Predictors of rational management of diarrhea in an endemic setting: observation from India.
ABSTRACT: Decades after the establishment of clear guidelines for management, mostly due to irrational approach, diarrhea is still a major concern in the developing world, including India. The scenario is even worse in urban slums owing to poor health-seeking and socio-environmental vulnerability. Determining the distribution of rational diarrhea management by practitioners and identification of its important predictors seemed urgent to minimize the potential for antibiotic resistance, diarrhea-related mortality and morbidity in these areas.Between May 2011 and January 2012, 264 consenting, randomly selected qualified and non-qualified practitioners (including pharmacists) were interviewed in the slums of Kolkata, a populous city in eastern India, regarding their characteristics, diarrhea-related knowledge (overall and in six separate domains: signs/symptoms, occurrence/spread, management, prevention/control, cholera and ORS), prescribed antibiotics, intravenous fluid (IVF) and laboratory investigations. Rationality was established based on standard textbooks.Among participants, 53.03% had no medical qualifications, 6.06% were attached to Governmental hospitals, 19.32% had best knowledge regarding diarrhea. While treating diarrhea, 7.20%, 17.80% and 20.08% respectively advised antibiotics, IVF and laboratory tests rationally. Logistic regression revealed that qualified and Governmental-sector practitioners managed diarrhea more rationally. Having best diarrhea-related knowledge regarding signs/symptoms (OR=5.49, p value=0.020), occurrence/spread (OR=3.26, p value=0.035) and overall (OR=6.82, p value=0.006) were associated with rational antibiotic prescription. Rational IVF administration was associated with best knowledge regarding diarrheal signs/symptoms (OR=3.00, p value=0.017), occurrence/spread (OR=3.57, p value=0.004), prevention/control (OR=4.89, p value=0.037), ORS (OR=2.55, p value=0.029) and overall (OR=4.57, p value<0.001). Best overall (OR=2.68, p value=0.020) and cholera-related knowledge (OR=2.34, p value=0.019) were associated with rational laboratory testing strategy.Diarrheal management practices were unsatisfactory in urban slums where practitioners' knowledge was a strong predictor for rational management. Interventions targeting non-qualified, independent practitioners to improve their diarrhea-related knowledge seemed to be required urgently to ensure efficient management of diarrhea in these endemic settings.
Project description:In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap).To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods.Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P?<?.001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.
Project description:Programs aimed at reducing the burden of diarrhea among children under-five in low-resource settings typically allocate resources to training community-level health workers, but studies have suggested that provider knowledge does not necessarily translate into adequate practice. A diarrhea management program implemented in Bihar, Gujarat and Uttar Pradesh, India trained private sector rural medical practitioners (RMPs) and public sector Accredited Social Health Activists (ASHAs) and Anganwadi workers (AWWs) in adequate treatment of childhood diarrhea with oral rehydration salts (ORS) and zinc. We used cross-sectional program evaluation data to determine the association between observed diarrhea treatment practices and reported knowledge of ORS and zinc among each provider cadre.We conducted principal components analysis on providers' responses to diarrhea treatment questions in order to generate a novel scale assessing ORS/zinc knowledge. We subsequently regressed a binary indicator of whether ORS/zinc was prescribed during direct observation onto the resulting knowledge scores, controlling for other relevant knowledge predictors.There was a positive association between ORS/zinc knowledge score and prescribing ORS and zinc to young children with diarrhea among private sector RMPs (aOR: 2.32; 95% CI: 1.29-4.17) and public sector ASHAs and AWWs (aOR 2.48; 95% CI: 1.90-3.24). Controlling for knowledge score, receipt of training in the preceding 6 months was a good predictor of adequate prescribing in the public but not the private sector. In the public sector, direct access to ORS and zinc supplies was also highly associated with prescribing.To enhance the management of childhood diarrhea in India, programmatic activities should center on increasing knowledge of ORS and zinc among public and private sector providers through biannual trainings but should also focus on ensuring sustained access to an adequate supply chain.
Project description:BACKGROUND:Acute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers' knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care. METHODS:A web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey. RESULTS:Responses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years' experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years' experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%. CONCLUSION:Our results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.
Project description:To control the double burden of communicable and non-communicable diseases (NCDs), in the developing world, understanding the patterns of morbidity and healthcare-seeking is critical. The objective of this cross-sectional study was to determine the distribution, predictors and inter-relationship of perceived morbidity and related healthcare-seeking behavior in a poor-resource setting.Between October 2013 and July 2014, 43999 consenting subjects were recruited from 10107 households in Malda district of West Bengal state in India, through multistage random sampling, using probability proportional-to-size. Information on socio-demographics, behaviors, recent ailments, perceived severity and healthcare-seeking were analyzed in SAS-9.3.2.Recent illnesses were reported by 55.91% (n=24,600) participants. Among diagnosed ailments (n=23,626), 50.92% (n=12,031) were NCDs. Respiratory (17.28%, n=7605)), gastrointestinal (13.48%, n=5929) and musculoskeletal (6.25%, n=2749) problems were predominant. Non-qualified practitioners treated 53.16% (n=13,074) episodes. Older children/adolescents [adjusted odds ratio for private healthcare providers (AORPri)=0.76, 95% confidence interval=0.71-0.83) and for Govt. healthcare provider (AORGovt)=0.80(0.68-0.95)], females [AORGovt=0.80(0.73-0.88)], Muslims [AORPri=0.85(0.69-0.76) and AORGovt=0.92(0.87-0.96)], backward castes [AORGovt=0.93(0.91-0.96)] and rural residents [AORPri=0.82(0.75-0.89) and AORGovt=0.72(0.64-0.81)] had lower odds of visiting qualified practitioners. Apparently less severe NCDs [acid-peptic disorders: AORPri=0.41(0.37-0.46) & AORGovt=0.41(0.37-0.46), osteoarthritis: AORPri=0.72(0.59-0.68) & AORGovt=0.58(0.43-0.78)], gastrointestinal [AORPri=0.28(0.24-0.33) & AORGovt=0.69(0.58-0.81)], respiratory [AORPri=0.35(0.32-0.39) & AORGovt=0.46(0.41-0.52)] and skin infections [AORPri=0.65(0.55-0.77)] were also less often treated by qualified practitioners. Better education [AORPri=1.91(1.65-2.22) for ≥graduation], sanitation [AORPri=1.58(1.42-1.75)] and access to safe water [AORPri=1.33(1.05-1.67)] were associated with healthcare-seeking from qualified private practitioners. Longstanding NCDs [chronic obstructive pulmonary diseases: AORPri=1.80(1.46-2.23), hypertension: AORPri=1.94(1.60-2.36), diabetes: AORPri=4.94(3.55-6.87)] and serious infections [typhoid: AORPri=2.86(2.04-4.03)] were also more commonly treated by qualified private practitioners. Potential limitations included temporal ambiguity, reverse causation, generalizability issues and misclassification.In this poor-resource setting with high morbidity, ailments and their perceived severity were important predictors for healthcare-seeking. Interventions to improve awareness and healthcare-seeking among under-privileged and vulnerable population with efforts to improve the knowledge and practice of non-qualified practitioners probably required urgently.
Project description:<h4>Background</h4>Irritable bowel syndrome is a common condition in general practice. It occurs in 10 to 20% of the population, but less than half seek medical assistance with the complaint.<h4>Methods</h4>A questionnaire was sent to the 406 GPs listed on the West Sussex Health Authority Medical List to investigate their views of this condition and whether they felt hypnotherapy had a place in its management<h4>Results</h4>38% of general practitioners responded. The achieved sample shared the characteristics of target sample. Nearly half thought that irritable bowel syndrome (IBS) was a "nervous complaint" and used a combination of "the placebo effect of personal care," therapeutic, and dietary advice. There is considerable divergence in the perceived effectiveness of current approaches. Over 70% thought that hypnotherapy may have a role in the management of patients with IBS; though the majority (68%) felt that this should not be offered by general practitioners. 84% felt that this should be offered by qualified hypnotherapist, with 40% feeling that this should be offered outside the health service.<h4>Conclusions</h4>General practitioners vary in their perceptions of what constitutes effective therapy in IBS. They are willing to consider referral to a qualified hypnotherapist.
Project description:Childhood diarrhea continues to be a major cause of under-five (U-5) mortality globally and in India. In this study, 1571 U-5 children residing in nine rural villages and four urban slums in Ujjain, India were included with the objective to use community participation and drug utilization research to improve diarrheal case management. The mean age was 2.08 years, with 297 (19%), children living in high diarrheal index households. Most mothers (70%) considered stale food, teething (62%), and hot weather (55%) as causes of diarrhea. Water, sanitation, and hygiene (WASH)-related characteristics revealed that most (93%) households had toilets, but only 23% of the children used them. The study identified ineffective household water treatment by filtration through cloth by most (93%) households and dumping of household waste on the streets (89%). The results revealed low community awareness of correct causes of diarrhea (poor hand hygiene, 21%; littering around the household, 15%) and of correct diarrhea treatment (oral rehydration solution (ORS) and zinc use, 29% and 11%, respectively) and a high antibiotic prescription rate by healthcare providers (83%). Based on the results of the present study, context-specific house-to-house interventions will be designed and implemented.
Project description:Unsafe drinking water and poor sanitation and hygiene lead to deterioration of the child health condition in low- and middle-income countries. This study aimed to evaluate the nutritional and health status of children living in an urban slum and to clarify the factors contributing to undernutrition and diarrhea prevalence by focusing on water, sanitation, and hygiene from three viewpoints: household environments, child personal hygiene practices, and knowledge and awareness. The study was conducted at a preschool and two elementary schools in the densely populated area of Bandung, Indonesia. Participants were 228 pairs of children and their caretakers. The survey involved 1) anthropometric measurements (height and weight), 2) handwashing observation using a checklist, and 3) questionnaires. On multivariate logistic regression analysis, not using a towel for handwashing practices (adjusted odds ratio [AOR] = 2.37; 95% confidence interval [CI] = 1.13-4.96) was significantly associated with an increased risk of stunting. Regarding household environments, children from households using tap water as drinking water were significantly associated with an increased risk of stunting and thinness compared with households using tank water (AOR = 2.26; 95% CI = 1.03-4.93; and AOR = 2.88; 95% CI = 1.13-7.35, respectively). Moreover, children from households using open containers for water storage were significantly associated with an increased risk of diarrhea (AOR = 5.01; 95% CI = 1.08-23.15). Therefore, drinking water management at home and proper personal hygiene practices of children are important for maintaining and promoting child health in urban Indonesian slums.
Project description:BACKGROUND:Early diagnosis of tuberculosis (TB) and involvement of the public-private partnership are critical to eradicate TB. Patients need to receive proper treatment through the National Tuberculosis Control Programme (NTP). This study describes various predictors for health seeking behaviour of TB patients and health system delay made by the different health care providers. METHODS:A cross-sectional study was conducted in a public health facility of a rural area in Bangladesh. Newly diagnosed smear positive pulmonary TB (PTB) patients who were???15 years of age were sequentially enrolled in this study. The socio-demographic characteristics and proportion of health care utilization by the patients, and health system delay made by the health care providers were calculated. Multivariate analysis was conducted to determine the independent association of the risk factors with the time to seek medical care. RESULTS:Two hundred and eighty patients were enrolled in this study. Among them, 73.6% were male and 26.4% were female. A hundred percent of patients primarily sought treatment for their cough, 170 (60.7%) first consulted a non-qualified practitioner while 110 patients (39.3%) first consulted with qualified practitioners about their symptoms. Pharmacy contact was the highest (27.9%) among the non-qualified practitioners, and 58.9% non-qualified practitioners prescribed treatment without any laboratory investigation. The average health system delay was 68.5 days. Multiple logistic regressions revealed a significant difference between uneducated and educated patients (OR 2.33; CI 1.39-3.92), and qualified and non-qualified practitioners (OR 2.34; CI 1.38-3.96) to be independent predictors of health system delay. CONCLUSIONS:Compared to men, fewer women sought TB treatment. Uneducated patients and questionably qualified practitioners made for a longer delay in detecting TB. Increasing public health awareness and improving health seeking behavior of females and uneducated patients, and greater participation of the qualified practitioners in the NTP are highly recommended.
Project description:Types of privately insured outpatient treatment provided by in-network practitioners were examined in a national managed behavioral health care organization to consider how practitioner type and expertise are related to diagnoses of mental disorders, substance use disorders, or both. Using 2004 practitioner credentialing, patient enrollment, and claims data, the investigators found that two-thirds of claims for psychiatrists involved medication management and two-thirds also involved psychotherapy (an overlap of about 30%). Most patients with substance use disorders saw practitioners who had specialized alcohol or drug disorder training. Claims for patients with more complex co-occurring mental and substance use disorders indicate utilization of appropriately qualified practitioners with substantial experience on average.
Project description:As applications for IVF have expanded over the years, so too have approaches to controlled ovarian stimulation (COS) for IVF. With this expansion and improved knowledge of basic reproductive biology, there is increasing interest in how COS practice influences IVF outcomes, and whether or not specific treatment scenarios call for personalized approaches to COS. For the majority of women undergoing COS and their treating physicians, the goal is to achieve a healthy live birth through IVF in a fresh cycle. Opinions on how COS strategy best leads to this common goal varies among centers as many clinicians base COS strategy not on evidence obtained through prospective randomized trials, but rather through observational studies and experience. Overall, when it comes to COS most clinicians recognize the approach should not be "one size fits all," but rather a patient-centered approach that takes the existing evidence into consideration. We outline the existing evidence for best practices in COS for IVF, highlighting how these practices may be incorporated into a patient-centered approach.