Appropriate Management of Acute Diarrhea in Children Among Public and Private Providers in Gujarat, India: A Cross-Sectional Survey

Abstract

Diarrhea remains a leading cause of morbidity and mortality among children under 5 years of age in low- and middle-income countries. In 2006, the Indian government formally endorsed the World Health Organization guidelines that introduced zinc supplementation and low-osmolarity oral rehydration salts (ORS) for the treatment of diarrhea. Despite this, zinc is rarely prescribed and has not been available in the public sector in India until very recently. The Diarrhea Alleviation Through Zinc and ORS Treatment (DAZT) project was implemented in Gujarat between 2011 and 2013 to accelerate the uptake of zinc and ORS among public and private providers in 6 rural districts. As part of an external evaluation of DAZT, we interviewed 619 randomly selected facility- and community-based public and private providers 2-3 months after a 1-day training event had been completed (or, in the case of private providers, after at least 1 drug-detailing visit by a pharmaceutical representative had occurred) and supplies were in place. The purpose of the interviews was to assess providers' knowledge of appropriate treatment for diarrhea in children, reported treatment practices, and availability of drugs in stock. More than 80% of all providers interviewed reported they had received training or a drug-detailing visit on diarrheal treatment in the past 6 months. Most providers in all cadres (range, 68% to 100%) correctly described how to prepare ORS and nearly all (range, 90% to 100%) reported routinely prescribing it to treat diarrhea in children. Reported routine prescription of zinc was lower, ranging from 62% among private providers to 96% among auxiliary nurse-midwives. Among providers who reported ever not recommending zinc (n = 242), the 2 most frequently reported reasons for not doing so were not completely understanding zinc for diarrhea treatment and not having zinc in stock at the time of contact with the patient. In a multiple logistic regression analysis, recent training or drug-detailing visits and having zinc in stock were associated with reported zinc prescribing (P<.05). Recent training among public providers was significantly associated with having correct knowledge of zinc treatment duration and dosage, but the same was not true of drug-detailing visits among private providers. Treating diarrhea with zinc and low-osmolarity ORS is new for public and private providers in India and other low- and middle-income countries. Sufficient training and logistics support to ensure consistent supplies are critical if providers are to begin routinely treating all diarrhea episodes with zinc and ORS.

FIGURE 1.

Flowchart of Private Provider Survey Participants

FIGURE 2.

Flowchart of Public Provider Participants Abbreviations: ANMs, auxiliary nurse-midwives; ASHAs, Accredited Social Health Activists; AWWs, Anganwadi workers; MOs, medical officers; PHCs, primary health centers.

FIGURE 3.

Main Reasons^a for Not Recommending Zinc Among Providers Who Reported Ever Not Recommending Zinc, Gujarat, India (n=242)^b Abbreviations: ANMs, auxiliary nurse-midwives; ASHAs, Accredited Social Health Activists; AWWs, Anganwadi workers; MOs, medical officers; PPs, private providers. ^a Other reasons (not shown on chart) reported by private providers but no other provider cadre: caregiver could not afford zinc (17); caregivers prefer treatments that provide quick recovery (7); other drugs are better for diarrhea treatment (4); zinc is not widely accepted among providers (3); profit margin for zinc is not as large as for other drugs (2); zinc is not an effective treatment (2). ^b The 242 providers who reported ever not recommending zinc included 107 private providers, 56 AWWs, 38 ASHAs, 19 MOs, and 22 ANMs.