Management of childhood diarrhea by healthcare professionals in low income countries: An integrative review

Accepted Manuscript Title: Management of childhood diarrhea by healthcare professionals in low income countries: An integrative review Authors: MS Ana F. Diallo BSN PhD Xiaomei Cong RN Wendy A. Henderson PhD, MSN, CRNP PhD Jacqueline McGrath RN PII: DOI: Reference:

S0020-7489(16)30131-6 http://dx.doi.org/doi:10.1016/j.ijnurstu.2016.08.014 NS 2812

To appear in: Received date: Revised date: Accepted date:

22-12-2015 17-8-2016 19-8-2016

Please cite this article as: Diallo, Ana F., Cong, Xiaomei, Henderson, Wendy A., McGrath, Jacqueline, Management of childhood diarrhea by healthcare professionals in low income countries: An integrative review.International Journal of Nursing Studies http://dx.doi.org/10.1016/j.ijnurstu.2016.08.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

1

Management of childhood diarrhea by healthcare professionals in low income countries: An integrative review Ana F. Diallo, MS, BSN, RN1 Xiaomei Cong, PhD, RN1 Wendy A. Henderson, PhD, MSN, CRNP2 Jacqueline McGrath, PhD, RN, FNAP, FAAN1, 3

1

University of Connecticut, School of Nursing, Storrs, Connecticut, USA

2

National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA

3

Connecticut Children’s Medical Center, Hartford, Connecticut, USA

Corresponding author: Ana F. Diallo, BSN, RN University of Connecticut, School of Nursing, U-4026 Storrs, CT 06269-4026, USA (804) 852-0538

2

Abstract Background: The significant drop in child mortality due to diarrhea has been primarily attributed to the use of oral rehydration solutions, continuous feeding and zinc supplementation. Nevertheless uptake of these interventions have been slow in developing countries and many children suffering from diarrhea are not receiving adequate care according to the World Health Organization recommended guidelines for the clinical management of childhood diarrhea. Objectives: The aim of this integrative review is to appraise healthcare professionals' management of childhood diarrhea in low-income countries. Design: Whittemore and Knafl integrative review method was used, in conjunction with the Reporting of Observational Studies in Epidemiology (STROBE) checklist for reporting observational cohort, case control and cross sectional studies. Method: A comprehensive search performed from December 2014 to April 2015 used five databases and focused on observational studies of healthcare professional's management of childhood diarrhea in low-income countries. Results: A total of 21 studies were included in the review. Eight studies used a survey design while three used some type of simulated client survey referring to a fictitious case of a child with diarrhea. Retrospective chart reviews were used in one study. Only one study used direct observation of the healthcare professionals during practice and the remaining eight used a combination of research designs. Studies were completed in South East Asia (n = 13), SubSaharan Africa (n = 6) and South America (n = 2). Conclusion: Studies report that healthcare providers have adequate knowledge of the etiology of diarrhea and the severe signs of dehydration associated with diarrhea. More importantly, regardless of geographical settings and year of study publication, inconsistencies were noted in healthcare professionals' physical examination, prescription of oral rehydration solutions, antibiotics and other medications as well as education provided to the primary caregivers. Factors other than knowledge about diarrhea were shown to significantly influence prescriptive behaviors of healthcare professionals. This review demonstrates that "knowledge is not enough" to ensure the appropriate use of oral rehydration solutions, zinc and antibiotics by healthcare professionals in the management of childhood diarrhea.

Keywords: antibiotics use; childhood diarrhea; healthcare providers; low income countries; prescribing behaviors; oral rehydration therapy; World Health Organization; clinical management of childhood diarrhea.

3

1-Introduction Ranked as the second leading cause of death in children under the age of 5, diarrhea is responsible for approximately 578 000 deaths and 1.7 billion reported episodes each year (Liu et al., 2015). Beginning in 1978, diarrheal-control programs led by the World Health Organization (WHO), focused on the promotion of safe drinking water and oral rehydration solutions (ORS) in conjunction with continued feeding (Fontaine et al., 2009). By 1988, more than 100 countries adopted diarrheal diseases control programs following the WHO recommendation that focuses on the promotion of oral rehydration solutions as a major aspect of management (WHO, 1989). Diarrhea-control programs have been reported to account for substantial reductions in childhood mortality due to diarrhea, decreasing by 20.8% between 2000 and 2013 in South Asia and by 16.8% in Sub-Saharan African during the same period (Lui et al., 2015). As of 2004, the WHO updated its childhood diarrhea management guidelines with a new oral rehydration formulation containing decreased glucose and sodium concentrations. Studies demonstrated that the reduced osmolarity of oral rehydration was safer than the original oral rehydration solutions and decreased stool output by 20% (Hahn, Kim & Garner, 2002). Oral zinc supplementation is recommended for 10 to 14 days at 20mg per day in children 6 months and older and 10mg per day in those younger than 6 months (WHO, 2005). It is important to note that the guidelines included the prescription of antibiotic therapy only in cases of bloody diarrhea or cholera. Despite the success of the early diarrhea-control programs and the updated WHO guidelines, many children under the age of 5 do not receive adequate treatment during an episode of diarrhea. Recent reports indicated that only 40% of children suffering from diarrhea worldwide received oral rehydration or increased fluid intake with continued feeding as part of their

4

management (United Nations Children’s Fund, 2013). This increase is only 10% greater (approximately) than the 1995 global percentage of children under 5 years who received oral rehydration as treatment for their diarrhea (Fontaine et al., 2009). The unchanged rate of use of oral rehydration solutions over the past two decades has been linked to the diversion of international funding toward malaria and AIDS after the incorporation of diarrhea-control programs into the Integrated Management of Childhood Illness approach (Fontaine et al., 2009). Management of diarrhea programs were moved down in the priority list of national and international institutions. This is despite the fact that diarrhea causes more deaths than AIDS, malaria and measles combined (United Nations Children’s Fund / World Health Organization, 2009). In addition, the incorporation of the diarrhea-control program into Integrated Management of Childhood Illness caused inconsistencies in healthcare professionals’ training and community programming specific to diarrhea management (Fontaine et al., 2009). Healthcare professionals (mainly physicians, pharmacists, midwives and nurses) at the public and private levels play an important role in the management of childhood diarrhea. Recent studies performed in South India and Sub-Saharan Africa have shown that, regardless of receiving formal diarrhea management training, healthcare professionals treating children with diarrhea tended to prescribe more antibiotics, injections and anti-diarrheal medications than oral rehydration solutions and zinc (Pathak, Pathak, Marrone, Diwan, & Lundborg, 2011; Sood & Wagner, 2014). Efforts are therefore needed to evaluate healthcare professionals’ clinical management of childhood diarrhea in the most affected area of the globe. The purpose of this integrative review is to evaluate the clinical practice of healthcare professionals in the management of diarrhea in children. The study will answer the following research question: What has been healthcare professionals’ management of childhood diarrhea

5

in low income countries between 1988 and 2014? The ultimate goal of the study is to explore the clinical practice of healthcare professionals, as it occurs in the natural settings over the years and across geographical settings. A synthesis of observational studies, completed between 1988 and 2014, will strengthen the literature and provide a broad picture of the magnitude of the problem in the most affected regions of the world. Recommendations for how best to change practice will also be discussed. 2-Method 2-1 Search strategy and selection criteria Due to the global reach of the WHO guidelines, physicians’ and other advanced health workers’ training manuals for the treatment of diarrhea published in 1984 and 2004 were used to guide the literature search. According to the manuals, healthcare care professionals’ training should be based on three major elements: a fundamental knowledge about diarrhea; the assessment of the clinical signs and symptoms presented by a child with diarrhea; and the clinical management based on the different types of diarrhea. Observational studies reporting on at least two or more of the following outcomes related to healthcare professionals’ clinical management of childhood diarrhea following the WHO guidelines were included. The measured outcomes were: 1) healthcare professionals’ knowledge about childhood diarrhea and assessment of the dangerous signs and symptoms; 2) the prescription of oral rehydration solutions, antibiotics and other drugs for the clinical management; and 3) the prescription of zinc supplementation. Healthcare professionals were defined as any individual with some medical or pharmacological training, including physicians, pharmacists, nurses and midwives. The review was restricted to studies performed in low-income countries as defined by the World Bank (World Bank Group,

6

2014). The literature search included studies published between 1988, when most national programs for the control of diarrheal diseases were established, and 2014, published in English. Exclusion criteria were: studies reporting infections other than those causing diarrheal diseases in children; and studies focusing only on drug therapies and the management of a population of children older than 5 years. A comprehensive literature search was performed using five databases between December 2014 and April 2015. The databases were PubMed, CINAHL, Scopus, World Health Organization Global Health Library and CAB Direct. The following keywords, MeSH terms and headings were used in various combinations: adherence, guideline, practice guideline, management, prescribing patterns, knowledge attitude and practice, attitude of health personnel, physicians’ practice patterns, health care providers, healthcare professionals, nurses, midwives, physicians, doctors, pharmacist, pediatrician, clinical management, diarrhea, diarrhoea, infant, children and preschool. In addition, references in retrieved articles and other related reviews were searched for relevant studies.

3- Results A total of 4,125 articles were retrieved using the different combinations of keywords, MeSH terms and headings. Setting the limitations to years of publications between 1988 and 2015, 3,222 articles remained. After screening the abstracts, 2,971 publications were excluded primarily because they were duplicates and did not focus on management of childhood diarrhea

7

by healthcare professionals. An additional 230 articles were removed from the review because of their study designs or because they were conducted in a country that was not defined by the World Bank as a low-income country. Finally, a total of 21 studies were included in the review. Data analysis was completed following the Whittemore and Knafl (2005) method of integrative review and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used for evaluation of the studies’ findings, data extraction and organization. The selected publications were observational studies and reported on healthcare professionals’ management of childhood diarrhea in low-income countries. Eight studies used a survey design while three used some type of simulated client survey, in which a member of the research team approached healthcare professionals with a fictitious case of a child with diarrhea. Retrospective chart reviews were used in one study. Only one study used direct observation of the healthcare professionals during practice. The remaining eight used a combination of research designs. The study samples varied and included one or more healthcare professional groups. Of the 21 studies, 15 focused on physicians, five explored pharmacists’ management of childhood diarrhea, while only one study included nurses and nurse midwives as research respondents (Figure 3). Completed both in urban and rural settings between 1989 and 2014, these 21 studies were representative of the three continents accounting for the highest proportion of children suffering of diarrhea: East Asia (n = 13), Sub-Saharan Africa (n = 6) and South America (n = 2). Further details of the studies’ demographics are presented in Table1. Since the study sample differs in many aspects (e.g., geography, time, study population, research setting), the analysis needed to be based on a generalized approach allowing incorporation of all the diverse features of the selected studies. The WHO training manuals for the treatment of

8

childhood diarrhea (WHO, 1984; WHO, 2005) were considered the reference for the formulation of many national guidelines on the clinical management of diarrhea in children worldwide. The analysis was therefore based on the essential elements of the clinical management of childhood diarrhea according to the WHO training manuals. The training manuals were used to ensure an analytical approach that controlled for the diversity of the study sample and led to the focus on three major outcomes. In addition to the initial predetermined outcomes, a frequent theme emerged from the analysis and led to a fourth outcome measure. These outcomes are: 1) healthcare providers’ knowledge about childhood diarrhea and assessment of the dangerous signs and symptoms; 2) the prescription of oral rehydration solutions, antibiotics and other drugs for the clinical management; 3) the prescription of zinc supplementation; and 4) factors affecting prescribing behaviors. The outcomes are presented in a chronological manner to compare and contrast management before and after the 2004 World Health Organization guidelines. This approach allows identification of changes in the clinical management of diarrhea over time.

3-1 Knowledge about diarrhea In most studies, healthcare professionals’ knowledge about diarrhea was assessed at three levels: 1) the most common cause of diarrhea in children; 2) assessment of signs of severe dehydration; and 3) caregivers’ education about home therapy for childhood diarrhea.

9

Etiology of diarrhea. In general, healthcare professionals showed adequate knowledge of the etiology of diarrheal diseases and the most frequent signs of severe dehydration. Viral infections were reported as the most common cause of diarrheal diseases in children (Berih, McIntyre, & Lynk, 1989; Kanungo et al., 2014; Paredes, de la Pena, Flores-Guerra, Diaz, & Trostle, 1996). In a survey study, Okeke et al. (1996) examined the knowledge of, attitudes toward and practices with oral rehydration solutions in 91 medical providers in the state of Enugu, Nigeria. A majority of medical providers (74%) identified the most common cause of diarrhea in children to be of viral origin. The next most common etiology reported by the providers was bacterial (20%), then protozoal infections (Okeke, Okafor, Amah, Onwuasigwe, & Ndu, 1996). In a more recent publication, knowledge of diarrhea and its management was also evaluated in physicians working in the slums of Kolkata (Kanungo et al., 2014). The majority of the participants (59.47%) cited viruses as the most common diarrheagenic pathogens (Kanungo et al., 2014). Participating physicians recognized that the most frequent episodes of diarrhea in children were caused by viruses. The same physicians acknowledged that, except for cases of severe or bloody diarrhea, antimicrobial therapy was not necessary for the treatment of the diarrhea (Kanungo et al., 2014; Paredes et al., 1996).The viral origin of the most frequent cases of childhood diarrhea was reported by healthcare professionals before and after 2004 in countries in Sub-Saharan Africa and South Asia. Assessment of signs of severe dehydration. While the results of the studies indicate that the majority of the healthcare professionals could correctly define the most common causes of diarrhea and identify diarrhea’s dangerous signs, inconsistencies were found in the questions asked in health histories and physical examination characteristics. Berih et al. (1989) evaluated the prescribing behaviors of pharmacists in Sudan using a research team member with a fictitious

10

case of a child suffering from diarrhea. The authors reported that out of 63 pharmacists, 40 (63.5%) did not perform a health history before recommending a treatment plan for the child (Berih et al., 1989). Interestingly, pharmacists who asked at least one question pertinent to the child’s symptoms, more frequently made referrals to a physician and were less likely to recommend antimicrobial drugs (Berih et al., 1989). These results are consistent with findings reported by Beria and colleagues (1998). In their study, the authors reviewed medical reports to explore physicians’ prescribing behaviors for childhood diarrhea in parts of Brazil. The authors found that 98% of physicians (n = 54) completed a health history. At least 65% of the physicians performed a physical examination to assess for other signs of severe dehydration. However, assessing or asking about the presence of blood in the stool, for example, did not occur regularly. They found that only 22% of the surveyed physicians checked for the presence of blood in the stool (Beria, Damiani, dos Santos, & Lombardi, 1998). Inconsistencies in health history practices appeared to exist over time and in varied geographical settings. They appear to be related with providers’ training and experiences. In a more recent study completed in Thailand by Saengcharoen and Lerkiatbundit (2010), a comparison of the management of childhood diarrhea was conducted between pharmacies with a registered pharmacists who could sell antibiotics without prescriptions (type I) and pharmacies not required to employ registered pharmacists and could only sell over-the-counter drugs (type II). In type I, 55.2% pharmacists asked questions specific to the child’s history. However, in type II pharmacies, only 21.1% of the personnel in these pharmacies took a history of the child’s symptoms before providing treatment (Saengcharoen & Lerkiatbundit, 2010). Studies’ results indicate that healthcare professionals with a higher level of training are more likely to assess signs of severe dehydration in children with diarrhea compared to those who did

11

not receive advanced training. Regardless of the professionals’ level of training, dates of the studies’ publication and study sites’ locations, these studies documented that assessments of severe signs of diarrhea and physical examinations were not performed at every encounter. Caregivers’ education on home management of diarrheal diseases. Management of diarrhea mostly occurs at home, and adequate care is ensured when caregivers receive the correct education on dosage and preparation of oral rehydration solutions and continued feeding practices. This requires caregivers to receive correct information by healthcare professionals at the hospital and community level. Therefore, healthcare professionals’ knowledge of diarrhea and its correct treatment is a safeguard for the appropriate management of the condition in children outside of the health system. Overall, healthcare providers’ education related to home nutritional management for diarrhea was reported to be “unclear” across the study findings. In a study completed by Paredes et al. (1996), mothers described physicians’ instructions for continuous feeding to be vague. Out of 44 health professionals surveyed, only four prescribed oral rehydration solutions with correct prescription instructions (Paredes et al., 1996). All but one of the 44 physicians recommended continued exclusive breastfeeding for children under three months and diluted bottle milk for children aged three to 36 months (Paredes et al., 1996). In another recent study, Alam and colleagues (2003) evaluated rural medical practitioners’ education of primary caregivers in the management of rehydration therapy during childhood diarrhea. While 79.4% of observed healthcare providers advised the caregivers on home rehydration management, only 22% provided correct instructions to the families and more than 75% were prescribing fluids such as tea and glucose water that are not advised during management of diarrhea (Alam, Khan, & Amir, 2003).

12

Appropriate nutritional recommendations related to both food and milk consumption were reported by only 2.6% of Thai pharmacists interviewed by Saengcharoen et al. (2010). Taking these strategies individually, recommendations related to providing an all milk diet (breastmilk or formula) were provided by only 6.1%, while recommendations on appropriate food intake were given by 12.2% of the pharmacists (Saengcharoen & Lerkiatbundit, 2010). Healthcare professionals’ reported knowledge about diarrhea has been similar over the years and across different countries of the world. Higher education levels appear to improve healthcare professionals’ history taking and assessment of the signs of severe dehydration. However, the training does not ensure the practice of these initial steps, critical in the management of childhood diarrhea, on a regular basis. Reports on caregivers’ education follow the same trends. Regardless of dates of the studies and the location of their sites, the studies’ findings report that healthcare professionals’ instructions to caregivers in the nutritional management of childhood diarrhea were not consistent. 3-2 Prescription for oral rehydration solutions, antibiotics and other drugs for the management of diarrheal diseases. Oral rehydration solutions. The majority of the healthcare professionals reported having knowledge about the importance of oral rehydration solutions and stated prescribing it frequently when treating childhood diarrhea. The percentages of those recommending oral rehydration solutions were noted to be greater than 50% of providers but rarely higher than 70% (Okeke et al., 1996; Saengcharoen & Lerkiatbundit, 2010). Limited prescription of oral rehydration solutions alone in the management of childhood diarrhea was described by some healthcare professionals who reported facing challenges with acceptability of oral rehydration solutions in children. Bitter and salty taste, disagreeable color and induced nausea and vomiting were the

13

frequent reasons physicians believed the rehydration therapy was not accepted by the patients and their families (Gani et al., 1991). The unpalatable taste of the oral rehydration solutions was considered to be a deterrent for caretakers to use oral rehydration solutions alone for the management of diarrhea. For these reasons, healthcare professionals tended to prescribe other medications considered more effective, like antibiotics or anti-diarrheal medications (Gani et al., 1991; Paredes et al., 1996). Survey, observation or fictitious case studies highlighted a gap between healthcare providers’ reported knowledge about oral rehydration solutions and its prescription versus their actual prescription during management of children with diarrhea (Beria et al., 1998; Gani et al., 1991; Nizami, Khan, & Bhutta, 1996; Younas et al., 2009). In the study authored by Gani and colleagues (1991), the researchers used both interviews and observation intervention to assess physicians’ prescribing behaviors in Indonesia. While 100% of the physicians reported prescribing oral rehydration solutions in their management of childhood diarrhea during the survey, only 75% were actually observed prescribing the rehydration therapy (Gani et al., 1991). With the WHO recommended change in the formulation of oral rehydration solutions published since 2004, the hope was to increase the consumption of rehydration therapy (WHO, 2004). However, more recent studies still report limited prescription of oral rehydration solution alone. The same gap between reported versus observed prescription of oral rehydration solutions has been described. Agrawal et al. (2008) reported that 73% of medical officers and 81% of interns knew the preparation of oral rehydration solutions as recommended by the WHO 2004 guidelines. Of the medical officers and interns who were interviewed, only 31% stated giving oral rehydration solutions, continuous feeding and zinc, while 62.5% recommended antibiotics in 50% of the cases (Agrawal et al., 2008).

14

The researchers (2008) also interviewed other healthcare professional groups such as auxiliary nurse midwives, health assistants, nursing students and traditional healers. They found that 55% of auxiliary nurse midwives, 36% of health assistants and 72% nursing students knew the appropriate dosages for the preparation of oral rehydration solution. In terms of diarrhea treatment, 33% of nursing students, 20% of auxiliary nurse midwives and health assistants declared recommending oral rehydration solutions and continuous feeding (Agrawal et al., 2008). Similar to the studies’ finding on the knowledge of diarrhea, patterns seem to exist in the gap between knowledge and practice across the studies’ dates and geographical settings. The published reports on rehydration solution in healthcare professionals’ management of childhood diarrhea also highlight a limited knowledge about the correct preparation and consistent prescription of the therapy. Antibiotics. High prescription rates of antibiotics were reported in many of the studies, regardless of the fact that healthcare professionals acknowledged that viruses rather than bacteria were the most common pathogens causing diarrhea in children (Berih et al., 1989; Howteerakul, Higginbotham, Freeman, & Dibley, 2003; Naeem, 2014). Gani et al. (1991) interviewed and observed physicians’ clinical practice during treatment of diarrhea in children in Jakarta. Although physicians believed the most frequent cause of diarrhea was viral, 61% reported prescribing antibiotics while 94% were actually observed prescribing antibiotics for treatment of acute diarrhea in children (Gani et al., 1991). The prescription of oral rehydration solutions in combination with antibiotics was consistently high across the selected studies. A total of 70% of healthcare professionals participating in the study led by Igun and colleagues in Nigeria (1994) reported combining antibiotics and oral rehydration solutions in their management of the diarrheal diseases in children. However, the

15

prescription of a therapeutic combination was not evaluated in the record review completed within this study to identify whether gaps existed between what was stated by the providers and what was actually prescribed (Igun, 1994). Almost twenty years later and with a growing concern about antibiotic resistance, the prescription of antibiotics reported as “unnecessary” in cases of childhood diarrhea remains significant. Younas et al. (2009) stated that 91.25% of children (n = 80) admitted to the hospital for acute watery diarrhea, received antibiotics either orally or parentally. The indiscriminate prescription of antibiotics in cases of childhood diarrhea by physicians was reported to be given to treat co-infections, prevent complications or secondary infections and was also related to reported uncertainty about the etiology of the disease (Paredes et al., 1996; Younas et al., 2009). Younas et al. (2009) reported that metronidazole was given by medical officers in 61.25% of the children treated for diarrhea. The drug was either taken in combination with other drugs or with oral rehydration solutions. Co-trimaxazole was frequently cited by healthcare providers as a treatment of choice for the treatment of diarrhea (Howteerakul, Higginbotham, & Dibley, 2004; Howteerakul et al., 2003; Nizami et al., 1996; Saengcharoen & Lerkiatbundit, 2010). This drug, however, is primarily prescribed as prophylaxis therapy in the treatment of severe cases of Pneumocystis jirovecii pneumonia in HIV-infected or HIV-exposed infants under the age of 1 year, and prophylaxis treatment for malaria and severe bacterial infections in adult and children taking antiretroviral treatment (WHO, 2010). The drug is not recommended nor is it needed for children suffering of diarrheal diseases who are not infected or exposed to HIV (WHO, 2010). Antidiarrheal. Antidiarrheal drugs have never been recommended in the management of childhood diarrhea (WHO, 2005). The prescription of these drugs has been linked to undesirable and sometimes fatal side effects in children. While physicians, interviewed by Paredes et al.

16

(1996) recognized antidiarrheal as “unnecessary” in the treatment of diarrhea and were aware of the national policy restricting its prescription, 26% believed in the effectiveness of these drugs, and they were prescribing them in combination with antibiotics. The study with the highest report of antidiarrheal medications prescribed for the management of childhood diarrhea, was performed a decade after the publication of the updated WHO guidelines by Naeem et al. (2014). The authors compared prescribing behaviors of physicians who attended a diarrhea training management course to those who did not. The physicians who did not attend the training course were significantly more likely to prescribe antidiarrheal drugs (44.1%) compared to those who attended the training course (17.4%) (Naeem, 2014). Consistent with the conclusions drawn from the analysis of the previous outcomes, training appears to make a substantial difference in healthcare providers’ practices during management of childhood diarrhea. Parallel to the reported knowledge about diarrhea and prescription of oral rehydration solutions, the studies’ findings indicate similarities in healthcare providers’ prescribing behaviors in the management of childhood diarrhea. Unnecessary prescription of antibiotics and antidiarrheal drugs have been reported in countries located in three different continents over the last thirty years. Although the findings indicate higher prescriptions rates of oral rehydration solutions based on the healthcare professionals’ medical training, education does not ensure consistent prescription of oral rehydration solutions or limited prescription of antibiotics and other medications in the management of diarrhea in children under 5. 3-3 Prescription of zinc supplementation

17

Recommendations of zinc supplementation with rehydration therapy were added in the 2004 WHO guidelines for children with acute non-dysenteric watery diarrhea (WHO, 2004). When reported in the studies, however, zinc supplementation was either not prescribed or prescribed in only very limited occasions (Chakraborti, Barik, Singh, & Nag, 2011; Lofgren, Tao, Larsson, Kyakulaga, & Forsberg, 2012; Pathak et al., 2011; Younas et al., 2009). Healthcare providers’ knowledge about the benefits of zinc in the management of childhood diarrhea was low. Among 843 prescriptions to children being treated for diarrhea by surveyed physicians and pharmacists in Ujjain district, India, Pathak et al. (2011) noted that zinc was prescribed alone in only 27% of the cases and in combination with oral rehydration solutions in only 22% of the cases. In addition, the authors reported that only in 6 of the 843 prescriptions did physicians follow the national guidelines, and they included only oral rehydration solutions and zinc in their management (Pathak et al., 2011). More recently, Lofgren and her research team (2012) reviewed medical records and interviewed staff at health centers and drug shops in a rural district of Uganda. The authors reported that, at the time of the study, zinc supplementation was not cited in the national clinical guidelines (Uganda) for diarrhea management and was not distributed to the health centers and the staff at the health centers never reported zinc as part of their treatment for childhood diarrhea (Lofgren et al., 2012). The most common reasons for the limited prescription of zinc was both institutional (not available) and financial (too costly). Changes in policies at the national level and the lack of funding were reported as major reasons why zinc was unavailable at the local level in health centers and/or drug shops in Numutumba district (Lofgren et al., 2012; Pathak et al., 2011). The majority of the countries where the studies were conducted have established clear guidelines in the management of childhood diarrhea which mirror the WHO guidelines (Indian Academy of

18

Pediatrics, 2006; Kenyan Ministry of Public Health and Sanitation, 2010; Paediatric Management Group (PMG) in South Africa; Bhatnagar et al., 2007; Wittenberg, 2012; International Vaccine Access Center & Johns Hopkins Bloomberg School of Public Health, 2015). National diarrhea management programs exist and are reported to focus frequently on training community members and healthcare professionals to increase their knowledge about adequate management of childhood diarrhea and adherence to national guidelines. However, these data indicate that improving knowledge does not necessarily translate into improved practice in the studied settings. In fact, the studies’ documenting limited prescription of oral rehydration solutions and zinc supplementation as well as the over-prescribing of antibiotics and other drugs reflects the presence of a gap between the WHO or countries’ specific national guidelines, on the one hand, and the healthcare professionals’ treatment choices in the management of childhood diarrhea, on the other. Factors other than training and knowledge have been frequently reported to significantly influence the actual practice of healthcare professionals in the management of childhood diarrhea. 3- 4 Factors other than knowledge about diarrhea, influencing management of childhood diarrhea A total of 15 studies reported factors other than knowledge about diarrhea, influencing healthcare providers’ prescribing patterns in childhood diarrhea (Gani et al., 1991; Howteerakul et al., 2003; Saengcharoen & Lerkiatbundit, 2010). Frequently cited factors included the healthcare providers’ training, perceived severity of the symptoms associated with diarrhea, caregivers’ expectation and related effects of financial profits (Figure 4). Each factor was frequently reported in combination with other influencing factors.

19

Training and specialization have been described as a factor influencing healthcare providers’ prescribing patterns. Professionals with more years of medical training and those working in pediatrics settings tended to prescribe more oral rehydration solutions and less antibiotics or antidiarrheal drugs (Naeem, 2014; Paredes et al., 1996). With the limited laboratory resources available to confirm the diagnosis of infectious diseases, especially shigella or cholera, many healthcare professionals declared prescribing antibiotics and antidiarrheals whenever the child was presenting with at least two signs of severe dehydration (Kanungo et al., 2014; Saengcharoen & Lerkiatbundit, 2010). While some healthcare professionals recognized that drug prescribing practices were in some cases unnecessary, they did not change their practice to avoid caregiver disappointment and thus, families seeking care elsewhere. Similar caregivers’ pressure was reported in Thailand by Howteerakul and colleagues (2003). Thai physicians noted prescription of multiple drugs to satisfy mothers, mostly those who openly requested a specific medication (Howteerakul et al., 2003). Satisfaction of caretakers was perceived by the participants as a way to protect the child, to maintain the health professionals’ reputations, and most importantly to maintain a faithful clientele. Compared to oral rehydration solutions, drug prescriptions are more expensive and constitute a higher profit margin for pharmacists and private providers, as in Sudan for example. Sudanese pharmacists were reported to sell oral rehydration solutions at an average price of $ 0.68 cents compared to antibiotics which cost approximately $2.81 (Berih et al., 1989). Financial motivation was also cited by Nizami et al. (1996) as a reason for private practitioners to prescribe unnecessary drug therapy for childhood diarrhea in Pakistan. The authors shared that general practitioners in private settings were not paid and did not receive financial supports from

20

the government, so medication prescriptions were an important source of income for them (Nizami et al., 1996). Dispensing a combination of drugs, such as oral rehydration solutions and injectable antibiotics, was reported to provide a higher profit margin (Kanungo et al., 2014). Caretakers’ expectations for effective and rapid treatment were perceived by the healthcare providers as a determinant to their choice of treatment in diarrheal disease management. Mothers in particular were reported to expect to receive drug prescriptions from physicians rather than simple oral rehydration therapy (Howteerakul et al., 2003; Paredes et al., 1996; Pathak et al., 2011). Nigerian pharmacists reported that mothers expected to receive drug prescriptions for fast relief of diarrheal symptoms (Igun, 1994). This situation was reported to put the pharmacists in a position where they felt pressured to prescribe drugs that were considered by the authors, inappropriate for treating diarrhea. 5- Discussion Although healthcare professionals across the different studies demonstrated adequate knowledge about the etiology of diarrhea and signs of dehydration, that knowledge did not seem to ensure appropriate management of childhood diarrhea as recommended by the WHO guidelines. Discrepancies between healthcare providers’ knowledge about diarrhea and the actual practice were consistently reported regardless of the year of publication, the geographical setting and the healthcare profession. Studies that used either survey and observation or fictitious cases of sick children, all highlighted the gap between healthcare providers’ reported knowledge about diarrhea versus their observed practice. A clear illustration of this gap was the limited practice of taking a health history before ruling out a diagnosis and formulating a treatment plan. While the WHO guidelines advocate for a

21

thorough health history and physical assessment, especially asking about the presence of blood in stool, before deciding to prescribe antibiotics, this practice was not reported as standard on a regular basis. When the assessment and health history were performed and absence of blood was reported, the findings did not prevent healthcare providers in many studies from prescribing antibiotics or antidiarrheal medicines. While the studies reported limited knowledge and prescription of zinc by healthcare providers, knowledge about oral rehydration solutions and their role in the treatment of diarrhea seemed to be high among healthcare professionals. However, actual prescriptions of oral rehydration solutions alone and correct knowledge on the composition and preparation seemed low. Our findings across these studies indicated that higher prescription rates of rehydration therapy were noted when it was combined with antibiotics, antidiarrheal or other medicines. A combination of oral rehydration solutions with other therapies was often due to the fact that healthcare providers believed that rehydration therapy was not efficient or well tolerated by the children because of the unattractive taste and other side effects. High prescription rates of antibiotics and antidiarrheal were consistently reported across the different studies. The findings mirror the unnecessary prescription of these medications reported by other studies worldwide. In fact, excessive prescription of antibiotics has been common and well documented over the last three decades. In a cross-sectional study done in Thailand by Howteerakul et al. (2004), it was reported that appropriate antibiotic drugs were dispensed in only 27.4 % of cases and that cotrimoxazole was prescribed in 51% of the case (Howteerakul et al., 2004). These reports highlight the concerns related to the magnitude of antibacterial drug resistance secondary to antibiotics excessively prescribed, which is now considered a global health issue (WHO, 2014).

22

Correct management of the disease relies on correct knowledge of the etiology, identification of specific symptoms, and appropriate therapies. This review echoes the conclusions of many other calls for action and publications related to diarrheal diseases. While unique in its design and analysis, the present work reiterates what was already known about the management of diarrheal diseases in the literature: knowledge is not enough. Because the known strategies have led to limited results in the past 30 years, current training programs for healthcare providers are not effective in addressing the issue. 6- Limitations As is with any review, limitations exist. These include the possibility that not all relevant studies were identified because the literature search did not comprise unpublished studies and research completed in languages other than English. In addition, almost half of the included studies did not use a strong quality study design. The data analysis in these studies did not follow all the methodological criteria specific to observational studies. Future research with stronger study designs is needed. The nature of the review, an integrative review allowing inclusion of studies with different research designs, also opens the door for potential biases in the analysis. However, the strategies proposed by Whittemore and Knafl and the use of one study design decrease bias and ensure stronger analysis of the data. In addition, the sample population, healthcare providers, included numerous professions with different education and training. So including all these different groups of health providers at once might have introduced confounding variables that could have reduced or exaggerated the analysis of the data. Future reviews need to be completed focusing on single healthcare professional groups individually, to develop a clearer and in-depth understanding of the management of childhood diarrhea within each group.

23

7- Recommendations for Practice and Research The selected studies represented the regions of the world where children are the most affected by diarrhea and included the healthcare professions that are the most likely to provide care to sick children. However, nurses and midwives were mentioned in only one study, while 15 included physicians, and five studied pharmacists’ behaviors. These findings are not reflective of the composition of healthcare providers in the healthcare systems in many developing countries around the world. According to the WHO, nurses and midwives constitute approximately 80% of the healthcare services worldwide. The nurse/midwife-to-physician ratio varies from 2:1 to more than 15:1 in every country in Sub-Saharan Africa and the majority of the countries in South Asia (WHO, 2015). Therefore, the current design of training and research programs on the management of childhood diarrhea needs to be further evaluated. The programs must incorporate the different factors, other than knowledge, influencing healthcare providers’ prescribing behaviors. These factors include the healthcare providers’ training and experience, caregivers’ expectations and related effects of financial profits. In addition, more research is need to address the largest healthcare provider groups: nurses and midwives. 8- Conclusion This integrative review shows that knowledge about diarrhea is not enough to ensure proper management of childhood diarrhea. The unchanged prescribing rates of oral rehydration solutions and zinc supplementation, while antibiotic prescriptions remain high in the management of childhood diarrhea, indicate the limited effectiveness of the healthcare providers’ current training on the recommended clinical management of childhood diarrhea. The gap

24

between knowledge and practice, especially in the high prescription rates of antibiotics and other drugs, has been a constant challenge for sustainable adherence to the WHO guidelines to reduce childhood morbidity and mortality related to diarrhea. This gap cannot be resolved without reevaluating the effectiveness of current training programs in the management of childhood diarrhea.

Contribution of paper What is already known:  

Diarrhea remains the major cause of death for children under the age of 5 years. Oral rehydration therapy, zinc supplementation and continuous feeding are cost-effective measures accounting for the significant drop in childhood mortality in the past 30 years.  Use of these interventions is limited, and many children who suffer from diarrhea in lowincome countries do not receive oral rehydration therapy and continued feeding.  Lack of training and support of healthcare providers has been identified as a barrier for the slow progress made in tackling childhood diarrhea worldwide. What this paper adds: Regardless of time, geographical settings and training   



Healthcare providers’ prescription of oral rehydration therapy and caregivers education about rehydration therapy remain inconsistent; Unnecessary prescription of antibiotics and antidiarrheal medications remains high. Influencing factors, especially, caregivers’ expectations, healthcare providers’ experience and perception of the severity of the disease as well as financial profit play a significant role in the healthcare providers ’clinical practices during management of childhood diarrhea. While considered the largest healthcare profession, nurses and midwives are the least represented healthcare provider groups included in studies evaluating the clinical management of childhood diarrhea.

25

References Agrawal, L. M., Shuaib, A. R., Alam, S., Ashraf, M., Malik, Z. K., Malik, M. A., & Khan, Z. Knowledge of diarrheal management in various levels of public health system in Aligarh. Current Pediatric Reviews, 12(1 & 2), 35-37. Alam, S., Khan, Z., & Amir, A. (2003). Knowledge of diarrhea management among rural practitioners. Indian Journal of Pediatrics, 70(3), 217-219. Barron, P. M., Ephraim, G., Hira, M., Kathawaroo, S., & Thomas, C. (1989). Dispensing habits of Johannesburg pharmacists in treating acute infantile diarrhoea. South African Medical Journal, 76(9), 487-489. Beria, J. U., Damiani, M. F., dos Santos, I. S., & Lombardi, C. (1998). Physicians' prescribing behaviour for diarrhoea in children: An ethnoepidemiological study in Southern Brazil. Social Science & Medicine, 47(3), 341-346. Berih, A. A., McIntyre, L., & Lynk, A. D. (1989). Pharmacy dispensing practices for Sudanese children with diarrhoea. Public Health, 103(6), 455-458. Bhatnagar, S., Lodha, R., Choudhury, P., Sachdev, H. P., Shah, N., Narayan, S., . . . Indian Academy of Pediatrics. (2007). IAP Guidelines 2006 on management of acute diarrhea. Indian Pediatrics, 44(5), 380-389. Chakraborti, S., Barik, K. L., Singh, A. K., & Nag, S. S. (2011). Prescribing practices of doctors in management of acute diarrhea. Indian Pediatrics, 48(10), 811-812.

26

Fischer Walker, C. L., Fontaine, O., Young, M. W., & Black, R. E. (2009). Zinc and low osmolarity oral rehydration salts for diarrhoea: A renewed call to action. Bulletin of the World Health Organization, 87(10), 780-786. Fischer Walker, C. L., Perin, J., Aryee, M. J., Boschi-Pinto, C., & Black, R. E. (2012). Diarrhea incidence in low- and middle-income countries in 1990 and 2010: A systematic review. BMC Public Health, 12, 220. doi:10.1186/1471-2458-12-220 Fontaine, O., Kosek, M., Bhatnagar, S., Boschi-Pinto, C., Chan, K. Y., Duggan, C., . . . Rudan, I. (2009). Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. PLoS medicine., 6(3), e41. doi:10.1371/journal.pmed.1000041 Gani, L., Arif, H., Widjaja, S. K., Adi, R., Prasadja, H., Tampubolon, L. H., . . . Jauri, R. (1991). Physicians' prescribing practice for treatment of acute diarrhoea in young children in Jakarta. Journal of Diarrhoeal Diseases Research, 9(3), 194-199. Goel, P. K., Ross-Degnan, D., McLaughlin, T. J., & Soumerai, S. B. (1996). Influence of location and staff knowledge on quality of retail pharmacy prescribing for childhood diarrhea in Kenya. International Journal for Quality in Health Care, 8(6), 519-526. Hahn, S., Kim, S., & Garner, P. (2002). Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. The Cochrane Database of Systematic Reviews, 1, CD002847. Howteerakul, N., Higginbotham, N., Freeman, S., & Dibley, M. J. (2003). ORS is never enough: Physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand. Social Science & Medicine, 57(6), 1031-1044.

27

Igun, U. A. (1994). The knowledge-practice gap: An empirical example from prescription for diarrhoea in Nigeria. Journal of Diarrhoeal Diseases Research, 12(1), 65-69. International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. (2015). Pneumonia and diarrhea progress report 2015: Sustainable progress in the post-2015 era. Retrieved from www.jhsph. edu/research/centers-and-institutes/ivac/ resources/IVAC-2015-Pneumonia-DiarrheaProgress-Report.pdf Kanungo, S., Mahapatra, T., Bhaduri, B., Mahapatra, S., Chakraborty, N. D., Manna, B., & Sur, D. (2014). Diarrhoea-related knowledge and practice of physicians in urban slums of Kolkata, India. Epidemiology and Infection, 142(2), 314-326. doi:10.1017/s0950268813001076 The Government of Kenya Ministry of Public Health and Sanitation. (2014). Policy guidelines for the management of diarrhea in children below five years in Kenya. Retrieved from http://guidelines.health.go.ke:8000/media/Policy_Guidelines_for_Management_of_Diarr hoea_in_Children_Below.pdf Liu, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J. E., . . . Black, R. E. (2015). Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet, 385(9966), 430-440. doi: 10.1016/s0140-6736(14)61698-6 Lofgren, J., Tao, W., Larsson, E., Kyakulaga, F., & Forsberg, B. C. (2012). Treatment patterns of childhood diarrhoea in rural Uganda: A cross-sectional survey. BMC International Health and Human Rights, 12, 19. doi:10.1186/1472-698x-12-19

28

Naeem, M., Shaukat, M. S., Naheed, I., Imdad, S., & Mirza, R. (2014). Role of general practitioners in prescribing drugs, ORS and zinc in the Management of acute watery diarrhea for children under 5 years of age. Pakistan Journal of Medical and Health Sciences, 8(1), 204-207. Nizami, S. Q., Khan, I. A., & Bhutta, Z. A. (1996). Drug prescribing practices of general practitioners and paediatricians for childhood diarrhoea in Karachi, Pakistan. Social Science & Medicine, 42(8), 1133-1139. Okeke, T. A., Okafor, H. U., Amah, A. C., Onwuasigwe, C. N., & Ndu, A. C. (1996). Knowledge, attitude, practice, and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria. Journal of Diarrhoeal Diseases Research, 14(1), 33-36. Paredes, P., de la Pena, M., Flores-Guerra, E., Diaz, J., & Trostle, J. (1996). Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: Knowledge may not be the clue. Social Science & Medicine, 42(8), 1141-1153. Pathak, D., Pathak, A., Marrone, G., Diwan, V., & Lundborg, C. S. (2011). Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India--A cross-sectional prescription analysis. BMC Infectious Diseases, 11, 32. doi:10.1186/14712334-11-32 Saengcharoen, W., & Lerkiatbundit, S. (2010). Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand. The International Journal of Pharmacy Practice, 18(6), 323-331. doi:10.1111/j.2042-7174.2010.00066.x Younas, M., Shah, F., Khan, J., Kaleem-ur-Rehman, S., Imtiaz, M., Qureshi, M. S., & Talaat, A. (2009). Clinical audit of treatment of acute watery diarrhoea in paediatrics unit,

29

Hayatabad Medical Complex, Peshawar. Journal of Postgraduate Medical Institute, 23(4), 369-372. United Nations Children’s Fund/ World Health Organization. (2009). Diarrhoea: Why children are still dying and what can be done. Geneva: The United Nations Children’s Fund (UNICEF). United Nations Children’s Fund. (2013). Childinfo statistics: Diarrhoea. Geneva: The United Nations Children’s Fund (UNICEF), World Health Organization (WHO). Retrieved from http://data.unicef.org/child-health/diarrhoeal-disease. Wittenberg, D. F. (2012). Management guidelines for acute infective diarrhoea / gastroenteritis in infants. South African Medical Journal, 102(2), 104-107. World Health Organization, Programme for Control of Diarrhoeal Diseases. (1989). Seventh programme report 1988–89. Geneva: WHO. WHO document WHO/CDD/90.34. World Health Organization & United Nations Children’s Fund. (2004). WHO/UNICEF joint statement: Clinical management of acute diarrhoea. Geneva: WHO. Co-published by UNICEF. Retrieved from: http://www.unicef.org/publications/index_21433.html World Health Organization. (2010). WHO recommendations on the management of diarrhoea and pneumonia in HIV-infected infants and children: Integrated Management of Childhood Illness (IMCI). Geneva: World Health Organization. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK305342/ World Health Organization & United Nations Children’s Fund. (2010). Countdown to 2015 decade report (2000-2010) with country profiles: Taking stock of maternal, newborn and

30

child survival. Geneva: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/44346/1/9789241599573_eng.pdf World Health Organization. (2013). Diarrhoeal disease: Fact sheet number 330. Geneva: World Health Organization. Retrieved from http://www.who.int/mediacentre/factsheets/fs330/en/. World Health Organization. (2014). Antimicrobial resistance: Global report on surveillance. Geneva: World Health Organization. Retrieved from: http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf

Alam, S., Khan, Z., & Amir, A. (2003). Knowledge of diarrhea management among rural practitioners. Indian J Pediatr, 70(3), 217-219. Beria, J. U., Damiani, M. F., dos Santos, I. S., & Lombardi, C. (1998). Physicians' prescribing behaviour for diarrhoea in children: an ethnoepidemiological study in Southern Brazil. Soc Sci Med, 47(3), 341346. Berih, A. A., McIntyre, L., & Lynk, A. D. (1989). Pharmacy dispensing practices for Sudanese children with diarrhoea. Public Health, 103(6), 455-458. Chakraborti, S., Barik, K. L., Singh, A. K., & Nag, S. S. (2011). Prescribing practices of doctors in management of acute diarrhea. Indian Pediatr, 48(10), 811-812.

31 Fontaine, O., Kosek, M., Bhatnagar, S., Boschi-Pinto, C., Chan, K. Y., Duggan, C., . . . Rudan, I. (2009). Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. PLoS Med, 6(3), e41. doi: 10.1371/journal.pmed.1000041 Gani, L., Arif, H., Widjaja, S. K., Adi, R., Prasadja, H., Tampubolon, L. H., . . . Jauri, R. (1991). Physicians' prescribing practice for treatment of acute diarrhoea in young children in Jakarta. J Diarrhoeal Dis Res, 9(3), 194-199. Howteerakul, N., Higginbotham, N., & Dibley, M. J. (2004). Antimicrobial use in children under five years with diarrhea in a central region province, Thailand. Southeast Asian J Trop Med Public Health, 35(1), 181-187. Howteerakul, N., Higginbotham, N., Freeman, S., & Dibley, M. J. (2003). ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand. Soc Sci Med, 57(6), 1031-1044. Igun, U. A. (1994). The knowledge-practice gap: an empirical example from prescription for diarrhoea in Nigeria. J Diarrhoeal Dis Res, 12(1), 65-69. Kanungo, S., Mahapatra, T., Bhaduri, B., Mahapatra, S., Chakraborty, N. D., Manna, B., & Sur, D. (2014). Diarrhoea-related knowledge and practice of physicians in urban slums of Kolkata, India. Epidemiol Infect, 142(2), 314-326. doi: 10.1017/s0950268813001076 Lofgren, J., Tao, W., Larsson, E., Kyakulaga, F., & Forsberg, B. C. (2012). Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey. BMC Int Health Hum Rights, 12, 19. doi: 10.1186/1472-698x-12-19 Naeem, M., Shaukat, M. S., Naheed, I., Imdad, S., & Mirza, R. (2014). Role of General Practitioners in Prescribing Drugs, ORS and Zinc in the Management of Acute Watery Diarrhea for Children Under 5 Years of Age. Pakistan Journal of Medical and Health Sciences, 8(1), 204-207.

32 Nizami, S. Q., Khan, I. A., & Bhutta, Z. A. (1996). Drug prescribing practices of general practitioners and paediatricians for childhood diarrhoea in Karachi, Pakistan. Soc Sci Med, 42(8), 1133-1139. Okeke, T. A., Okafor, H. U., Amah, A. C., Onwuasigwe, C. N., & Ndu, A. C. (1996). Knowledge, attitude, practice, and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria. J Diarrhoeal Dis Res, 14(1), 33-36. Paredes, P., de la Pena, M., Flores-Guerra, E., Diaz, J., & Trostle, J. (1996). Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: knowledge may not be the clue. Soc Sci Med, 42(8), 1141-1153. Pathak, D., Pathak, A., Marrone, G., Diwan, V., & Lundborg, C. S. (2011). Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India--a cross-sectional prescription analysis. BMC Infect Dis, 11, 32. doi: 10.1186/1471-2334-11-32 Saengcharoen, W., & Lerkiatbundit, S. (2010). Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand. Int J Pharm Pract, 18(6), 323-331. doi: 10.1111/j.2042-7174.2010.00066.x Sood, N., & Wagner, Z. (2014). Private sector provision of oral rehydration therapy for child diarrhea in Sub-Saharan Africa. The American journal of tropical medicine and hygiene, 90(5), 939-944. Younas, M., Shah, F., Khan, J., Kaleem-ur-Rehman, S., Imtiaz, M., Qureshi, M. S., & Talaat, A. (2009). Clinical audit of treatment of acute watery diarrhoea in paediatrics unit, Hayatabad Medical Complex, Peshawar. Journal of Postgraduate Medical Institute, 23(4), 369-372.

33 Figure 1 Existing WHO guidelines for preventing and treating diarrhea in children (WHO, 2010) Prevention

Give vitamin A to all children > 6 months of age every 6 months (100 000 IU for 6–12 months and 200 000 IU for ≥12 months) up to 5 years of age.

Treatment and management

Treat dehydration with ORS solution (or an intravenous electrolyte solution in cases of severe dehydration). With increased fluids and continued feeding, all children with diarrhea should be given zinc supplementation at 20 mg for 10–14 days; infants < 6 months should receive 10 mg. Use antibiotics only when appropriate (i.e. bloody diarrhea), and abstain from administering anti-diarrheal drugs. Ciprofloxacin is the most appropriate drug for treatment of bloody diarrhea, rather than nalidixic acid, which leads to rapid development of resistance. Ciprofloxacin should be used at an oral dose of 15 mg/kg twice daily for 3 days. Advise mothers to increase fluids and continue feeding during future episodes. Give multivitamins and micronutrients daily for 2 weeks to all children with persistent diarrhea (folate 50 µg, zinc 10 mg, vitamin A 400 µg, iron 10 mg, copper 1 mg, magnesium 80 mg). Give lactose-free (or low-lactose) diet to children > 6 months with persistent diarrhea and who are unable to breastfeed. Assess every child with persistent diarrhea for nonintestinal infections (pneumonia, sepsis, urinary tract infection, oral thrush, otitis media), and treat appropriately.

Other related recommendations

Test children of unknown HIV status, who are living in areas of where HIV prevalence is 1% or more and who present to a health facility. Household water treatment methods that are effective in reducing diarrhea and storage of water in containers that do not allow manual contact are recommended for people with HIV and their households. Proper disposal of feces in a toilet or latrine or at a minimum, by burial in the ground is recommended for people with HIV and their households. Promotion of hand-washing with soap after defecation, handling of human or animal feces and before food preparation and eating, with the provision of soap, are recommended for people with HIV and their households. Refer HIV-exposed infants and children for co-trimoxazole prophylaxis and HIV-infected children for ART.

34

Figure 2 Selection process (((diarrhea) OR(diarrhoea) OR (diarrh*))) AND ((doctor) OR (physician*) OR (pharmacist*) OR (nurse OR midwives) OR (healthcare worker) OR (healthcare professional))

4125 articles found

903 excluded due to years of publication and English language

3222 articles remained

2971 excluded based on eligibility criteria and duplicates

251 abstracts screened

230 articles excluded for not focusing on management of childhood diarrhea by healthcare professionals

21 studies selected

35

Number of studies

Figure 3 Measured Outcomes for Management of Diarrhea Based on Year of Publication 10 9 8 7 6 5 4 3 2 1 0

1989-1990 1991-2000 2001-2010 2010-2014

Measured outcomes over years

36

Figure 4 Factors influencing healthcare professionals’ management of childhood diarrhea in low income countries

37 Table 1 Healthcare Providers Management of Diarrhea Study Characteristics

Geographic positions

Numbers of Studies

South East Asia

13

Sub Saharan Africa

6

Latin America

2

Years of Publication

1989- 2014

Study Design Structured questionnaires

8

Simulated client survey

3

Chart review

1

Observations

1

Combination of designs

8

Study Population Medical doctors

15

Pharmacists

6

Nurses, midwives, nursing students

1

38

Table 2 Individual Study’s Characteristics #

Study

Country/ Setting

Participants

Sample Size

Aim

Design

World Health Organization Guideline published in 1988

1

Barron et al. 1989

South Africa (urban)

Pharmacists

60

2

Berih et al. 1989

Sudan (Urban)

Pharmacists

63

3

Gani et al. 1991 Igun et al. 1994

Indonesia (Urban) Nigeria (Urban/Rural)

Physicians

195

Pharmacists

135

5

Goel et al. 1996

Kenya (Urban/Rural)

Pharmacists

6

Nizami et al. 1996

Pakistan (Urban)

90

7

Parades et al. 1996

Peru (Urban)

General practitioners Pediatricians Physicians

8

Okeke et al. 1996 Buch et al. 1997

Nigeria (Urban) Pakistan

91

Choudhry et al., 1997

Pakistan (Urban)

Private medical practitioners General practitioners Chemists Hospital residents MBBS doctors Pediatricians General physicians

4

9

10

44

-

262

To determine pharmacists’ knowledge, advice and methods of treatment of acute diarrhea in young children To study the dispensing practices of pharmacists with respects to the management of infantile diarrhea To investigate prescribing practices of physicians treating acute childhood diarrhea To document the prescribing practices of retail pharmacies for diarrhea and to analyze the implications of such practices for the diarrhea problem To examine the influence between rural versus urban location, neighborhood socio-economic status and clinical knowledge of pharmacy assistants on quality of prescribing in retail pharmacies To report differences in practicing behaviors between general practitioners and pediatricians.

Structure interview Survey

To explore the factors influencing physicians’ prescribing practices for cases of acute childhood diarrhea To identify the knowledge, attitude, and practice of oral rehydration therapy. To study on the inadequacies in the current management practices of acute diarrhea at various levels of practitioners

Exploratory research: indepth interviews/ Confederates visits Structured questionnaires

To determine physicians reported practices in childhood diarrhea and to identify factors affecting this behavior

Semi- structured questionnaires

Tomson’s survey design

Observation Interviews Open and confederates surveys

Surrogate patient technique

Observations

Open ended questionnaires

39

Table 2 Continued #

Study

Country/ Setting

Participants

Sampl e Size

11

Beria et al. 1998

Brazil

Physicians

33

12

Alam et al. 2003

India (Rural)

Rural medical practitioners

202

13

Howteerak ul et al. 2003

Thailand(Urb an/Rural)

Physicians

38

Aim To develop a better understanding of the dynamics of physicians and patients’ behaviors in the treatment of childhood diarrhea To determine the knowledge of rural medical practitioners of the district of Aligarh about the management of diarrhea. To document the prevalence of suboptimal prescribing and quality of care offered to children and quality of care offered to children admitted as inpatients or outpatients to government hospital suffering from diarrhea.

Design Record reviews

Questionnaires

Quantitative and qualitative methods

World Health Organization Guideline published in 2004

14

Agrawal et al., 2008

India (Urban)

Medical officers and interns Paramedics Medical officers

362

To determine the knowledge among various levels of government health system.

Questionnaires

15

Younas et al., 2009

Pakistan (Urban)

-

Retrospective study

Thailand (Urban)

Pharmacists

115

Chakraborti et al., 2011

India

-

18

Pathak et al., 2011

India (Urban)

General practitioners Pediatricians Practitioners in pharmacies and hospital

19

Lofgren et al., 2012

Uganda (Rural)

77

20

Kanungo et al., 2014

India (Urban)

Nursing assistants Nurses/ Midwives Clinical officers Pharmacists

To estimate the frequency rate of inappropriate drug use and a deficiency in the knowledge and practice treatment protocols To compare practice behavior and attitudes of pharmacy personnel in the management of childhood diarrhea between type I and type II pharmacies, between those surveyed in 2008 and in 2001, and between new- and old- generation pharmacists. To determine the prescribing practices of doctors in management of acute diarrhea in children in the age group of 6 month-5 years To determine the level of adherence to treatment guidelines for acute diarrhea in children up to 12 years and to explore the factors affecting prescribing of ORS with zinc and antibiotics. To investigate knowledge and practices among staff at health centers and drug shops in a rural setting in Uganda in order to explore the scope for improvement of diarrhea case management

16

Saengcharo en et al., 2010

17

20

To assess physicians’ characteristics, knowledge and practice regarding diarrhea

Cross-sectional study

21

Naeem et al. 2014

Pakistan (Urban)

General practitioners

380

To appraise the general practitioners in the management of acute watery diarrhea for children under 5 years and to identify various factors contributing in the gaps of current practices of general practitioners for the case management of diarrhea

Cross-sectional study: semi-structured questionnaire

22

Simulated client Questionnaire

Review of hospital records Cross- sectional quantitative study: survey Review of records Structured interviews