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.
 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 re-

evaluating 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 low-
income 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

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 32

Nizami, S. Q., Khan, I. A., & Bhutta, Z. A. (1996). Drug prescribing practices of general practitioners and

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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

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 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 Treat dehydration with ORS solution (or an intravenous electrolyte solution in cases of severe
management 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 Test children of unknown HIV status, who are living in areas of where HIV prevalence is 1% or
recommendations 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

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
 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/ Participants Sample Aim Design

Setting Size

World Health Organization Guideline published in 1988

1 Barron et South Africa Pharmacists 60 To determine pharmacists’ knowledge, advice and Structure interview Survey
al. 1989 (urban) methods of treatment of acute diarrhea in young
children
2 Berih et 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. Indonesia Physicians 195 To investigate prescribing practices of physicians Observation
1991 (Urban) treating acute childhood diarrhea Interviews
4 Igun et 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. Kenya Pharmacists To examine the influence between rural versus Surrogate patient
1996 (Urban/Rural) urban location, 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. 1996 (Urban) practitioners between general practitioners and pediatricians.
Pediatricians
7 Parades et Peru (Urban) Physicians 44 To explore the factors influencing physicians’ Exploratory research: in-
al. 1996 prescribing practices for cases of acute childhood depth interviews/
diarrhea Confederates visits
8 Okeke et al. Nigeria Private medical 91 To identify the knowledge, attitude, and practice of Structured questionnaires
1996 (Urban) practitioners oral rehydration therapy.
9 Buch et al. Pakistan General - 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- structured
et al., 1997 (Urban) physicians childhood diarrhea and to identify factors affecting questionnaires
this behavior
 39

Table 2 Continued
# Study Country/ Participants Sampl Aim Design
Setting e Size
11 Beria 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. 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.
13 Howteerak Thailand(Urb Physicians 38 To document the prevalence of suboptimal Quantitative and
ul et al. 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.

World Health Organization Guideline published in 2004

14 Agrawal et India (Urban) Medical officers 362 To determine the knowledge among various levels Questionnaires
al., 2008 and interns of government health system.
Paramedics
15 Younas et Pakistan Medical officers - To estimate the frequency rate of inappropriate Retrospective study
al., 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., (Urban) pharmacy personnel in the management of Questionnaire
2010 childhood diarrhea between type I and type II
pharmacies, between those surveyed in 2008 and in
2001, and between new- and old- generation
pharmacists.
17 Chakraborti India General - To determine the prescribing practices of doctors in Review of hospital
et 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- sectional
al., 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.
19 Lofgren et Uganda Nursing 77 To investigate knowledge and practices among staff Review of records
al., 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, knowledge and Cross-sectional study
al., 2014 practice regarding diarrhea
21 Naeem et Pakistan General 380 To appraise the general practitioners in the Cross-sectional study:
al. 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