Diarrhoeal diseases is a major target in the global efforts to increase survival and reduce the disease burden in children
]. Prevention is of primary importance in these efforts but adequate management of cases is essential to reduce mortality, in particular the administration of Oral Rehydration Solutions (ORS) to treat dehydration
]. The findings in this study highlight areas for improvement in diarrhoea case management.
Respondents’ knowledge about symptoms and danger signs of dehydration showed positive results but also that there was room for improvement. Such knowledge is essential as most deaths from diarrhoea are caused by dehydration. Staff in HC generally scored better than those in DS. Further training of staff on diarrhoea, its symptoms and potential consequences is called for. In particular, clinic based training with hands-on experience from treating cases should be considered as it has proven to be particularly effective
Knowledge on treatment with ORS was generally good. ORS was the stated first hand treatment choice in 87% of the interviews in the HC and in 67% of the DS. Equally many (87% respectively 70%) claimed that they recommend ORS in real practice. In the record review 78% of the cases had been given rehydration therapy. Still, it was only the third most commonly recommended medicine in childhood diarrhoea. In one third of the facilities ORS was out of stock.
Overuse of inappropriate medication during childhood diarrhoea is common
]. Antibiotics are extensively used in diarrhoea case management
], even though they are only recommended in few cases of diarrhoea. Anti-diarrhoeal medicines are not recommended at all in children
Antibiotics are often attained from other sources than from trained medical personnel
]. In the present study over 80% of the respondents stated they recommend antibiotics. Still, antibiotics are only indicated in dysentery, cholera and for certain cases of persistent diarrhea
]. Overuse cause potentially harmful side effects and contributes to bacterial resistance development
]. In the record review, dysentery was a rare diagnosis (2%) and it cannot motivate that 76% of the cases were recommended antibiotics.
Despite the high use of antibiotics, microbes were not mentioned equally frequent as pathogens in diarrhoea (52% in HC and 17% in DS). Worms and bacteria were the most well-known microbes while viral pathogens, that often cause childhood diarrhea
], were never mentioned. Improved knowledge about diarrhoea etiology and when to treat with antibiotics, could possibly decrease the antibiotic usage.
Antidiarrhoeals were never recommended in the HC and sold in only 9% of the DS, corresponding to a much lower use rate than that of previous studies
Previous studies have suggested that caretakers may prefer a combination of ORS and other medicines to single therapy with ORS. Zinc has shown to increase ORS usage
] and reduce the use of antibiotics and antidiarrhoeals
]. In our study zinc was never used but half of the respondents had heard about the medicine. A recent study from India showed that, even when available, zinc is rarely used
]. Zinc was introduced as standard treatment in childhood diarrhoea through the WHO/UNICEF joint statement on the clinical management of acute diarrhoea in 2004
]. However, it is often unavailable in most countries due to difficulties in including it in national policy plans or due to lack of funding
]. This was also the case in Uganda at the time of the study. Efforts need to be made to increase the availability of zinc so that children with diarrhoea can benefit from the therapy.
Correct management of diseases relies on correct knowledge on causes, symptoms and therapies. The frequency of correct answers in the interviews increased with the level of education, but care was often provided by the least educated personnel. Adequate and continuous training will most likely contribute to improved diarrhoea case management. Training within the IMCI strategy has previously shown to significantly improve the quality of care for children under five
Drug shops are often the first line of health care in low-income settings like Namutumba district so it is crucial to also involve drug shop attendants in training. Registration and monitoring of DS is needed to reach this group of health care providers with information and training opportunities.
We agree with other researchers that “training is not enough”
] and other measures must be taken parallel to knowledge transfer to achieve desired changes in behaviour. Still knowledge among providers is a necessary pre-requisite for large-scale and sustainable improvements in case management.
Most children in the record review were recommended treatment for concomitant diseases. Possibly the integrated child case management has contributed to this diagnostic overlap as diagnoses in this setting generally are based on history and clinical examination. In reality, cross diagnosing decrease the risk of missing a case of any of the three potentially life-threatening childhood diseases in the study setting (malaria, pneumonia and diarrhoea). The issue of overlapping symptoms in child illnesses in Uganda has been extensively studied and discussed for pneumonia and malaria
]. Overlap issues in diarrhoea have been much less studied and should be a focus in future research.
The results from this provider survey are higher for ORS prescription than for ORS use as documented in community household surveys from the area. There are several reasons for this discrepancy. One is that some community members do not seek care from the providers investigated and their case management is likely to differ from those who seek a provider′s advice. Another is that the ORS prescribed may not be bought or little, if at all, used. Hence, we cannot draw conclusions on community practices from a survey of providers.
The record reviews at the HC registered the recommended medicines. It was not specified whether the medicines were given at the facility or had to be purchased elsewhere.
Most drug shops in the district were visited but since there was no official registration of DS, some DS may have been missed in the sample. However, it was clear from interviews that the large majority of drug shops were identified and included in the study.
The study was carried out in a rural district in Uganda which limits its generalisability. However, as documented its findings are in line with findings from other places.
The principal investigator of the study was performing the interviews together with an interpreter. This arrangement was selected to improve quality control. However, it may have increased the risk of over-reporting good practices. Generally, self-reported practices have lower validity than other more objective measurements. In this study, record reviews served as such a measurement. It is a limitation of the study that no such records were available in drug shops.