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Indian Journal of Community Medicine

Knowledge and Perception of Practising Doctors in The Management of Acute Watery Diarrhoea

Author(s): P. Parekh, P. Gandhi, J. Nadkarni

Vol. 29, No. 2 (2004-04 - 2004-06)

Abstract:

Research Question: Are medical practitioners using rational therapy for treating children with acute watery diarrhoea?

Objectives: 1. To study the oral rehydration therapy being propagated by medical practitioners. 2. Whether proper emphasis is being laid on feeding a child during diarrhoea. 3. To study drug therapy being prescribed by practitioners.

Study Design: Interviews based on semistructured questionnaire.

Setting: Private clinics of practitioners, government dispensaries and medical college.

Participants: Medical practitioners and interns.

Sample Size: A total of 180 medical practitioners and 35 interns were interrogated for this study.

Statistical Analysis: Simple percentage.

Results: Majority of the practising doctors were aware of the use of ORS in a child with acute watery diarrhoea, but they did not know the exact chemical composition of ORS to be prescribed hence they were unable to choose the correct brand of commercial ORS packets available in the market. Majority of the practitioners (95.5%) and all the interns advised to continue breast feeding during diarrhoea. Most of the practitioners (88.88%) prescribed drugs for diarrhoea. Choice of antidiarrhoeal drug was correct in only 20% of practitioners. Two thirds (65%) of the practitioners had not attended any continuing education programme pertaining to diarrhoea) disease and its management.

Conclusions: Practitioners working in the private sector also need to be involved in CME programmes. The quality of CME programmes need to be reinforced.

Key Words: Oral rehydration therapy, medical practitioners

Introduction:

In India diarrhoea) illness remains a dominant cause of mortality, morbidity and undernutrition in early childhood. Diarrhoea) disease control programme of WHO was launched in 1978 which advocated several intervention measures, all of which centre around wide-spread practice of "Oral Rehydration Therapy"1. It consists of giving by mouth, a solution to replace the water and salt lost from the body during diarrhoea. The discovery of oral rehydration therapy has revolutionized the treatment of diarrhoea) disease which has been described as the "Most important medical advance of this century".2 The present study was undertaken with the objective to assess the practising doctors knowledge and attitude towards management of acute diarrhoea in children.

Subjects and Methods

A total of 180 medical practitioners and 35 interns were interviewed for this study. The doctors were from government and private sectors practising in the city of Indore. These practitioners were paediatricians, general duty doctors, specialists from other branches doing general practice and practitioners of non allopathic medicine. The study was carried out over a period of six months. After taking a prior appointment of the practitioner an interview was arranged. Rapport was established and he was explained the purpose of this study. An open ended questionnaire which was especially designed for the study was either filled up during the first visit or in some cases in the second visit. A note was made of their qualification, place of practice (govt/private), number of years of practice, paediatric component of their practice and any previous exposure to continuing medical education programme related to management of diarrhoea. The questions were primarily related to their knowledge and practice of drug therapy, oral rehydration therapy, feeding advice and parenteral therapy in a child with acute watery diarrhoea.

Results

Breakdown of the 215 practitioners who participated in the study is depicted in Table I.

Table I

Paediatricians MBBS Other Specialists Non-allopathic Interns Total
61 69 36 14 35 215
(28.37%) (32.09%) (16.74%) (6.51%) (16.27%)  

On interviewing the practitioners about the use of home available fluids (HAF) in children with diarrhoea, 78.82% of the practitioners and 85.11 % of interns felt that HAF should be given to all children with diarrhoea irrespective of the presence of dehydration. Only 28.33% of practitioners could answer correctly the composition of ORS. More Paediatricians 42.6% (26161), had correct knowledge about composition of ORS than MBBS doctors 24.6% (17,169) , other specialists 19.4% (7,136) and non-allopaths 7.1% (1,114). Only 28.6% (10,135) interns possessed correct knowledge about ORS.

Most of the practitioners (56.11 %) preferred to give flavoured ORS as it increases palatability thereby improving the acceptance by the child. On the other hand majority of interns (60%) were against the use of flavoured ORS and knew the reason correctly (Table II). Proper reconstitution of ORS was correctly answered by 58.88% of the practitioners and 91.42% of interns. Nearly two thirds of the practitioners (65.55%) consisting large number of paediatricians preferred boiled and cooled water for reconstitution of ORS. Preparation of sugar salt solution was incorrectly advised by 56.66% of practitioners and 85.11% of interns: Sixty five percent of practitioners were prescribing fruit j uice for treating dehydration. Mausami juice was the most preferred followed by orange juice. Soft drinks (Limca) advised by 16.3% and 10.5% preferred Glucon D.

Regarding use of drugs in diarrhoea 88.88% felt that giving a drug in acute watery diarrhoea is a must and 44.44% preferred more than one drug. Of the interns, 31.42% did not prefer to give drugs in acute watery diarrhoea (Table III).

The choice of antidiarrhoeal drug was correct in only 20% of practitioners. Others were prescribing several additional drugs either in combination or alone. The common drugs prescribed in combination were lactobacillus, metronidazole and kaolin with neomycin. Third generation cephalosporins in acute watery diarrhoea were prescribed by 11.11% of practitioners. No difference was observed between doctors from the government and private sectors. Majority of the doctors were prescribing drugs on the basis of severity of dehydration. The choice of drugs in 55.78% of paediatricians was also based on the severity of dehydration. Aminoglycosides and third generation cephalosporins were preferred in severe dehydration.

An analysis of opinion regarding feeding during an attack of acute watery diarrhoea revealed that 89.44% of the practitioners and all the interns preferred to continue breast feeding.

Table II: Opinion About Prescribing Flavoured ORS

Paediatricians
n=61
MBBS
n=69
Other
Specialists
n=36
Non
Allopaths
n=14
Total
n=180
Interns
n=35
Yes 33 (54.09%) 36 (52.17%) 24 (66.6%) 8 (57.14%) 101 (56.11%) 10 (28.57%)
No 23 (37.70%) 17 (24.63%) 9 (25.00%) 3 (21.42%) 52 (28.88%) 21 (60%)
No Specific Choice - 5 (5.79%) 2 (5.55%) - 6 (3.33%) 1 (2.85%a)
ORS Not Prescribed 3 (4..91%) - - 1 (7.14%) 4 (2.22%) -
Unanswered 2 (3.27%) 2 (2.89%) 1 (2.77%) 2 (14.28%) 7 (3.88%) 1 (2.85%)

Amongst those who knew the WHO formula in more than half (52.94%) of doctors, the commercial brand prescribed did not match with the WHO composition. (Table III) Two thirds (65%) of the practitioners had not attended any continuing education programme pertaining to diarrhoea) disease and its management. Amongst those who had undergone the training programme majority of them belonged to the government sector (Table III). However, 89.44% of practitioners and all the interns expressed their desire to attend a CME programme on diarrhoea and its management to update their knowledge.

Discussion

The modern management of acute diarrhoea) illness emphasizes oral rehydration, early feeding and judicious use of anti-diarrhoea) drugs. Such simple methods play an important role in the prevention of complications of diarrhoea specially dehydration and malnutrition with minimum expenditure. The medical practitioner plays a major role in the management of diarrhoea) disease. Therefore, it is important to know the prevailing knowledge and practices amongst the practitioners of the c ommunity.

A study by Singh3 revealed that almost all the doctors depended on routine use of antibiotics and only 37% considered oral rehydration therapy (ORT) i mportant. In our study majority felt that both ORT as well as drugs were i mportant in the management of diarrhoea. Though the choice of antidiarrhoeal drug was correct in only 20% of the practitioners.

Arur VR4 in his study observed that only 44% of the doctors were prescribing the correct brand of the ORS. Electral which contains less sodium and more glucose was the most preferred commercial brand. Nalin et al5 reported that use of low sodium formula resulted in lower sodium absorption and diarrhoea persisted for a longer time. In the present study majority of the doctors knew the importance of ORS in the management of diarrhoea but only 28.33% knew the WHO formula of ORS to be prescribed.

Those who knew the correct composition of ORS were working in government hospitals and dispensaries and had attended CME programmes on Diarrhoea) Management. Unfortunately, more than half of the doctors (58.94%) prescribed a commercial brand of ORS not having the rationale composition. Electral which contains less sodium and more glucose was the most preferred commercial brand. It is obvious from the above analysis that although the practising doctor is aware of the use of ORS in a child with diarrhoea he does not know the exact chemical composition of ORS to be prescribed and hence is unable to choose the correct brand of commercial ORS packets available in the market. He is mostly guided by the company's medical representative. Availability of a wide variety of commercial brands in the market has just increased the cost of ORS packet and created confusion in the mind of the practitioner. They also considered flavoured ORS as better choice as it increases palatability and improves acceptance by the child. They were unaware that such a practice can lead to hyperelectrolytemia. One third of practitioners are unaware about the correct method of reconstitution of ORS and also the duration for which reconstituted ORS can be used. But still observation of our study was better as compared to study by Arur VR4 where only 10% of doctors knew the correct method of reconstitution.

Sugar salt solution (SSS) can be used for correcting dehydration when ORS packets are not available. Any change in composition of SSS, i.e. too much of sugar and salt can produce osmotic diarrhoea and hypernatraemia and less amount of constituents may not be effective. Commercial lemonades and fruit juices should be avoided as these contain too much of saccharose and produce osmotic diarrhoea. In the present study practitioners were advising fruit juices, Limca and Glucon-D.

Breast feeding not only prevents risk of illness but remarkably reduces complications of acute watery diarrhoea8. Infants who are breast fed during diarrhoea gain weight better and rarely develop persistent diarrhoea.6 There is no physiological basis for resting the bowel during diarrhoea. It was very encouraging to observe in the present study that 95.5% of practitioners and all the interns advised to continue breast feeding during diarrhoea. They also preferred semisolids to be continued especially rice, lentils, sago, curd, banana, etc.

Ringer lactate is the fluid of choice for correcting severe dehydration8. But most preferred fluid is Isolyte P There is a need to emphasize during training about rationale use of parenteral fluids in dehydration. It is also important to teach that stool examination is not a must in the correct management of acute watery diarrhoea. Fifty percent of the practitioners in our study felt that stool examination is mandatory.

Patwari et al8 have emphasized the importance of CME programme for practising doctors. Sixty five percent of doctors in our study had not attended any CME programme on Diarrhoea) Management. Amongst those who had attended most of them were from the government sector. Most (89.4%) of the practitioners and all the interns expressed their keen desire to attend such updates.

Table III: Opinion About Number of Drugs Prescribed

Paediatricians
n=61
MBBS
n=69
Other
Specialists
n=36
Non
Allopaths
n=14
Total
n-180
Interns
n=35
None 8(13.11%) 6(8.69%) 6(16.66%) - 20(11.11%) 11(31.42%)
One 41(67.21 %) 25(36.23%) 12(33.33%) 2(14.28%) 80(44.44%) 16(45.71%)
More than One 12(19.67%) 38(55.07%) 18(49.99%) 12(76.97%) 80(44.44%) 8(22.85%)

Table IV: Previous Exposure to C.M.E. Programme about Diarrhoea) Disease and its Management

Yes Paediatrician
n=(61)
M.B.B.S. n (69) Other Specialists
n=(36)
Non-Allopaths n=(14) Total n=(180)
Govt
(6)
Private
(55)
Govt
(30)
Private
(39)
Govt.
(24)
Private
(12)
Govt
(-)
Private
(14)
5(83.33%) 30(54.54%) 16(53.33%) - 11(45.83%) 1(8.33%) - - 63(35%)

To conclude our study revealed that though practitioners are aware of the importance of ORT in diarrhoea management, detail of ORS composition, preparation, storage etc. needs to be emphasised. Those working in the private sector need to be involved in the CME programmes as a large component of patients utilize private health facilities. The quality of CME programmes needs to be re-enforced. These updates must lay more stress on practical demonstrations of case assessment and management.

References

  1. A manual for the treatment of acute diarrhoea WHO, Geneva: CDD/Ser/80,2, 1980.
  2. Editorial, Water with sugar and salt. Lancet ii : 300, 1978.
  3. Singh T. Inadequacies in management of diarrhoea at the peripheral non teaching level. Indian J. Pediatr. 1990, 57 : 89-92.
  4. Arur VR. Use and misuse of oral rehydration solutions in general practice. Indian Pediatr. 1988, 25 : 750-753.
  5. Nalin DR, Harland E, Ramlal A et al. Comparison of low and high sodium and potassium content in oral rehydration solution. J. Pediatr. 1980, 97 848-853.
  6. Khin Maung V, Wai NN, Myo K. Effect on clinical outcome of breast feeding during acute diarrhoea. Br. Med. J. 1985, 290 : 587.
  7. Arora NK, Bhan MK. Nutritional management of acute diarrhoea. Indian J. Pediatr. 1991, 58 : 763-767.
  8. Patwari AK. Anand V, Kumar H. Aneja S, Mullick D. Knowledge and perception of residents regarding case management of acute diarrhoea. Indian Pediatr. 1991, 28: 887-890.

Department of Paediatrics,
M.G.M. Medical College,
Indore 48, Anoop Nagar, Indore - 452 008,
E-mail: [email protected]

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