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

To appear in:

Received date: 22-12-2015
Revised date: 17-8-2016
Accepted date: 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

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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), Sub-
Saharan 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.

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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

Healthcare professionals (mainly physicians. healthcare professionals treating children with diarrhea tended to prescribe more antibiotics. injections and anti-diarrheal medications than oral rehydration solutions and zinc (Pathak. 2011. Sood & Wagner. 4 management (United Nations Children’s Fund. 2014).. The study will answer the following research question: What has been healthcare professionals’ management of childhood diarrhea . Marrone. & Lundborg. Recent studies performed in South India and Sub-Saharan Africa have shown that. 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. In addition. The purpose of this integrative review is to evaluate the clinical practice of healthcare professionals in the management of diarrhea in children. 2009). 2009). 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.. regardless of receiving formal diarrhea management training. 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. Pathak. malaria and measles combined (United Nations Children’s Fund / World Health Organization. Efforts are therefore needed to evaluate healthcare professionals’ clinical management of childhood diarrhea in the most affected area of the globe. 2009). 2013). pharmacists. Diwan. 2009). midwives and nurses) at the public and private levels play an important role in the management of childhood diarrhea. 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.

healthcare care professionals’ training should be based on three major elements: a fundamental knowledge about diarrhea. antibiotics and other drugs for the clinical management. will strengthen the literature and provide a broad picture of the magnitude of the problem in the most affected regions of the world. and the clinical management based on the different types of diarrhea. . 2-Method 2-1 Search strategy and selection criteria Due to the global reach of the WHO guidelines. The measured outcomes were: 1) healthcare professionals’ knowledge about childhood diarrhea and assessment of the dangerous signs and symptoms. 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. 5 in low income countries between 1988 and 2014? The ultimate goal of the study is to explore the clinical practice of healthcare professionals. Recommendations for how best to change practice will also be discussed. the assessment of the clinical signs and symptoms presented by a child with diarrhea. 2) the prescription of oral rehydration solutions. 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. According to the manuals. The review was restricted to studies performed in low-income countries as defined by the World Bank (World Bank Group. Healthcare professionals were defined as any individual with some medical or pharmacological training. A synthesis of observational studies. as it occurs in the natural settings over the years and across geographical settings. nurses and midwives. including physicians. and 3) the prescription of zinc supplementation. completed between 1988 and 2014. pharmacists.

doctors. management. Scopus. physicians. and 2014. nurses. MeSH terms and headings. The databases were PubMed. practice guideline. published in English. CINAHL. MeSH terms and headings were used in various combinations: adherence. 3. and studies focusing only on drug therapies and the management of a population of children older than 5 years. knowledge attitude and practice. attitude of health personnel. children and preschool. pediatrician. healthcare professionals. midwives.971 publications were excluded primarily because they were duplicates and did not focus on management of childhood diarrhea .Results A total of 4. prescribing patterns. 6 2014). references in retrieved articles and other related reviews were searched for relevant studies. The following keywords. health care providers. diarrhea. In addition. World Health Organization Global Health Library and CAB Direct. physicians’ practice patterns. The literature search included studies published between 1988.222 articles remained. After screening the abstracts. A comprehensive literature search was performed using five databases between December 2014 and April 2015. Exclusion criteria were: studies reporting infections other than those causing diarrheal diseases in children. clinical management. when most national programs for the control of diarrheal diseases were established.125 articles were retrieved using the different combinations of keywords. 2. guideline. 3. Setting the limitations to years of publications between 1988 and 2015. pharmacist. diarrhoea. infant.

in which a member of the research team approached healthcare professionals with a fictitious case of a child with diarrhea. Completed both in urban and rural settings between 1989 and 2014. while only one study included nurses and nurse midwives as research respondents (Figure 3). The remaining eight used a combination of research designs. 15 focused on physicians. 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. Of the 21 studies. The selected publications were observational studies and reported on healthcare professionals’ management of childhood diarrhea in low-income countries. Further details of the studies’ demographics are presented in Table1.g. study population. the analysis needed to be based on a generalized approach allowing incorporation of all the diverse features of the selected studies. research setting). a total of 21 studies were included in the review.. Finally. Only one study used direct observation of the healthcare professionals during practice. Retrospective chart reviews were used in one study. time. 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. The study samples varied and included one or more healthcare professional groups. Eight studies used a survey design while three used some type of simulated client survey. Sub-Saharan Africa (n = 6) and South America (n = 2). Since the study sample differs in many aspects (e. data extraction and organization. five explored pharmacists’ management of childhood diarrhea. geography. The WHO training manuals for the treatment of . these 21 studies were representative of the three continents accounting for the highest proportion of children suffering of diarrhea: East Asia (n = 13). 7 by healthcare professionals.

2) the prescription of oral rehydration solutions. and 3) caregivers’ education about home therapy for childhood diarrhea. WHO. healthcare professionals’ knowledge about diarrhea was assessed at three levels: 1) the most common cause of diarrhea in children. 3-1 Knowledge about diarrhea In most studies. 2) assessment of signs of severe dehydration. antibiotics and other drugs for the clinical management. 8 childhood diarrhea (WHO. 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. These outcomes are: 1) healthcare providers’ knowledge about childhood diarrhea and assessment of the dangerous signs and symptoms. 2005) were considered the reference for the formulation of many national guidelines on the clinical management of diarrhea in children worldwide. In addition to the initial predetermined outcomes. The analysis was therefore based on the essential elements of the clinical management of childhood diarrhea according to the WHO training manuals. and 4) factors affecting prescribing behaviors. . 1984. a frequent theme emerged from the analysis and led to a fourth outcome measure. This approach allows identification of changes in the clinical management of diarrhea over time. The outcomes are presented in a chronological manner to compare and contrast management before and after the 2004 World Health Organization guidelines. 3) the prescription of zinc supplementation.

In a survey study. 2014). attitudes toward and practices with oral rehydration solutions in 91 medical providers in the state of Enugu.. 2014). & Ndu. The same physicians acknowledged that.. Participating physicians recognized that the most frequent episodes of diarrhea in children were caused by viruses. Kanungo et al. Berih et al. The majority of the participants (59. Flores-Guerra. 1996). Okafor. de la Pena.. 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.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. Diaz. 2014. 1996). (1989) evaluated the prescribing behaviors of pharmacists in Sudan using a research team member with a fictitious . 9 Etiology of diarrhea. 1996). (1996) examined the knowledge of. McIntyre.. & Lynk. healthcare professionals showed adequate knowledge of the etiology of diarrheal diseases and the most frequent signs of severe dehydration. Amah. Nigeria. 1989. Assessment of signs of severe dehydration. inconsistencies were found in the questions asked in health histories and physical examination characteristics. & Trostle. Viral infections were reported as the most common cause of diarrheal diseases in children (Berih. then protozoal infections (Okeke. A majority of medical providers (74%) identified the most common cause of diarrhea in children to be of viral origin.. antimicrobial therapy was not necessary for the treatment of the diarrhea (Kanungo et al. In general. The next most common etiology reported by the providers was bacterial (20%). knowledge of diarrhea and its management was also evaluated in physicians working in the slums of Kolkata (Kanungo et al. 2014.47%) cited viruses as the most common diarrheagenic pathogens (Kanungo et al. Paredes. Paredes et al. In a more recent publication. except for cases of severe or bloody diarrhea. Okeke et al. Onwuasigwe.

Damiani. In a more recent study completed in Thailand by Saengcharoen and Lerkiatbundit (2010). The authors reported that out of 63 pharmacists. Inconsistencies in health history practices appeared to exist over time and in varied geographical settings. 1989).. dos Santos. In type I. only 21. assessing or asking about the presence of blood in the stool. for example.. did not occur regularly. 2010). pharmacists who asked at least one question pertinent to the child’s symptoms. in type II pharmacies. & Lombardi.2% pharmacists asked questions specific to the child’s history. 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). However. more frequently made referrals to a physician and were less likely to recommend antimicrobial drugs (Berih et al. 10 case of a child suffering from diarrhea. 40 (63. 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 .5%) did not perform a health history before recommending a treatment plan for the child (Berih et al. In their study. Interestingly. 1989). These results are consistent with findings reported by Beria and colleagues (1998). However. 1998). They found that only 22% of the surveyed physicians checked for the presence of blood in the stool (Beria.1% of the personnel in these pharmacies took a history of the child’s symptoms before providing treatment (Saengcharoen & Lerkiatbundit. They appear to be related with providers’ training and experiences. The authors found that 98% of physicians (n = 54) completed a health history. the authors reviewed medical reports to explore physicians’ prescribing behaviors for childhood diarrhea in parts of Brazil. At least 65% of the physicians performed a physical examination to assess for other signs of severe dehydration. 55.

Khan. 11 not receive advanced training. Overall.. Out of 44 health professionals surveyed. 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. Caregivers’ education on home management of diarrheal diseases.4% of observed healthcare providers advised the caregivers on home rehydration management. and adequate care is ensured when caregivers receive the correct education on dosage and preparation of oral rehydration solutions and continued feeding practices. (1996). Management of diarrhea mostly occurs at home. While 79. 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. In another recent study. mothers described physicians’ instructions for continuous feeding to be vague. Regardless of the professionals’ level of training. only four prescribed oral rehydration solutions with correct prescription instructions (Paredes et al. Therefore. Alam and colleagues (2003) evaluated rural medical practitioners’ education of primary caregivers in the management of rehydration therapy during childhood diarrhea. 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). healthcare providers’ education related to home nutritional management for diarrhea was reported to be “unclear” across the study findings. . 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. & Amir. 2003). In a study completed by Paredes et al. This requires caregivers to receive correct information by healthcare professionals at the hospital and community level..

antibiotics and other drugs for the management of diarrheal diseases.1%. However. Taking these strategies individually.6% of Thai pharmacists interviewed by Saengcharoen et al. on a regular basis. recommendations related to providing an all milk diet (breastmilk or formula) were provided by only 6. Reports on caregivers’ education follow the same trends. Oral rehydration solutions. 1996. (2010). Saengcharoen & Lerkiatbundit. the studies’ findings report that healthcare professionals’ instructions to caregivers in the nutritional management of childhood diarrhea were not consistent. Regardless of dates of the studies and the location of their sites. Healthcare professionals’ reported knowledge about diarrhea has been similar over the years and across different countries of the world. critical in the management of childhood diarrhea. 12 Appropriate nutritional recommendations related to both food and milk consumption were reported by only 2.2% of the pharmacists (Saengcharoen & Lerkiatbundit. 3-2 Prescription for 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 training does not ensure the practice of these initial steps. disagreeable color and induced nausea and vomiting were the .. Bitter and salty taste. 2010). Higher education levels appear to improve healthcare professionals’ history taking and assessment of the signs of severe dehydration. while recommendations on appropriate food intake were given by 12. 2010). 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. 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.

like antibiotics or anti-diarrheal medications (Gani et al. 1996). Survey... the researchers used both interviews and observation intervention to assess physicians’ prescribing behaviors in Indonesia. Of the medical officers and interns who were interviewed. 1991. The same gap between reported versus observed prescription of oral rehydration solutions has been described. Younas et al.5% recommended antibiotics in 50% of the cases (Agrawal et al.. 1991). With the WHO recommended change in the formulation of oral rehydration solutions published since 2004. While 100% of the physicians reported prescribing oral rehydration solutions in their management of childhood diarrhea during the survey. Khan. 1991. & Bhutta. 1998. 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.. However. 1991). In the study authored by Gani and colleagues (1991). continuous feeding and zinc. 13 frequent reasons physicians believed the rehydration therapy was not accepted by the patients and their families (Gani et al. Paredes et al. 1996. the hope was to increase the consumption of rehydration therapy (WHO... healthcare professionals tended to prescribe other medications considered more effective. only 31% stated giving oral rehydration solutions. 2008). Nizami. more recent studies still report limited prescription of oral rehydration solution alone. For these reasons... 2009). only 75% were actually observed prescribing the rehydration therapy (Gani et al. Agrawal et al. 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. Gani et al. while 62. 2004). (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. .

. 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. 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. 33% of nursing students. High prescription rates of antibiotics were reported in many of the studies. 2008). the . Naeem. (1991) interviewed and observed physicians’ clinical practice during treatment of diarrhea in children in Jakarta.. 1989. 14 The researchers (2008) also interviewed other healthcare professional groups such as auxiliary nurse midwives. They found that 55% of auxiliary nurse midwives. nursing students and traditional healers. health assistants. Gani et al. & Dibley. 36% of health assistants and 72% nursing students knew the appropriate dosages for the preparation of oral rehydration solution. patterns seem to exist in the gap between knowledge and practice across the studies’ dates and geographical settings. 2003. 20% of auxiliary nurse midwives and health assistants declared recommending oral rehydration solutions and continuous feeding (Agrawal et al.. Similar to the studies’ finding on the knowledge of diarrhea. Although physicians believed the most frequent cause of diarrhea was viral. Higginbotham. The prescription of oral rehydration solutions in combination with antibiotics was consistently high across the selected studies. However. Freeman. Howteerakul. 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. Antibiotics. 61% reported prescribing antibiotics while 94% were actually observed prescribing antibiotics for treatment of acute diarrhea in children (Gani et al. In terms of diarrhea treatment. 2014). 1991).

& Dibley. 2005). 1996. 1994). (2009) reported that metronidazole was given by medical officers in 61. 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. prevent complications or secondary infections and was also related to reported uncertainty about the etiology of the disease (Paredes et al. While physicians. Saengcharoen & Lerkiatbundit.25% of children (n = 80) admitted to the hospital for acute watery diarrhea. interviewed by Paredes et al. Younas et al. 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. . This drug. the prescription of antibiotics reported as “unnecessary” in cases of childhood diarrhea remains significant.. 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). Co-trimaxazole was frequently cited by healthcare providers as a treatment of choice for the treatment of diarrhea (Howteerakul. received antibiotics either orally or parentally. Almost twenty years later and with a growing concern about antibiotic resistance. Antidiarrheal... Howteerakul et al. The drug was either taken in combination with other drugs or with oral rehydration solutions. however. Higginbotham. 2009).25% of the children treated for diarrhea. 2003. 2004. 1996. (2009) stated that 91. 2010). and prophylaxis treatment for malaria and severe bacterial infections in adult and children taking antiretroviral treatment (WHO. The prescription of these drugs has been linked to undesirable and sometimes fatal side effects in children.. Nizami et al. 2010). Younas et al. Antidiarrheal drugs have never been recommended in the management of childhood diarrhea (WHO. The indiscriminate prescription of antibiotics in cases of childhood diarrhea by physicians was reported to be given to treat co-infections. Younas et al.

Parallel to the reported knowledge about diarrhea and prescription of oral rehydration solutions. 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. training appears to make a substantial difference in healthcare providers’ practices during management of childhood diarrhea.4%) (Naeem. the studies’ findings indicate similarities in healthcare providers’ prescribing behaviors in the management of childhood diarrhea. 26% believed in the effectiveness of these drugs. 2014). (2014). was performed a decade after the publication of the updated WHO guidelines by Naeem et al. 3-3 Prescription of zinc supplementation . Unnecessary prescription of antibiotics and antidiarrheal drugs have been reported in countries located in three different continents over the last thirty years.1%) compared to those who attended the training course (17. Consistent with the conclusions drawn from the analysis of the previous outcomes. Although the findings indicate higher prescriptions rates of oral rehydration solutions based on the healthcare professionals’ medical training. The authors compared prescribing behaviors of physicians who attended a diarrhea training management course to those who did not. 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. The physicians who did not attend the training course were significantly more likely to prescribe antidiarrheal drugs (44. 16 (1996) recognized antidiarrheal as “unnecessary” in the treatment of diarrhea and were aware of the national policy restricting its prescription.

The authors reported that. 2011). (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. 17 Recommendations of zinc supplementation with rehydration therapy were added in the 2004 WHO guidelines for children with acute non-dysenteric watery diarrhea (WHO. however. 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 . 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)... the authors reported that only in 6 of the 843 prescriptions did physicians follow the national guidelines. Pathak et al. at the time of the study. 2009). 2012. Among 843 prescriptions to children being treated for diarrhea by surveyed physicians and pharmacists in Ujjain district. 2012. 2011. More recently.. The most common reasons for the limited prescription of zinc was both institutional (not available) and financial (too costly). 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. 2011.. 2004).. Singh. Younas et al. Pathak et al. Lofgren and her research team (2012) reviewed medical records and interviewed staff at health centers and drug shops in a rural district of Uganda. India. Tao. When reported in the studies. zinc supplementation was either not prescribed or prescribed in only very limited occasions (Chakraborti. Lofgren. Larsson. Barik. Healthcare providers’ knowledge about the benefits of zinc in the management of childhood diarrhea was low. & Nag. Kyakulaga. Pathak et al. & Forsberg.. 2011). In addition. and they included only oral rehydration solutions and zinc in their management (Pathak et al.

Wittenberg. 2003. However. 2007.. Paediatric Management Group (PMG) in South Africa. 2006.4 Factors other than knowledge about diarrhea. Bhatnagar et al. perceived severity of the symptoms associated with 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. International Vaccine Access Center & Johns Hopkins Bloomberg School of Public Health. Saengcharoen & Lerkiatbundit. on the one hand. influencing management of childhood diarrhea A total of 15 studies reported factors other than knowledge about diarrhea.. 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.. these data indicate that improving knowledge does not necessarily translate into improved practice in the studied settings. Each factor was frequently reported in combination with other influencing factors. 1991. influencing healthcare providers’ prescribing patterns in childhood diarrhea (Gani et al. 3. 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. caregivers’ expectation and related effects of financial profits (Figure 4). Kenyan Ministry of Public Health and Sanitation. 2010. Frequently cited factors included the healthcare providers’ training. 2015). In fact. . and the healthcare professionals’ treatment choices in the management of childhood diarrhea. 18 Pediatrics. Howteerakul et al. 2010). 2012.

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. While some healthcare professionals recognized that drug prescribing practices were in some cases unnecessary. to maintain the health professionals’ reputations. as in Sudan for example.81 (Berih et al. families seeking care elsewhere. Saengcharoen & Lerkiatbundit.68 cents compared to antibiotics which cost approximately $2. 2003). 19 Training and specialization have been described as a factor influencing healthcare providers’ prescribing patterns. 1996).. Financial motivation was also cited by Nizami et al. Paredes et al. 1989). 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. Sudanese pharmacists were reported to sell oral rehydration solutions at an average price of $ 0. Thai physicians noted prescription of multiple drugs to satisfy mothers. 2010). mostly those who openly requested a specific medication (Howteerakul et al. and most importantly to maintain a faithful clientele. (1996) as a reason for private practitioners to prescribe unnecessary drug therapy for childhood diarrhea in Pakistan. 2014. Satisfaction of caretakers was perceived by the participants as a way to protect the child.. With the limited laboratory resources available to confirm the diagnosis of infectious diseases. drug prescriptions are more expensive and constitute a higher profit margin for pharmacists and private providers. they did not change their practice to avoid caregiver disappointment and thus. Similar caregivers’ pressure was reported in Thailand by Howteerakul and colleagues (2003). The authors shared that general practitioners in private settings were not paid and did not receive financial supports from ... especially shigella or cholera. Compared to oral rehydration solutions.

Paredes et al. Dispensing a combination of drugs.. all highlighted the gap between healthcare providers’ reported knowledge about diarrhea versus their observed practice. Pathak et al. Discrepancies between healthcare providers’ knowledge about diarrhea and the actual practice were consistently reported regardless of the year of publication.. that knowledge did not seem to ensure appropriate management of childhood diarrhea as recommended by the WHO guidelines. 2011). 5. Nigerian pharmacists reported that mothers expected to receive drug prescriptions for fast relief of diarrheal symptoms (Igun. While the WHO guidelines advocate for a . 1996). inappropriate for treating diarrhea. Mothers in particular were reported to expect to receive drug prescriptions from physicians rather than simple oral rehydration therapy (Howteerakul et al. 1994). so medication prescriptions were an important source of income for them (Nizami et al. Studies that used either survey and observation or fictitious cases of sick children. 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. 20 the government. 1996. the geographical setting and the healthcare profession. such as oral rehydration solutions and injectable antibiotics... was reported to provide a higher profit margin (Kanungo et al.Discussion Although healthcare professionals across the different studies demonstrated adequate knowledge about the etiology of diarrhea and signs of dehydration. 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. 2003.. This situation was reported to put the pharmacists in a position where they felt pressured to prescribe drugs that were considered by the authors. 2014).

Our findings across these studies indicated that higher prescription rates of rehydration therapy were noted when it was combined with antibiotics. (2004). knowledge about oral rehydration solutions and their role in the treatment of diarrhea seemed to be high among healthcare professionals. it was reported that appropriate antibiotic drugs were dispensed in only 27. 2014). this practice was not reported as standard on a regular basis. However. 2004). When the assessment and health history were performed and absence of blood was reported. High prescription rates of antibiotics and antidiarrheal were consistently reported across the different studies. 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. 21 thorough health history and physical assessment. actual prescriptions of oral rehydration solutions alone and correct knowledge on the composition and preparation seemed low. excessive prescription of antibiotics has been common and well documented over the last three decades. the findings did not prevent healthcare providers in many studies from prescribing antibiotics or antidiarrheal medicines. before deciding to prescribe antibiotics. These reports highlight the concerns related to the magnitude of antibacterial drug resistance secondary to antibiotics excessively prescribed.. While the studies reported limited knowledge and prescription of zinc by healthcare providers. . The findings mirror the unnecessary prescription of these medications reported by other studies worldwide. In fact.4 % of cases and that cotrimoxazole was prescribed in 51% of the case (Howteerakul et al. In a cross-sectional study done in Thailand by Howteerakul et al. especially asking about the presence of blood in stool. antidiarrheal or other medicines. which is now considered a global health issue (WHO.

and appropriate therapies. In addition. However. an integrative review allowing inclusion of studies with different research designs. the strategies proposed by Whittemore and Knafl and the use of one study design decrease bias and ensure stronger analysis of the data. While unique in its design and analysis. In addition. 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. almost half of the included studies did not use a strong quality study design.Limitations As is with any review. limitations exist. the present work reiterates what was already known about the management of diarrheal diseases in the literature: knowledge is not enough. included numerous professions with different education and training. also opens the door for potential biases in the analysis. to develop a clearer and in-depth understanding of the management of childhood diarrhea within each group. 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. healthcare providers. . The nature of the review. 6. Future research with stronger study designs is needed. current training programs for healthcare providers are not effective in addressing the issue. the sample population. identification of specific symptoms. Because the known strategies have led to limited results in the past 30 years. 22 Correct management of the disease relies on correct knowledge of the etiology. Future reviews need to be completed focusing on single healthcare professional groups individually. This review echoes the conclusions of many other calls for action and publications related to diarrheal diseases. The data analysis in these studies did not follow all the methodological criteria specific to observational studies.

The unchanged prescribing rates of oral rehydration solutions and zinc supplementation. These findings are not reflective of the composition of healthcare providers in the healthcare systems in many developing countries around the world. indicate the limited effectiveness of the healthcare providers’ current training on the recommended clinical management of childhood diarrhea. 8. According to the WHO. 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.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. 23 7. However. The programs must incorporate the different factors. more research is need to address the largest healthcare provider groups: nurses and midwives. while antibiotic prescriptions remain high in the management of childhood diarrhea. caregivers’ expectations and related effects of financial profits. while 15 included physicians. In addition. nurses and midwives constitute approximately 80% of the healthcare services worldwide. These factors include the healthcare providers’ training and experience. other than knowledge. the current design of training and research programs on the management of childhood diarrhea needs to be further evaluated. and five studied pharmacists’ behaviors. nurses and midwives were mentioned in only one study. 2015). Therefore. influencing healthcare providers’ prescribing behaviors. The gap .Conclusion This integrative review shows that knowledge about diarrhea is not enough to ensure proper management of childhood diarrhea.

caregivers’ expectations. especially in the high prescription rates of antibiotics and other drugs. geographical settings and training  Healthcare providers’ prescription of oral rehydration therapy and caregivers education about rehydration therapy remain inconsistent.  Oral rehydration therapy. 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. and many children who suffer from diarrhea in low- income countries do not receive oral rehydration therapy and continued feeding.  Influencing factors.  Use of these interventions is limited. zinc supplementation and continuous feeding are cost-effective measures accounting for the significant drop in childhood mortality in the past 30 years.  Lack of training and support of healthcare providers has been identified as a barrier for the slow progress made in tackling childhood diarrhea worldwide. . especially.  Unnecessary prescription of antibiotics and antidiarrheal medications remains high. 24 between knowledge and practice.  While considered the largest healthcare profession. What this paper adds: Regardless of time. nurses and midwives are the least represented healthcare provider groups included in studies evaluating the clinical 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. 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 re- evaluating the effectiveness of current training programs in the management of childhood diarrhea.

. A. (1989). 103(6). . Barron. Kathawaroo.. Shuaib. C. IAP Guidelines 2006 on management of acute diarrhea. Physicians' prescribing behaviour for diarrhoea in children: An ethnoepidemiological study in Southern Brazil. R. K.. Indian Journal of Pediatrics. & Nag. S. M.. . H. Alam. (1998). Z. F. L. S. I. Dispensing habits of Johannesburg pharmacists in treating acute infantile diarrhoea. A.. 341-346. M.. M. 487-489. C. Knowledge of diarrhea management among rural practitioners. (2007). L. Berih. Chakraborti.. & Amir. P. Pharmacy dispensing practices for Sudanese children with diarrhoea. Indian Pediatrics. 48(10). 380-389. .. McIntyre. & Lynk. dos Santos. . Narayan. 217-219. A. N. A.. P. & Lombardi. 25 References Agrawal. S. Prescribing practices of doctors in management of acute diarrhea. Indian Academy of Pediatrics.. Current Pediatric Reviews. M.. S. Barik. U. Bhatnagar.. Lodha. A... & Khan. Malik. 455-458. & Thomas. 811-812. Alam. P. G. L. Knowledge of diarrheal management in various levels of public health system in Aligarh. S. Khan. Singh. Public Health. 76(9). K.. A. South African Medical Journal. K. Shah. Indian Pediatrics.. 47(3).. J. (2003). Z. R. S. Sachdev. 70(3). Social Science & Medicine.. S. S. M.. 35-37. Ashraf. D. Choudhury. Malik.. Z. 12(1 & 2). Damiani. Beria. Ephraim. Hira. (2011).. S... (1989). 44(5)... M. A..

doi:10.. J. Goel. J. N. & Dibley. 220. L. . Prasadja. 6(3). S. Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. Tampubolon. 9(3). S. ORS is never enough: Physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand.. Chan.. McLaughlin. Zinc and low osmolarity oral rehydration salts for diarrhoea: A renewed call to action. 12. Hahn. P. I. ..and middle-income countries in 1990 and 2010: A systematic review. Boschi-Pinto. Perin.. . & Black... Howteerakul. (2003). C.1371/journal. J. M.. & Soumerai. Kosek. M. Influence of location and staff knowledge on quality of retail pharmacy prescribing for childhood diarrhea in Kenya. S. Bulletin of the World Health Organization. BMC Public Health.. C. Social Science & Medicine.1000041 Gani. Physicians' prescribing practice for treatment of acute diarrhoea in young children in Jakarta. (2009). K. Kim... M.. Ross-Degnan.. 57(6). O. E. J. (2002). e41.. Young. Arif. & Black.1186/1471-2458-12-220 Fontaine. Diarrhea incidence in low. 780-786.. Widjaja.. L. 8(6). Fontaine. 26 Fischer Walker. Journal of Diarrhoeal Diseases Research. E. K.. . H. Freeman. N. D.pmed. CD002847. C. R. The Cochrane Database of Systematic Reviews. Duggan. L. 194-199. S.. Higginbotham. S... M.. T. R. Bhatnagar. O.. Jauri. .. (2012).. H... . 87(10). W. C. Boschi-Pinto. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. (2009). PLoS medicine. H. (1991).. K. Aryee. R. P. 1031-1044. L. Rudan. doi:10. B. (1996). . Y. 1. C. Fischer Walker. S. 519-526. R. International Journal for Quality in Health Care. & Garner.. Adi.

Manna. E. Hogan. Johns Hopkins Bloomberg School of Public Health.jhsph. Treatment patterns of childhood diarrhoea in rural Uganda: A cross-sectional survey. .ke:8000/media/Policy_Guidelines_for_Management_of_Diarr hoea_in_Children_Below. Perin. India. .1186/1472-698x-12-19 . Retrieved from www.health. 12(1).. Bhaduri. and national causes of child mortality in 2000-13. & Sur.. Larsson. Pneumonia and diarrhea progress report 2015: Sustainable progress in the post-2015 era. doi:10.. B. J. 65-69.. Black. Retrieved from http://guidelines.. S. E. (2014). . with projections to inform post-2015 priorities: an updated systematic analysis. 19.pdf Kanungo. U. S.1016/s0140-6736(14)61698-6 Lofgren. edu/research/centers-and-institutes/ivac/ resources/IVAC-2015-Pneumonia-DiarrheaProgress-Report. L. J.. Lancet. 385(9966). Global. doi:10.. S.. Epidemiology and Infection. (2015). International Vaccine Access Center (IVAC). 430-440. I. Lawn. (2012).. Rudan... (1994). D.1017/s0950268813001076 The Government of Kenya Ministry of Public Health and Sanitation. BMC International Health and Human Rights. (2015). T. Policy guidelines for the management of diarrhea in children below five years in Kenya. & Forsberg. Kyakulaga. 314-326. D. Mahapatra. 142(2).pdf Liu. J.go. F. Mahapatra. C. N.. B. Diarrhoea-related knowledge and practice of physicians in urban slums of Kolkata. Oza. 27 Igun. D.. 12. (2014). regional. B. Chakraborty. R. A. W. Journal of Diarrhoeal Diseases Research. The knowledge-practice gap: An empirical example from prescription for diarrhoea in Nigeria. E.. Tao.. doi: 10..

S. 11. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain. Social Science & Medicine. C. S. P.. V. doi:10.. (1996). Okeke. & Ndu.00066. C. practice. M.. S. Khan. Clinical audit of treatment of acute watery diarrhoea in paediatrics unit. de la Pena. A.. 1133-1139.. Nizami. A. Imtiaz. India--A cross-sectional prescription analysis.. (2011).2042-7174. I. 204-207.. Khan.. Paredes. 28 Naeem. & Bhutta. Diaz. 32. Pakistan Journal of Medical and Health Sciences.. J. J. A. Journal of Diarrhoeal Diseases Research. attitude. Z. Naheed. H. M. Pathak. The International Journal of Pharmacy Practice. 8(1). Imdad. Role of general practitioners in prescribing drugs. 33-36. (2010). E. 1141-1153.... M. Kaleem-ur-Rehman. I. S. S. & Lerkiatbundit. BMC Infectious Diseases. J.. U.. Onwuasigwe. Shaukat. 14(1)... Marrone. & Mirza. M.. M. . F. Amah. Shah. D. & Lundborg. S.. A. 42(8). Flores-Guerra. W. (2014). Knowledge.. Pathak. doi:10. ORS and zinc in the Management of acute watery diarrhea for children under 5 years of age. Diwan. (1996). R. and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria. N. A..2010.. & Trostle. & Talaat. A.. 42(8). 18(6). C. M. Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand. T. Drug prescribing practices of general practitioners and paediatricians for childhood diarrhoea in Karachi.1111/j. Q. C. Pakistan.. Okafor. G. Social Science & Medicine. (1996). Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: Knowledge may not be the clue.x Younas. Qureshi. A. S..1186/1471- 2334-11-32 Saengcharoen.. 323-331. (2009).

United Nations Children’s Fund/ World Health Organization. World Health Organization.nlm. (2013). (1989). Geneva: WHO. (2010). United Nations Children’s Fund. WHO document WHO/CDD/90. Geneva: World Health Organization. F.gov/books/NBK305342/ World Health Organization & United Nations Children’s Fund.org/child-health/diarrhoeal-disease. Retrieved from: http://www. Programme for Control of Diarrhoeal Diseases. Countdown to 2015 decade report (2000-2010) with country profiles: Taking stock of maternal. Diarrhoea: Why children are still dying and what can be done. 104-107. D.unicef. South African Medical Journal.34. newborn and . Co-published by UNICEF. Wittenberg. Peshawar.ncbi. Geneva: The United Nations Children’s Fund (UNICEF). Geneva: The United Nations Children’s Fund (UNICEF). Geneva: WHO.unicef. Childinfo statistics: Diarrhoea. (2010).html World Health Organization. WHO/UNICEF joint statement: Clinical management of acute diarrhoea. Journal of Postgraduate Medical Institute. Retrieved from http://data. Seventh programme report 1988–89. 102(2). (2004).nih. World Health Organization (WHO). (2012). 29 Hayatabad Medical Complex. 23(4).org/publications/index_21433. 369-372. Retrieved from http://www. Management guidelines for acute infective diarrhoea / gastroenteritis in infants. WHO recommendations on the management of diarrhoea and pneumonia in HIV-infected infants and children: Integrated Management of Childhood Illness (IMCI). (2009). World Health Organization & United Nations Children’s Fund.

K. A. 48(10). Beria. S. Pharmacy dispensing practices for Sudanese children with diarrhoea.. A. L..int/iris/bitstream/10665/44346/1/9789241599573_eng. Singh. (1989). Damiani. Khan. U. Retrieved from http://apps.who. . 47(3). Diarrhoeal disease: Fact sheet number 330.pdf World Health Organization.. M.pdf Alam. Knowledge of diarrhea management among rural practitioners. 217-219. Indian J Pediatr. A. McIntyre.. (2013). I.who.. Berih. 30 child survival. D. & Lynk. 455-458. Retrieved from: http://apps. & Amir.int/mediacentre/factsheets/fs330/en/. Geneva: World Health Organization. S. Z.. Soc Sci Med. Geneva: World Health Organization. K. 70(3). 103(6). A. Retrieved from http://www. Prescribing practices of doctors in management of acute diarrhea. 811-812. (2003). Indian Pediatr.. J.. Chakraborti. 341- 346. Physicians' prescribing behaviour for diarrhoea in children: an ethnoepidemiological study in Southern Brazil. World Health Organization... S. S. & Lombardi. A. (2014). Antimicrobial resistance: Global report on surveillance. & Nag. (1998). Geneva: World Health Organization. Public Health.who. Barik. dos Santos. L. (2011). C. F. S.int/iris/bitstream/10665/112642/1/9789241564748_eng.

. T. F. Arif. Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey. I. B. 57(6). Southeast Asian J Trop Med Public Health.. J Diarrhoeal Dis Res. L. BMC Int Health Hum Rights. Epidemiol Infect. 12(1).. Kosek. Soc Sci Med.. S. 8(1). . Mahapatra... Howteerakul. Role of General Practitioners in Prescribing Drugs. E. A. Boschi-Pinto.. Adi. N. D. Tao.. R. (2009). S.. J.. Mahapatra. ..pmed.1186/1472-698x-12-19 Naeem. doi: 10. Jauri... 204-207. Duggan. L... Thailand. (2012). S.. S. . Widjaja. Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. Tampubolon. M. . S.. N.. & Dibley. O. India.. (2014). N. . Naheed.1371/journal. Prasadja. Chan. H. Bhaduri. 9(3). N. Physicians' prescribing practice for treatment of acute diarrhoea in young children in Jakarta. & Mirza. 31 Fontaine. K. Rudan.. doi: 10. 35(1). (2003). Manna. N. (2014). Diarrhoea-related knowledge and practice of physicians in urban slums of Kolkata. B. I. (1994). 19. 6(3). M. 12. Imdad. & Dibley. K. Shaukat. 314-326. J.1000041 Gani. & Sur. Bhatnagar. ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand. C. doi: 10. 65-69. Higginbotham. Higginbotham. C. (2004)... J. M. PLoS Med. Howteerakul. ORS and Zinc in the Management of Acute Watery Diarrhea for Children Under 5 Years of Age. Kyakulaga.. Freeman. Kanungo. S. 1031-1044. M. S. 181-187. W.. R. (1991). R. 194-199. Larsson. & Forsberg. J Diarrhoeal Dis Res. .. U..1017/s0950268813001076 Lofgren.. Igun. Pakistan Journal of Medical and Health Sciences. M.. Chakraborty. H. Antimicrobial use in children under five years with diarrhea in a central region province. C.. D.. The knowledge-practice gap: an empirical example from prescription for diarrhoea in Nigeria. Y. H. B. . e41. 142(2)..

1186/1471-2334-11-32 Saengcharoen. Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand. D. 323-331.2042-7174. Kaleem-ur-Rehman. Pathak.2010. Soc Sci Med. Soc Sci Med. M. & Trostle.. & Ndu. Drug prescribing practices of general practitioners and paediatricians for childhood diarrhoea in Karachi. N. W. 90(5).. P. Hayatabad Medical Complex. 939-944. 18(6). doi: 10. 42(8). (1996). A. J Diarrhoeal Dis Res. & Bhutta. Diaz. & Talaat. H. Int J Pharm Pract. Journal of Postgraduate Medical Institute.. Private sector provision of oral rehydration therapy for child diarrhea in Sub-Saharan Africa. (1996). J. Pathak. 1133-1139. Z.. S. India--a cross-sectional prescription analysis. N. (2014). Pakistan. and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria. 369-372. Amah. Z. 14(1). J. doi: 10.. S. Qureshi. & Wagner. practice. Khan. de la Pena. Khan. M. A. Imtiaz. F. Shah. C. (1996). 32. 1141-1153. Marrone. A. Clinical audit of treatment of acute watery diarrhoea in paediatrics unit.. T. A.00066. Diwan. Okeke. E. Flores-Guerra. J.1111/j. A. C.. & Lerkiatbundit. Paredes.. Onwuasigwe. 23(4). 11. C. Knowledge. 32 Nizami. A. I. Younas.. (2009). Q.. G. (2010).. C.. .. & Lundborg. 42(8). S. BMC Infect Dis.. M. Okafor..... Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain. (2011). The American journal of tropical medicine and hygiene. attitude.x Sood. U. S... Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: knowledge may not be the clue. V.. 33-36. S.. Peshawar. A. M.

handling of human or animal feces and before food preparation and eating. .e. Ciprofloxacin should be used at an oral dose of 15 mg/kg twice daily for 3 days. are recommended for people with HIV and their households. Give multivitamins and micronutrients daily for 2 weeks to all children with persistent diarrhea (folate 50 µg. With increased fluids and continued feeding. by burial in the ground is recommended for people with HIV and their households. sepsis. 33 Figure 1 Existing WHO guidelines for preventing and treating diarrhea in children (WHO. urinary tract infection. Other related Test children of unknown HIV status. and abstain from administering anti-diarrheal drugs. Ciprofloxacin is the most appropriate drug for treatment of bloody diarrhea. zinc 10 mg. rather than nalidixic acid. 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. copper 1 mg. vitamin A 400 µg. Assess every child with persistent diarrhea for nonintestinal infections (pneumonia. iron 10 mg. Proper disposal of feces in a toilet or latrine or at a minimum. all children with diarrhea should be given zinc supplementation at 20 mg for 10–14 days. infants < 6 months should receive 10 mg. 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. magnesium 80 mg). bloody diarrhea). which leads to rapid development of resistance. Use antibiotics only when appropriate (i. with the provision of soap. who are living in areas of where HIV prevalence is 1% or recommendations more and who present to a health facility. and treat appropriately. Advise mothers to increase fluids and continue feeding during future episodes. oral thrush. Refer HIV-exposed infants and children for co-trimoxazole prophylaxis and HIV-infected children for ART. Give lactose-free (or low-lactose) diet to children > 6 months with persistent diarrhea and who are unable to breastfeed. Promotion of hand-washing with soap after defecation. Treatment and Treat dehydration with ORS solution (or an intravenous electrolyte solution in cases of severe management dehydration). otitis media).

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 Figure 3 Measured Outcomes for Management of Diarrhea Based on Year of Publication 10 Number of studies 9 8 7 6 5 4 3 1989-1990 2 1 1991-2000 0 2001-2010 2010-2014 Measured outcomes over years .

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

midwives. 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. nursing students 1 .

To study on the inadequacies in the current Open ended 1997 practitioners management practices of acute diarrhea at various questionnaires Chemists levels of practitioners Hospital residents MBBS doctors Pediatricians 10 Choudhry Pakistan General 262 To determine physicians reported practices in Semi. 1989 (urban) methods of treatment of acute diarrhea in young children 2 Berih et al. Indonesia Physicians 195 To investigate prescribing practices of physicians Observation 1991 (Urban) treating acute childhood diarrhea Interviews 4 Igun et al. 1996 prescribing practices for cases of acute childhood depth interviews/ diarrhea Confederates visits 8 Okeke et al. 1997 (Urban) physicians childhood diarrhea and to identify factors affecting questionnaires this behavior . advice and Structure interview Survey al. Sudan (Urban) Pharmacists 63 To study the dispensing practices of pharmacists Tomson’s survey design 1989 with respects to the management of infantile diarrhea 3 Gani et al. neighborhood socio-economic technique status and clinical knowledge of pharmacy assistants on quality of prescribing in retail pharmacies 6 Nizami et Pakistan General 90 To report differences in practicing behaviors Observations al. and practice of Structured questionnaires 1996 (Urban) practitioners oral rehydration therapy..structured et al. Kenya Pharmacists To examine the influence between rural versus Surrogate patient 1996 (Urban/Rural) urban location. 38 Table 2 Individual Study’s Characteristics # Study Country/ Participants Sample Aim Design Setting Size World Health Organization Guideline published in 1988 1 Barron et South Africa Pharmacists 60 To determine pharmacists’ knowledge. Pediatricians 7 Parades et Peru (Urban) Physicians 44 To explore the factors influencing physicians’ Exploratory research: in- al. Nigeria Pharmacists 135 To document the prescribing practices of retail Open and confederates 1994 (Urban/Rural) pharmacies for diarrhea and to analyze the surveys implications of such practices for the diarrhea problem 5 Goel et al. Pakistan General . attitude. 9 Buch et al. 1996 (Urban) practitioners between general practitioners and pediatricians. Nigeria Private medical 91 To identify the knowledge.

.. India (Rural) Rural medical 202 To determine the knowledge of rural medical Questionnaires 2003 practitioners practitioners of the district of Aligarh about the management of diarrhea. an/Rural) prescribing and quality of care offered to children qualitative methods 2003 and quality of care offered to children admitted as inpatients or outpatients to government hospital suffering from diarrhea. 2014 (Urban) practitioners management of acute watery diarrhea for children semi-structured under 5 years and to identify various factors questionnaire contributing in the gaps of current practices of general practitioners for the case management of diarrhea . 2009 (Urban) drug use and a deficiency in the knowledge and practice treatment protocols 16 Saengcharo Thailand Pharmacists 115 To compare practice behavior and attitudes of Simulated client en et al. 17 Chakraborti India General . 2014 practice regarding diarrhea 21 Naeem et Pakistan General 380 To appraise the general practitioners in the Cross-sectional study: al. and between new. To estimate the frequency rate of inappropriate Retrospective study al. World Health Organization Guideline published in 2004 14 Agrawal et India (Urban) Medical officers 362 To determine the knowledge among various levels Questionnaires al... Paramedics 15 Younas et Pakistan Medical officers ..sectional al. 2011 practitioners management of acute diarrhea in children in the records Pediatricians age group of 6 month-5 years 18 Pathak et India (Urban) Practitioners in 22 To determine the level of adherence to treatment Cross. 13 Howteerak Thailand(Urb Physicians 38 To document the prevalence of suboptimal Quantitative and ul et al.. 2008 and interns of government health system. 2011 pharmacies and guidelines for acute diarrhea in children up to 12 quantitative study: hospital years and to explore the factors affecting survey prescribing of ORS with zinc and antibiotics. (Urban) pharmacy personnel in the management of Questionnaire 2010 childhood diarrhea between type I and type II pharmacies.and old. To determine the prescribing practices of doctors in Review of hospital et al. Brazil Physicians 33 To develop a better understanding of the dynamics Record reviews 1998 of physicians and patients’ behaviors in the treatment of childhood diarrhea 12 Alam et al. 19 Lofgren et Uganda Nursing 77 To investigate knowledge and practices among staff Review of records al.generation pharmacists. knowledge and Cross-sectional study al.. 39 Table 2 Continued # Study Country/ Participants Sampl Aim Design Setting e Size 11 Beria et al. between those surveyed in 2008 and in 2001. 2012 (Rural) assistants at health centers and drug shops in a rural setting in Structured interviews Nurses/ Uganda in order to explore the scope for Midwives improvement of diarrhea case management Clinical officers 20 Kanungo et India (Urban) Pharmacists 20 To assess physicians’ characteristics.