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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 51-59

Caregiver's acceptability of zinc tablet for treatment of childhood diarrhea in rural and urban communities


1 Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Medical Microbiology, Bayero University Kano, Kano, Nigeria

Date of Submission13-Nov-2018
Date of Decision05-Feb-2019
Date of Acceptance18-Feb-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Ibrahim Rabiu Jalo
Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano
Nigeria
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DOI: 10.4103/smj.smj_61_18

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  Abstract 


Background: Zinc supplementation is a simple and affordable strategy for managing acute diarrhoea and preventing subsequent growth faltering and malnutrition. It has been shown that ORS and supplemental zinc, combined with continued feeding are the recommended interventions for treating diarrhoea among children. Objective: To determine the knowledge and acceptability of Zinc tablets in treatment of childhood dirrhoea. Materials and Methods: A comparative cross-sectional design was used. Data was analysed at univariate, bivariate and multivariate level using SPSS version 20. Results: Knowledge of caregivers about zinc treatment was found to be fair (40.4%) in both settings; up to 136 (45.0%) of the respondents had good knowledge. Over a half 84 (56.0%) of caregivers in the urban community compared to a quarter 52 (34.2%) of those in the rural community had good knowledge. This difference was statistically significant between urban and rural caregivers (P < 0.00). Up to 180 (81.1%) of the caregivers that have used zinc had good level of acceptability. Respondent's level of acceptability of zinc was similar in the urban 98 (81.7%) and rural communities 82(80.4%) respectively. Conclusion: There exist a wide gap between knowledge of zinc supplementation and its acceptability among caregivers and health education should be tailored to address the knowledge gaps of mothers and target women who are more at risk of poor practice.

Keywords: Acceptability, Kano, rural, urban, zinc


How to cite this article:
Jalo IR, Jibo A M, Gajida A U, Kwaku A A, Awaisu N, Yusuf A M, Kauranmata A I, Yusuf S, Shuaibu S Y, Musa A, Abubakar I S. Caregiver's acceptability of zinc tablet for treatment of childhood diarrhea in rural and urban communities. Sahel Med J 2020;23:51-9

How to cite this URL:
Jalo IR, Jibo A M, Gajida A U, Kwaku A A, Awaisu N, Yusuf A M, Kauranmata A I, Yusuf S, Shuaibu S Y, Musa A, Abubakar I S. Caregiver's acceptability of zinc tablet for treatment of childhood diarrhea in rural and urban communities. Sahel Med J [serial online] 2020 [cited 2020 Apr 1];23:51-9. Available from: http://www.smjonline.org/text.asp?2020/23/1/51/280945




  Introduction Top


Zinc supplementation is a simple and affordable strategy for managing acute diarrhea and preventing subsequent growth faltering and malnutrition. It has been shown that oral rehydration salts (ORS) and supplemental zinc, combined with continued feeding are the recommended interventions for treating diarrhea among children. Zinc supplementation for the treatment of diarrhea has been shown to decrease the duration, severity of the diarrheal episode and diarrhea hospitalization rates. Studies have indicated that zinc supplementation is a simple and affordable strategy for managing acute diarrhea and preventing subsequent growth faltering and mores so it has been shown that ORS and supplemental zinc, combined with continued feeding, are the recommended interventions for treating diarrhea. According to the 2013 NDHS, 10% of children aged <5 years had diarrheal episodes in the 2 weeks before the survey, 42% of whom were taken to a health-care facility for advice or treatment, and 29.2% did not receive any treatment.[1] There is a high prevalence of zinc deficiency in Nigeria, national prevalence is estimated at 20%, slightly higher in rural (26%) than in urban areas (17%).[2]

It has been shown that ORS and supplemental zinc, combined with continued feeding, are the recommended interventions for treating diarrhea.[3] Full benefits of zinc treatment largely depend on the knowledge and acceptability of zinc tablets by caregivers. Thus, the promotion of key family practices to improve the health of children is expected to significantly improve their chances of survival.[4],[5]

Majority of diarrhea-related deaths occur at home, thus caregivers acceptance of effective intervention in the form of zinc tablet is extremely needed to significantly reduce these avoidable deaths. In addition to poor access to proper health care, most diarrheal episodes occur at home and may even end without necessarily having any contact with the health-care system. Information on the potential barriers and enablers to scaling up zinc treatment for diarrhea in northern Nigeria and especially Kano State is lacking.[6]

Prevention and treatment of dehydration with appropriate fluids, breastfeeding, continued feeding, and use of zinc and ORS will reduce the duration and severity of diarrheal episodes and lower their incidence. Families and communities are key to achieving the goals set for managing the disease by making the new recommendations routine practice in the home and health facility. However, an intervention may have a high level of efficacy under clinical research conditions, but this does not necessarily mean that the communities for which it is intended will accept the intervention and this may reduce the effectiveness of the intervention. Many sociocultural parameters can influence caregiver's use and acceptability of a new intervention, but a well-accepted intervention could easily be disseminated throughout the community. Kano State, located in northern Nigeria where the burden of diarrhea is high presents an opportunity for those at risk to benefit from using zinc; but clear, local information is needed to support decision-making on its adoption and scale up. Hence, the study aimed to assessed caregivers knowledge and acceptability of zinc tablet.


  Materials and Methods Top


Study design

A comparative cross-sectional design was used to assess caregiver's knowledge and acceptability of zinc tablet in rural and urban communities of Kano State, Nigeria from May to August 2018.

Study area

Two local government areas (LGAs)-Tarauni (Urban) and Bunkure (Rural) were selected.

Tarauni LGA was created out of Kano Municipal LGA in October 1996. It is the second largest and second most densely populated LGA in the whole state with a projected population of 292,204 based on 2006 census result with population of children aged 0–59 months being 29,220 and women constituting 143,179 of the total population.

Bunkure LGA was created from Rano LGA in 1988. It is located in the southern part of Kano about 36 km from the city. It is bordered to the south by Rano, to the south-east by Kibiya, to the east by Wudil, to the north-east by Dawakin-Kudu and Garko, to the north by Kura and to the west by Garun-Malam LGAs. It is located on latitude 11° 41' and longitude 80 33.' It has a land area of 487 km2 with a population of 281,223 projected from the 2006 census, with women constituting 137,799 and a population of children aged 0–59 months of 28,122. It consists of ten political wards.

Study population

The study population comprised caregivers of children within the ages of 0–59 months who had diarrhea 3 months before the survey.

Inclusion criteria

  • Caregivers of children who had diarrhea in the last 12 weeks
  • Caregivers who had been living in the study areas for at least 6 months at the time of the study.


Exclusion criteria

  • Visitors to the study area
  • Caregivers who are severely ill
  • Caregivers of children outside the age range 0–59 months.


Sample size determination

The sample size for the study was estimated using the formula for comparing two proportions,[7] as stated below:



n = minimum sample size in each group

Zα = Value of the standard normal deviate corresponding to the α level of significance at 95% (normal distribution table value = 1.96)

Z1−β= Value of the standard normal deviate corresponding to the power of the test at 80% (normal distribution table value = 0.84)

P1= Proportion of caregivers (in rural areas) who gave zinc to children with diarrhea (32).[8]

P2= Proportion of caregivers (in the urban area) who gave zinc to children with diarrhea (49.7).[9]

P1− P2= Difference in proportion between children treated with zinc.

n = (1.96 + 0.84)2 [0.32 (1-0.32) +0.49 (1-0.51)/(0.32-0.49)2

n = 2.630908/0.017424 = 140

A 10% nonresponse rate was added. Hence, the sample size of 154 caregivers each in the urban and rural areas was obtained.

Sampling technique

A multistage sampling technique was used to select participants as follows.

Stage 1: Selection of local government areas

In stage one, Tarauni LGA was selected from the list of urban LGAs and Bunkure LGA from the list of rural LGAs. Tarauni LGA was selected from the listed urban LGAs and Bunkure LGA from the list of rural LGAs.

Stage 2: Selection of wards from the two sampled local government areas

From both the urban and rural LGAs, 1 out of the 10 political wards was selected using simple random sampling technique by balloting. Wards in the selected LGAs were used as sampling frame.

Stage 3: Selection of settlements

From the two (2) selected wards of the two LGAs (one ward per LGA), settlements were listed out separately. The separate list of settlements in the two sampled LGAs constituted the sampling frame. One settlement was selected through simple random sampling by balloting.

Stage 4: Selection of houses

When selecting houses, a systematic sampling method was employed. The sampling frame was obtained from the list of all the houses in each settlement using the LGA microplan for supplemental polio immunization campaigns. The sampling interval was obtained by dividing the number of houses by the sample size. The sampling interval was thus, 10 for Babban layi in the urban settlement and for the rural settlements; it was 6 for Zango and 9 for Kofar Kudu, respectively.

The first house (starting point) was identified by selecting a number at random between one and the sampling interval from the table of random numbers. Subsequent houses were identified by adding the sampling interval to the serial number of the first sampled house. Where no eligible respondent was found in the sampled house, the next house was selected, where a compound or story building was selected, only one house or flat was randomly selected from the group of houses or flats in the building using a table of random numbers.

Stage 5: Selection of households

One household was chosen in each selected house, where there was more than one household in a selected house, one household was selected using simple random sampling technique through balloting. A total of 302 households were selected for this survey.

Stage 6: Selection of respondents

In the selected household, all caregivers were assessed to ascertain eligibility. Where only one caregiver satisfied the eligibility criteria, informed consent was obtained and respondent interviewed. Where more than one caregiver was eligible, one was selected by simple random sampling through balloting.

Study instrument

An interviewer-administered, pretested, structured questionnaire adapted from previous studies,[10],[11] was used to collect data from eligible caregivers. Four female and two male research assistants were recruited for this study, in other to reduce social desirability bias, research assistants were not from the settlements where they collected data. They had a minimum qualification of ordinary national diploma in health-related discipline and have been involved in community-level survey in the past. They were also fluent in the Hausa language and sensitive to the local culture. They were trained for 2 days (6 h per day) on the contents of the questionnaire, obtaining informed consent, and interviewing process.

The questionnaire for this study was pretested in two different LGAs in Kano State. Gwale (Urban) and Warawa (Rural) LGAs selected through simple random sampling by balloting.

Measurement of variables

Knowledge

An eleven-point scale was used to score the knowledge of zinc treatment, one point for each correct answer given and zero point for incorrect answers given as No or I don't know. The score was used to grade knowledge of respondents based on previous studies as having good, fair, and poor knowledge. Good knowledge if they scored between 8 and 11, fair knowledge as scores of 5–7, and poor knowledge as scores of 0–4.[10],[11]

Acceptability

Acceptability was measured on the basis of a caregiver's report of her child's behavior when given zinc. The caregivers were asked about their perception of the taste of the zinc tablet given to their children compared to other drugs. The response options were better, same, or worse than other medicines. They were also asked about their willingness to use zinc in the future [Table 5]a.

A 2-point scale was then used to score the acceptability of zinc treatment, a point for each correct answer given (perceived taste of zinc tablet; same or better taste compared to other drugs given to the child) and zero point for incorrect answers given as taste of zinc being worse than other drugs or I don't know. A point is also given if the caregiver is willing to use zinc tablet in the future. The score was used to grade acceptability of respondents based on previous studies as having good or poor acceptability. Poor acceptability if they scored between 0–1 and good acceptability as scores of ≥2.[12]

Data analysis

Data collected was cleaned, entered, and analyzed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. 2011. Knowledge and acceptability of zinc were the dependent variables. Chi-square test and Fisher's exact test were used where appropriate to analyzed factors associated with caregiver's knowledge and acceptability of zinc. At multivariate level, logistic regression analysis was used to obtain adjusted odds ratio (AOR) with 95% confidence intervals (CI) for predictors of knowledge and acceptability of zinc.

Ethical approval

Ethical approval for the study was obtained from the Health Research-Ethics Committee of Aminu Kano Teaching Hospital (NHREC/21/08/2008/AKTH/EC/1940). The informed written consent form was translated into Hausa language and signed by participants before the questionnaire was administered. For those who were not literate, details of the consent form were explained to them in the Hausa language, and they were asked to thumbprint to indicate consent with a witness.


  Results Top


One hundred and fifty-four questionnaires were administered each in the urban and rural communities. Of these, 150 (97.4%) in the urban and 152 (98.7%) in the rural communities were completed given a response rate of 98.0%.

The mean ages (± standard deviation) of respondents in the urban and rural communities were 26.4 ± 6.7 and 24.8 ± 5.4 years, respectively. About half (51.9%) of the caregivers that participated in the study were in the age group of 15–24 years. More than a third (38.7%) of participating caregivers in the urban community were in the age group of 25–34 years compared to a quarter (27.6%) of those in the rural community. Most caregivers from both communities (98.0% urban and 96.7% rural) are Hausa and of the Islamic faith (95.3% and 94.0%), respectively. More than a third (41.4%) of the respondents in the urban community had secondary education as against 26.2% of their rural contemporaries. Close to half (47.4%) of the caregivers in the rural setting had no formal education. The main occupation of caregivers participating in the urban LGA (77.0%) was petty trading while the majority of rural respondents were housewives (75.7%); followed by civil servants (15.3%) in the urban and petty traders (15.1) in the rural communities. Similarly, 16.7% and 8.0% of the spouses of caregivers had tertiary education in the urban and rural communities, respectively [Table 1].
Table 1: Summary of sociodemographic characteristics of respondents

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Eleven domains [Table 2] were used to assess knowledge of zinc by caregivers. Majority of respondents (85.3% and 78.3%) of caregivers in both urban and rural communities agreed that zinc is a good home remedy for childhood diarrhea. The most common reason for use by both urban and rural respondents with a similar proportion of >90% was zinc stops diarrhea (94.7% and 92.8%, respectively).
Table 2: Caregiver's knowledge of zinc tablet

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Another issue known by caregivers was health-care workers highly recommend the use of zinc with rural respondents having a greater proportion 50.7% as compared to the urban respondent's 28.7% and this difference was statistically significant (P < 0.05).

Knowledge of caregivers was found to be fair (40.4%) in both settings; up to 136 (45.0%) of the respondents had good knowledge of zinc. More than half 84 (56.0%) of the caregiver in the urban community compared to a quarter 52 (34.2%) of those in the rural community had good knowledge. This difference was statistically significant between urban and rural caregivers [Table 3].
Table 3: Overall knowledge of zinc treatment

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Knowledge of zinc plus ORS was significantly associated (P < 0.05) with gender, utilization, acceptability, and the severity of diarrhea in both settings. However, the occupation of the respondents was associated with knowledge in the rural community [Table 4].
Table 4: Factors associated with knowledge of zinc

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Up to 180 (81.1%) of the caregivers had a good level of acceptability in both settings. Respondent's level of acceptability of zinc was similar in the urban 98 (81.7%) and rural communities 82 (80.4%). This difference was not statistically significant between urban and rural caregivers with P > 0.05 [Table 5]b.


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Acceptability of zinc plus ORS was significantly associated (P < 0.05) with the utilization of zinc plus ORS, caregiver's age and educational attainment of respondents in both urban and rural communities [Table 6].
Table 6: Factors associated with zinc acceptability

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After adjusting for other covariates (age, education, partner's occupation, and acceptability): utilization, place of residence, and the severity of diarrhea were found to remain significant predictors of knowledge of zinc [Table 7]. Caregivers who did not used zinc (P = 0.00, AOR = 0.06, 95% CI = 0.017–0.189) are 94% less likely to have good knowledge, caregivers of children with severe diarrhea were five times more likely to have knowledge of zinc (P = 0.03, AOR = 4.62, 95% CI = 1.16–18.40) and urban residents are three times more likely to have good knowledge (P = 0.00, AOR = 3.1, 95% CI = 3.54–9.43).
Table 7: Predictors of knowledge of zinc

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After adjusting for other covariates (age, caregiver's sex, and partner's education): partners level of education was found to remain significant predictor of acceptability of zinc (P = 0.02, AOR = 1.52, 95% CI = 0.34–0.89) with caregivers whose partners had formal education being 1.5 times more likely to have good acceptability [Table 8].
Table 8: Predictors of zinc acceptability

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  Discussion Top


The proportion of caregivers in both urban and rural areas of Kano with good knowledge of zinc was found to be 56.0% and 34.2%, respectively, and more so up to 19.3% (one-fifth) of the caregivers in urban area as against only 9.9% (one-tenth) of their rural contemporaries were found to have poor knowledge. These figures were generally sub-optimal, especially for the rural area and this may partly explain the poor child health outcomes that have plagued the state for several years. This necessitates the need for more health promotion activities in all communities to improve knowledge and acceptability of zinc by caregivers; community sensitization and mass media campaigns could be a very effective strategy to reach more families/communities. However, there appeared to be an improvement in the level of caregiver's knowledge when compared with the reported figure of 13% in a previous study conducted in northern Nigeria on knowledge and practices of zinc treatment.[6] Similarly, Ogurinde reported that <1% of caregivers in northern Nigeria were knowledgeable about home management of diarrhea with zinc.[13]

Knowledge of zinc was significantly associated (P < 0.05) with gender, utilization, acceptability, and the severity of diarrhea in both settings. However, the occupation of the respondents was associated with knowledge in the rural community. Caregivers with poor knowledge were 96% less likely to use zinc, caregivers whose children had severe diarrhea were five times more likely to have good knowledge of zinc, and urban residents were three times more likely to have good knowledge. The knowledge gap identified in this survey is similar to the finding of a study conducted in the same region where awareness of caregivers was found to be 44% in Jigawa.[6] In Benin, Nigeria knowledge of home management of diarrhea was significantly associated with age, marital status, education, and social class of mothers,[14] whereas surveys in Iran and India reported knowledge of caregivers was significant associated with the age of caregiver, partners education, number of children, occupation of mother, maternal education, and socioeconomic status of caregivers.[15],[16],[17]

Acceptability of zinc tablet among caregivers was found to be optimal as up to 81.1% of the caregivers in both settings were found to have good acceptability; few of the respondents in the urban community 22 (18.3%) had poor acceptability similar to 20 (19.6%) of those in the rural community. This difference was not statistically significant between urban and rural caregivers (P = 0.94). Acceptability of zinc tablet was significantly associated (P < 0.05) with the utilization of zinc plus ORS, caregiver's age, and educational attainment of respondents in both urban and rural communities.

Similarly, evaluation of acceptability and knowledge of zinc-use to treat diarrhea in Kenya, 2009 reported that 79.5% of caregivers had good acceptability.[18] Recent programs in Bangladesh, Benin Republic, and India, achieved a rapid increase in zinc coverage over a short period, with relatively limited funds, by implementing targeted interventions that created demand for and widespread supply of the products.[19]

After adjusting for age and caregiver's sex; partner's education was found to remain an independent predictor of acceptability of zinc with caregivers whose partner has formal education being 1.5 times more likely to have good acceptability of zinc (P = 0.002, AOR = 1.53, 95% CI = 0.34–1.89). Enhanced acceptability of zinc has been linked to reductions in the misuse of antibiotics and increase in the use of ORS to treat diarrhea. Relevant stakeholders should ensure educational opportunities for caregivers and optimization of their economic status since education will enable caregivers to better understand the information given and also ensure improve utilization of health interventions like zinc tablet for diarrhea management.

Limitations of the study

  1. Questions on diarrhea were tied to the recent diarrheal episodes (past 3 months) only rather than prior episode of diarrhea and this was to avoid recall bias
  2. The medical background of the interviewers posed a risk for social desirability bias.



  Conclusion Top


There exists a wide gap between knowledge of zinc supplementation and its acceptability among caregivers in both rural and urban communities and therefore, health education should be tailored to address the knowledge gaps of mothers and target women who are more at risk of poor practice.

Acknowledgment

The authors wish to acknowledge the technical assistance provided by Network for Behavioral Research for Child Survival in Nigeria (NETBRECSIN).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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National Population Commission and ICF Macro. Nigeria Demographic and Health Survey. Abuja, Nigeria, and Rockville, Maryland, USA: National Population Commission and ICF International; 2013. p. 566. Available from: http://www.population.gov.ng. [Last cited on 2018 Oct 12].  Back to cited text no. 1
    
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Kung'u K, Owolabi O, Essien G, Francis T, Ngnie T, Neufeld LM. Promotion of zinc tablets with ORS through child health weeks improves caregiver knowledge, attitudes, and practice on treatment of diarrhoea in Nigeria. J Health Popul Nutr 2015:23;1-33.  Back to cited text no. 2
    
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Quigley P, Emmanuel S, Godden K. Building the “enabling environment” via a multi-sector nutrition platform to scale up micronutrient supplementation in Nigeria. Field Exch 2016;51:122-4.  Back to cited text no. 4
    
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Sabo O. Scaling up ORS and zinc treatment for diarrhoea. BMJ 2012;29:1-2.  Back to cited text no. 5
    
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Taylor DW. The calculation of sample size and power in biostatistics. Community Med Prim Health Care 2012:2;6-16.  Back to cited text no. 7
    
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Mbiti EN, Kungu J, Kabaka S, Lengewa C. Barriers and facilitating factors for uptake of zinc and ORS in Kenya ; a case of Kitui county. J Health Popul Nutr 2006;3:23.  Back to cited text no. 8
    
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Nielsen M, Hoogvorst A, Konradsen F, Mudasser M, van der Hoek W. Causes of childhood diarrhea as perceived by mothers in the Punjab, Pakistan. Southeast Asian J Trop Med Public Health 2003;34:343-51.  Back to cited text no. 10
    
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Otieno GA, Bigogo GM, Nyawanda BO, Aboud F, Breiman RF, Larson CP, et al. Caretakers' perception towards using zinc to treat childhood diarrhoea in rural Western Kenya. J Health Popul Nutr 2013;31:321-9.  Back to cited text no. 11
    
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Nasrin D, Larson CP, Sultana S, Khan TU. Acceptability of and adherence to dispersible zinc tablet in the treatment of acute childhood diarrhoea. J Health Popul Nutr 2005;23:215-21.  Back to cited text no. 12
    
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Ogunrinde OG, Raji T, Owolabi OA, Anigo KM. Knowledge, attitude and practice of home management of childhood diarrhoea among caregivers of under-5 children with diarrhoeal disease in Northwestern Nigeria. J Trop Pediatr 2012;58:143-6.  Back to cited text no. 13
    
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Amir AG, Ahmad T, Negin MA. Knowledge of mothers in management of diarrheoa in under-five children, in Kashan, Iran. Nurs Midwifery Stud 2013;2:158-62.  Back to cited text no. 15
    
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Omuemu VO, Ofuani IJ, Kubeyinje IC. Knowledge and use of zinc supplementation in the management of childhood diarrhoea among health care workers in public primary health facilities in Benin-city, Nigeria. Glob J Health Sci 2012;4:68-76.  Back to cited text no. 18
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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