medical care. For this reason alone, it may be fortunate that many in this sample erro- neously considered diarrhea a problem re- quiring immediate medical intervention rather than a problem that can be success- fully managed at home.

Fortunately, the knowledge deficits found in this population were relatively easy to correct. Through a simple, practical, health education workshop lasting about 45 minutes, knowledge about correct diarrhea care practices increased substantially. After the workshop, knowledge scores more than doubled and approached complete mastery. The proportion of correct responses in- creased for each participant and for each test question. Only the content pertaining to (a) the prevention of diarrhea, and (b) appropriate seeking of health care may need to be addressed differently in future work- shops. The prevention of diarrhea through better hygiene and food safety practices probably should be addressed in a separate workshop. Discouraging early and unnec- essary seeking of medical care by parents concerned about diarrhea may require clear messages to this effect from local health care providers.

Although ORS preparation skills were not formally evaluated, numerous minor mixing errors were observed during the mixing practice. Participants were often imprecise when measuring water or other ORS ingredients. In particular, despite a demonstration by the workshop instructor on how to level spoons of salt and sugar with a knife, many participants failed to correctly duplicate this skill during the mix- ing practice and required additional in- struction. Given the vulnerability of home- made ORS to mixing errors, the inclusion of the supervised mixing practice appears important to teaching correct preparation of ORS.

Although it was beyond the scope of this study to evaluate the impact of the work- shop on subsequent behavior, we are opti- mistic that the increased knowledge will lead to greater use of ORS, better feeding practices, more appropriate care seeking, and less use of antidiarrheal medications. The contents of the take-home packet were

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specifically designed to encourage and fa- cilitate behavior change. The visibility of the refrigerator magnet should help to prompt ORS use. Providing participants with low- cost recipes for homemade ORS should help to overcome financial barriers to the use of ORS. The special measuring spoon and mixing bottle should facilitate ease of mix- ing and storing homemade ORS. In addi- tion, daycare and preschool staff can con- tinue to remind parents to provide proper care of children with diarrhea and also serve as information resources. Still, the short- and long-term impact of this intervention on diarrhea care practices should be evalu- ated in future research.

Preschool and daycare settings were re- ceptive to hosting these workshops for staff and parents. Head Start and Even Start pro- grams in particular were extremely recep- tive given federal requirements for in-ser- vice training and the additional incentive of matching dollars. Of 11 preschool and daycare facilities in the county, 5 (45%) sponsored a workshop. Four sites received or distributed the information through other means. Only 2 sites (18%) were un- interested and failed to participate in any way. Thus, the intervention was demon- strated to be both feasible and effective.

It was not the goal of this study to maxi- mize participation or coverage, but it is pos- sible to estimate the extent to which the potential target audience was reached. The 11 preschool and daycare facilities in the county employed approximately 40 teach- ers and staff and served approximately 260 children. If the goal were to reach one par- ent per household and assuming 1.3 chil- dren per household (1,075 children under 5 in the countyI832 households with chil- dren under 5), the target audience for this intervention would have been approxi- mately240 adults (200 parents and 40 staff). Thirty-one adults attended a workshop: 15 parents and 16 teachers and staff. Thus, 8% of the parents and 40% of the teachers were reached through the workshops, approxi- mately 13% of the target audience. (If pre- vious intervention activities at nonpartici- pating sites are counted, approximately 19%

of the target audience was reached.) Participation by parents was consider-

ably lower than participation by sites and by teachers. However, a parental participa- tion rate of 8% may be relatively high when compared with other voluntary activities (e.g., participation in PTA meetings). In future efforts, higher parental participation may be achieved by offering more evening workshops combined with more aggressive promotion. Although preschool and daycare staff charged with scheduling the workshops were predisposed to daytime workshops, participation of parents was highest at evening workshops (of which there were only two).

An additional 54% of the target audi- ence may have been reached through the dissemination of information packets to parents by teachers and staff. In addition to the 31 packets given to workshop partici- pants, 6 of the 11 daycare and preschool facilities were given about 220 packets to distribute to teachers and parents unable to attend a workshop. These 6 sites served ap- proximately 186 children. Thus, an esti- mated 128 parents [(186/1.3 = 143) - 15 = 1281 did not attend a workshop but may have received an information packet. Pre- sumably at least two teachers (at the sixth site) did as well.

The exact number of parents who re- ceived a packet is not known. However, there is evidence that most, if not all, of the participating daycare and preschool facili- ties distributed packets to parents who were unable to attend the workshops. For ex- ample, two preschools requested additional packets. And one workshop participant, a preschool teacher, received a packet the day before her own workshop when she picked up her child at the county’s largest daycare.

Whether parents who received only the packets were influenced by the information in the packet is also unknown. The impact of the information packet alone in increas- ing knowledge or skills or changing behav- ior was not assessed. We would not expect the packet alone to be as effective as the workshop. But we can report that the high- est score on the pretest (68%) belonged to

the preschool teacher who received the packet from her child’s daycare prior to the workshop at her preschool. Her score on the pretest was comparable with a posttest score and suggests that the packet alone may have an effect.

This study has a number of limitations. These include the small sample size, the use of an instrument for which reliability was not established, and the failure to collect baseline knowledge data on 42% of the workshop participants. The most serious weaknesses are the focus on immediate changes in knowledge and the failure to evaluate the impact of the workshops on parental behavior. Still, the knowledge gains were of such magnitude and so consistent in their pattern that cautious optimism re- garding the effectiveness of the intervention seems warranted.

In summary, implementation of an edu- cational intervention to promote proper early care of diarrhea by parents proved fea- sible in early childhood settings. Daycare and preschool programs were receptive to hosting workshops on this topic for parents, teachers, and staff. The information pro- vided was much needed by the target audi- ence. Knowledge levels increased markedly among workshop participants. Replication of the intervention in other counties in the United States should be easy to achieve by health educators who are willing to ap- proach preschools and daycare facilities as a way to reach parents of young children. Further research is needed, however, to evaluate the impact of the workshops and the take-home packets on parental diarrhea care practices. Research also is needed on the cost-effectiveness of reaching parents through early childhood settings compared with educational interventions conducted through other channels such as well-child visits or community media campaigns.

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