Community Health Nursing: Diarrhoea in Community
Epidemiology, Prevention, Screening & Management
Table of Contents
1. Introduction to Diarrhoea in Community
Community health nurse educating a family about diarrhoea prevention and proper hygiene practices
Diarrhoea in community settings remains a significant public health challenge worldwide, particularly in developing countries. As community health nurses, understanding the epidemiology, prevention, and management of diarrhoea is crucial for reducing morbidity and mortality, especially among vulnerable populations such as children under five years.
Diarrhoea is characterized by the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It is typically a symptom of gastrointestinal infection, which can be caused by various bacterial, viral, and parasitic organisms.
Key Facts About Diarrhoea in Community
- Diarrhoea is the second leading cause of death in children under five years globally
- It is responsible for approximately 525,000 child deaths annually
- Most cases can be prevented through safe drinking water, adequate sanitation, and proper hygiene
- Community-based interventions are essential for effective prevention and control
- Oral rehydration therapy is a simple, effective treatment for most cases of diarrhoea in community settings
2. Epidemiology of Diarrhoea in Community
The epidemiology of diarrhoea in community settings varies significantly across regions, with developing countries bearing the highest burden. Understanding the epidemiological patterns is essential for implementing effective community-based preventive and control measures.
Global Burden
1.7 billion cases annually worldwide, with highest prevalence in resource-limited settings
Vulnerable Groups
Children under 5, immunocompromised individuals, and elderly are most susceptible
Seasonal Patterns
Often follows seasonal patterns with peaks during rainy seasons or summer months
2.1 Classification of Diarrhoea
| Type | Duration | Characteristics | Common Causes |
|---|---|---|---|
| Acute Diarrhoea | < 14 days | Sudden onset, self-limiting | Rotavirus, E. coli, Norovirus, Salmonella |
| Persistent Diarrhoea | 14-29 days | Prolonged episode, nutritional impact | Protracted infections, malnutrition, HIV |
| Chronic Diarrhoea | ≥ 30 days | Ongoing symptoms, significant health impact | IBD, celiac disease, malabsorption syndromes |
| Dysentery | Variable | Bloody diarrhoea with mucus | Shigella, Entamoeba histolytica |
| Secretory Diarrhoea | Variable | Large volume, watery stools | Cholera, ETEC, certain toxins |
2.2 Risk Factors for Diarrhoea in Community
Environmental Factors
- Inadequate sanitation facilities
- Poor access to clean drinking water
- Improper waste disposal
- Contaminated food sources
- Poor housing conditions
- Overcrowding
Host Factors
- Age (children < 5 years, elderly)
- Malnutrition
- Immunocompromised status
- Non-breastfed infants
- Previous gastrointestinal surgery
- Certain medications (antibiotics)
Community Risk Pattern Recognition
Community health nurses should actively monitor for clustering of diarrhoea cases, which may indicate community-level outbreaks requiring immediate public health intervention. Particular attention should be given to communities with poor infrastructure, limited healthcare access, and those affected by natural disasters or humanitarian crises where diarrhoea in community settings can spread rapidly.
3. Prevention & Control Measures for Diarrhoea in Community
Effective prevention and control of diarrhoea in community settings requires a multi-faceted approach addressing various determinants. Community health nurses play a pivotal role in implementing these strategies at individual, family, and community levels.
3.1 Primary Prevention
Water Safety
- Promote point-of-use water treatment
- Teach proper water storage methods
- Advocate for improved water supply systems
- Educate on boiling, filtering, or chemical disinfection
Hygiene Promotion
- Handwashing with soap at critical times
- Safe food preparation and storage
- Proper disposal of children’s feces
- Community-wide hygiene campaigns
Sanitation Improvement
- Promote latrine use and maintenance
- Support community-led total sanitation
- Advocate for improved sewage systems
- Waste management education
The F-Diagram: Breaking Transmission Routes
The F-Diagram illustrates how diarrhoea pathogens travel from feces to a new host through fingers, flies, fields, fluids, and food. Prevention strategies target these transmission routes:
- Feces → Barriers → New Host: Sanitation facilities, handwashing, food hygiene, water treatment, and fly control can effectively break this chain of transmission.
Immunization
Vaccination plays a critical role in preventing specific causes of diarrhoea in community settings:
| Vaccine | Target Pathogen | Schedule | Efficacy |
|---|---|---|---|
| Rotavirus vaccine | Rotavirus | 2-3 doses before 6 months | 70-85% against severe rotavirus diarrhoea |
| Cholera vaccine | Vibrio cholerae | 2 doses for adults, 3 for children | 60-85% protection for 2-3 years |
| Typhoid vaccine | Salmonella typhi | Single dose with boosters | 50-80% protection |
3.2 Secondary Prevention
Early detection and prompt treatment are essential to prevent complications from diarrhoea in community settings:
- Community-based surveillance for early detection of cases and outbreaks
- Training community health workers to recognize danger signs
- Establishing oral rehydration points in accessible community locations
- Promoting early care-seeking behaviors among caregivers
- Distributing ORS packets and zinc supplements to households with children
3.3 Tertiary Prevention
Tertiary prevention focuses on minimizing the long-term impacts of diarrhoea in community populations:
- Nutritional rehabilitation for children with persistent diarrhoea
- Management of chronic complications
- Community-based follow-up of cases with lingering effects
- Psychosocial support for families affected by severe or recurrent diarrhoea
Mnemonic: “WASH-5” for Diarrhoea Prevention
- W – Water treatment and safe storage
- A – Adequate handwashing with soap
- S – Sanitation facilities and proper use
- H – Hygiene education and behavior change
- 5 – Five critical times for handwashing: before eating, before preparing food, before feeding a child, after using toilet, after cleaning a child
4. Screening & Diagnosis of Diarrhoea in Community
Effective screening and diagnosis in community settings are essential for appropriate management of diarrhoea. Community health nurses should be proficient in assessing and classifying diarrhoea cases to determine appropriate interventions.
4.1 Clinical Assessment
History Taking
- Duration and onset of diarrhoea
- Frequency and characteristics of stools
- Presence of blood or mucus
- Associated symptoms (fever, vomiting, abdominal pain)
- Food and water consumption history
- Contact with similar cases
- Pre-existing conditions
- Recent travel or exposure
Physical Examination
- Vital signs monitoring
- Assessment of hydration status
- Weight measurement (especially in children)
- Abdominal examination
- Skin turgor assessment
- Mucous membrane examination
- Mental status evaluation
Dehydration Assessment in Community Settings
| Sign/Symptom | No Dehydration | Some Dehydration (5-10%) | Severe Dehydration (>10%) |
|---|---|---|---|
| General condition | Alert, responsive | Restless, irritable | Lethargic, unconscious |
| Eyes | Normal | Sunken | Very sunken |
| Thirst | Drinks normally | Thirsty, drinks eagerly | Unable to drink or drinks poorly |
| Skin pinch | Returns quickly | Returns slowly (< 2 seconds) | Returns very slowly (≥ 2 seconds) |
4.2 Laboratory Diagnosis
In community settings, laboratory investigations may be limited but are valuable when available, especially during outbreaks:
| Test | Purpose | Feasibility in Community |
|---|---|---|
| Stool microscopy | Identify parasites, WBCs, RBCs | Medium (requires basic lab) |
| Stool culture | Identify bacterial pathogens | Low (requires advanced lab) |
| Rapid diagnostic tests | Detect specific pathogens (cholera, rotavirus) | High (field-appropriate) |
| Dipstick tests | Screen for blood, WBCs, pH | High (field-appropriate) |
4.3 Differential Diagnosis
Community health nurses should consider various conditions that may present with symptoms similar to diarrhoea:
- Malaria (particularly in endemic areas)
- Pneumonia (children may present with diarrhoea as secondary symptom)
- Urinary tract infections
- Otitis media (in infants)
- Acute surgical conditions (appendicitis, intussusception)
- Inflammatory bowel disease
- Food allergies or intolerances
- Medication side effects
5. Primary Management of Diarrhoea in Community
The management of diarrhoea in community settings primarily focuses on preventing dehydration, maintaining nutrition, and preventing complications. Community health nurses should be proficient in implementing evidence-based interventions.
5.1 Rehydration
Oral Rehydration Therapy (ORT)
The cornerstone of diarrhoea management in community settings:
- Standard WHO ORS formulation (contains sodium, potassium, chloride, citrate, glucose)
- Low-osmolarity ORS preferred for non-cholera diarrhoea
- Homemade solutions when commercial ORS unavailable:
- 6 level teaspoons of sugar + ½ teaspoon of salt in 1 liter of clean water
Rehydration Plans
Based on dehydration assessment:
- Plan A: No dehydration – home fluids, continued feeding
- Plan B: Some dehydration – ORS 75 ml/kg over 4 hours, reassess
- Plan C: Severe dehydration – immediate IV therapy or nasogastric ORS if IV not available, urgent referral
Mnemonic: “FLUID” for Rehydration Principles
- F – Frequent small amounts of fluid
- L – Low-osmolarity ORS preferred
- U – Use clean water for mixing
- I – Intake monitoring (volume and frequency)
- D – Discard unused ORS after 24 hours
5.2 Nutrition
Nutritional Support During Diarrhoea
Continuing feeding during diarrhoea is crucial to prevent malnutrition and promote recovery:
- Continue breastfeeding for infants (increased frequency)
- Resume normal feeding as soon as rehydrated
- Provide small, frequent meals of energy-dense foods
- Avoid foods high in simple sugars which may worsen diarrhoea
- Give additional meal daily for 2 weeks after recovery
Recommended foods during diarrhoea in community management:
Foods to Encourage
- Soft, mashed starches (rice, potatoes, bananas)
- Well-cooked vegetables
- Lean meats, yogurt
- Freshly prepared foods
- Complex carbohydrates
Foods to Avoid
- High-sugar drinks and foods
- Spicy or heavily seasoned foods
- Fatty or fried foods
- Carbonated beverages
- Raw vegetables and fruits with skins
5.3 Medications
| Medication | Indication | Dosage | Considerations |
|---|---|---|---|
| Zinc supplements | All diarrhoea cases in children | 10mg/day (<6 months), 20mg/day (≥6 months) for 10-14 days | Reduces severity and duration, prevents recurrence |
| Antibiotics | Only for specific bacterial causes or dysentery | Varies by pathogen | Not routinely recommended for most cases of acute diarrhoea |
| Antiparasitics | Confirmed parasitic infection | Varies by parasite | Based on laboratory confirmation or strong clinical suspicion |
| Probiotics | Adjunct therapy | Varies by preparation | May reduce duration and severity in some cases |
Medications to Avoid in Diarrhoea Management
Community health nurses should discourage the use of:
- Antimotility agents (e.g., loperamide) in children <5 years
- Antibiotics for non-specific diarrhoea
- Antiemetics in children
- Adsorbents (e.g., kaolin, attapulgite) which have no proven efficacy
6. Referral & Follow-up for Diarrhoea in Community
Effective community management of diarrhoea requires clear guidelines for when to refer patients to higher levels of care and how to conduct appropriate follow-up.
6.1 Indications for Referral
Warning Signs Requiring Immediate Referral
- Severe dehydration
- Persistent vomiting
- High fever (>39°C/102.2°F)
- Bloody diarrhoea
- Severe abdominal pain
- Altered mental status
- Failure to improve after 2 days of ORT
- Severe malnutrition
- Infants <2 months with diarrhoea
- Suspected cholera in endemic areas
The community health nurse’s role in referral includes:
- Initiating ORT before transport
- Providing a referral note with assessment findings
- Arranging appropriate transportation
- Communicating with receiving facility if possible
- Educating family on importance of referral compliance
6.2 Follow-up Care
Follow-up is crucial for ensuring complete recovery and preventing recurrence of diarrhoea in community settings:
Routine Follow-up
- Home visits within 24-48 hours for children <5 years
- Assessment of hydration status
- Verification of ORS and zinc administration
- Monitoring of food intake
- Weight monitoring (especially in children)
- Reinforcement of preventive measures
Extended Follow-up
- Weekly follow-up for persistent diarrhoea
- Nutritional counseling
- Environmental assessment for risk factors
- Screening family members for similar symptoms
- Linking to social support services if needed
- Monitoring for post-diarrhoeal complications
Community-Based Surveillance
Community health nurses should maintain records of diarrhoeal cases to identify patterns, potential outbreaks, and high-risk areas. This surveillance data contributes to:
- Early outbreak detection
- Targeted prevention activities
- Resource allocation planning
- Evaluation of intervention effectiveness
- Policy development for diarrhoea in community management
7. Nursing Process for Diarrhoea in Community
Applying the nursing process provides a systematic approach to managing diarrhoea in community settings:
| Process Step | Key Components | Community Health Nursing Actions |
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8. Global Best Practices in Managing Diarrhoea in Community
Several innovative approaches to addressing diarrhoea in community settings have shown promising results globally:
Bangladesh: BRAC’s ORT Program
Community health workers trained as “ORT promoters” have successfully reduced childhood diarrhoea mortality through house-to-house education and ORS distribution, reaching over 13 million households.
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
India: Community-Led Total Sanitation
The approach focuses on eliminating open defecation through community mobilization rather than hardware subsidies, significantly reducing diarrhoeal disease in implementing villages.
Water Supply and Sanitation Collaborative Council
Kenya: Safe Water System
Combined approach of point-of-use water treatment with chlorine solution, safe water storage containers, and behavior change communication reduced diarrhoeal disease incidence by 24-59%.
Centers for Disease Control and Prevention
Integrated Global Initiatives
- UNICEF/WHO Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD): Comprehensive approach combining prevention and treatment strategies for both major childhood killers
- Scaling Up Nutrition (SUN) Movement: Addressing nutritional factors contributing to diarrhoea susceptibility and impact
- Clean Household Air For All initiative: Reducing exposure to household air pollution which has been linked to increased diarrhoea susceptibility
- WASH in Schools programs: Teaching proper hygiene practices at school age to establish lifelong habits
Transferable Lessons for Community Health Nurses
- Community ownership and participation are essential for sustainable change
- Simple technologies with proper education can have significant impact
- Integration of diarrhoea prevention with other health initiatives increases effectiveness
- Building on existing community structures improves program acceptance
- Empowering women as health educators and ORT providers strengthens outcomes
- Regular monitoring and evaluation help adapt approaches to local contexts
9. Mnemonics for Diarrhoea in Community Management
Mnemonics aid in remembering critical aspects of diarrhoea management in community settings:
“DIARRHOEA” Assessment
- D – Duration and frequency
- I – Intake and output balance
- A – Associated symptoms
- R – Risk factors (environmental, personal)
- R – Red flags requiring referral
- H – Hydration status assessment
- O – Oral rehydration capability
- E – Environmental conditions
- A – Age-related considerations
“WATER” Prevention Strategy
- W – Water safety practices
- A – Adequate handwashing
- T – Toilet use and maintenance
- E – Environmental cleanliness
- R – Refuse proper disposal
“REHYDRATE” Management Plan
- R – Replace fluids lost
- E – Electrolyte balance restoration
- H – Home-based care instructions
- Y – Yield to referral when necessary
- D – Diet continuation
- R – Regular monitoring
- A – Additional zinc supplementation
- T – Teach prevention strategies
- E – Evaluate outcomes
“GERMS” Transmission Prevention
- G – Good hand hygiene
- E – Environmental cleanliness
- R – Raw food cautious preparation
- M – Maintain safe water supply
- S – Sanitation facilities proper use
10. References
- World Health Organization. (2017). Diarrhoeal disease fact sheet. Retrieved from WHO website.
- UNICEF/WHO. (2009). Diarrhoea: Why children are still dying and what can be done.
- WHO/UNICEF. (2013). Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).
- Bhutta, Z. A., et al. (2013). Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost? The Lancet, 381(9875), 1417-1429.
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Community-based approaches to diarrhoea management.
- Centers for Disease Control and Prevention. (2015). Global WASH-Related Diseases and Contaminants.
- Kruk, M. E., et al. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health, 6(11), e1196-e1252.
- Pickering, A. J., et al. (2019). The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. The Lancet Global Health, 7(8), e1139-e1146.
- Troeger, C., et al. (2018). Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Infectious Diseases, 18(11), 1211-1228.
- Stenberg, K., et al. (2017). Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. The Lancet Global Health, 5(9), e875-e887.