Indian J Pediatr 1990; 57 : 89-92

Inadequacies in the Management of Diarrhea at the Peripheral

Non-teaching Level

Tejinder Singh

Division of Pediatrics, Mosaboni Mines Hospital, Singhbhum o

A knowledge-attitude-practices survey regarding diarrhea was done on 29 MBBS doctors and 36 RMPs. A predetermined questionnaire was put to them and later a random prescription audit was done. Diarrhea was considered to be bacterial in origin by majority of the participants and use of routine antibiotics was advocated by them. Only 37% and 25% of the doctors in the two groups considered ORS to be important. The difference in the responses in the two groups was not statistically significant. Almost all the doctors relied upon the drug industry to provide them information about drugs. Medicines containing multiple drugs were prescribed by 51% and 63% of the respondents to 'treat' diarrhea. It is suggested that pediatrics should be allotted more time in the MBBS curriculum. CME programmes should be organised to decrease the dependence of the doctors on drug industry.

Key Words : Diarrhea; Prescription audit; ORS; Pharmaceutical industry; Pediatric education.

Discovery of ORS can be termed as the most revolutionary one of the decade, since it has the potential of preventing 1.5 mil- lion deaths that occur each year due to di- arrhea related disorders? Diarrhea related deaths have been prevented to a great ex- tent in many developing countries, because of ORT but the impact has not yet been felt in India. 2 This may be due to differ- ences in the socio-economic conditions,

Reprint requests : Dr. Tejinder Singh, 6, Harvey Hostel, Christian Medical College Campus, Ludhiana - 141 008, Punjab.

non-availability of medical facilities, poor compliance of the consumers or to faulty prescribing practices. The present study is an attempt to evaluate the role of prescrib- ing practices of doctors in the management of diarrheal disorders at the peripheral non-teaching level.

MATERIAL AND METHODS

The study was based in an industrial hospital situated in a tribal area of Bihar. The participants were 29 MBBS doctors and 36 Registered Medical Practitioners (RMPs), without any recognised medical

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90 THE INDIAN JOURNAL OF PEDIATRICS Vol. 57, No. 1

degree. Out of 29 MBBS doctors, 12 were in service as GDMOs/Asstt. surgeons, while the remaining were engaged in pri- vate practice in a semi-urban area. The purpose of the study was explained to them and an express consent obtained. The first part of the study was an informal interroga- tion to assess their knowledge and attitudes regarding diarrhea, on the basis of a pre- determined questionnaire. The second part consisted of actual prescription audit. All the participants were requested to keep a carbon copy of prescriptions given for diar- rhea, for a period of 15 days. Out of these, two prescriptions each were randomly picked up by an independent observer (not a pediatrician) and audited by the author. All the results were statistically evaluated to find the significance of difference be- tween the two groups.

RESULTS

Etiology of diarrhea was believed to be bacterial by 62% of the MBBS and 92% of the registered doctors, who also incrimi- nated other factors like evil eye, bad weather, dietary indiscretion and so on. Correct assessment of the grade of dehy- dration was known to only 17% and 6% of the participants. ORS was considered im- portant by 38% and 25% respectively, whereas, 17% and 28% were of the opinion that most cases of diarrhea in children can be managed by antibiotics alone, without the use of ORS. Routine prescription of antibiotics was advocated by 79% and 83% of the doctors in the two groups. Source of information regarding drugs was the medi- cal representative for 59% and 92% while the other 34% and 8% depended on litera- ture produced by drug companies in the form of journal advertisements and MIMS. Complete cessation of feeds during a

TABLE 1. Showing the Knowledge and Attitudes Towards Diarrheal Disorders

MBBS doctors RMPs n =29 n=36

Etiology

Bacterial 18 (62.1) 2 (5.5) Viral 2 (6.8) 1 (2.7)

Others 9 (31.1) 33 (91.6)

Assessment of dehydration Correct 5 (17.2) 2 (5.5)

Incorrect 24 (82.7) 34 (94.4)

Role of ORS

Important 11 (37.9) 9 (25.0)

Adjuvant 13 (44.8) 17 (47.2)

Not needed 5 (17.2) 10 (27.7) Diet during diarrhea

Stop all feeds 13 (44.8) 18 (50.0)

Liquid diet 15 (51.7) 16 (44.4) Normal diet 1 (3.4) 2 (5.5)

Routine antibiotics

Useful 23 (79.3) 30 (83.3) Harmful 6 (21.6) 6 (16.6)

Source of information

Books 2 (6.8) -

MINIS 3 (10.3) 2 (5.5)

Advertisements 7 (24.1) 1 (2.7)

Medical representatives 17 (58.6) 33 (91.6)

Figures in parentheses are percentages. MIMS : Monthly index of medical specialities.

diarrheal episode was advised by 44% and 50% of the participants respectively. Only 3% and 5% were in favour of giving the usual diet to the child.

Prescription audit revealed that antibi- otics were prescribed by 48% and 50% as the first drug on the prescription; while 44% of both the groups prescribed anti-

SINGH : INADEQUACIES IN THE MANAGEMENT OF DIARRHEA 91

motility drugs as the first one. ORS was the firstline treatment in only.7% and 5% of the prescriptions. Among the anti-diarr- heals, single drug formulations were fa- voured by only 14% and 5% of the partici- pants; while 51% and 64% favoured com- binations containing more than 3 drugs.

DISCUSSION

Principles for managing diarrhea are unambiguous and can be summed up as avoidance of all drugs and continuation of normal diet. ORS is usually more than suf- ficient in most of these cases. 1 Efforts are being made on a global scale to teach mothers to use ORS even before medical help is available. How do we, then account for the fact that our health providers still rely on antibiotics and gut paralysers to treat diarrhea, side-tracking the use of ORS ?

It is important to note that the differ- ence in responses in the two groups are not significant. Is it not a pointer to the fact that 5 years of medical schooling has failed to make any impact on our graduates in the management of a simple yet important condition like diarrhea ?

The present medical curriculum does not match with the socio-economic condi- tions or disease pattern in our country and it is a tragic fact that whereas details of or- gan transplantations are poured on to the students, no effort is made to teach them the management of common problems like diarrhea and further evaluate them in this field. In absence of a university examina- tion, there is hardly any initiative for the students to learn about diarrhea or other common problems of children. It is no co- incidence that in countries like Thailand and Srilanka, which spend 33% of a gradu-

T.~dlLg 2. Results of Prescription Audit

MBBS doctors RMPs n=29 nffi36

First drug on the prescription Antibiotics 14 (48.2) 18 (50.0)

Antimotility 13 (44.8) "16 (44.4)

ORS 2 (6.8) 2 (5.5)

Choice of antidiarrheal

Single drug 4 (13.7) 2 (5.5)

Two drug formula 10 (34.4) 11 (30.5)

Multi drug formula 15 (51.7) 23 (63.8)

Differences not significant Figures in parentheses are percentages.

ate's time in Pediatrics, compared to 11% of ours, IMR is almost one third? The fact that there are only 5000 trained pediatri- cians available to treat 400 million children of our country 4 makes it all the more im- portant that our general practitioners should be thoroughly familiarised with the problems affecting our children.

There has been considerable improve- ment in our understanding of the manage- ment of diarrhea over the years-however, the knowledge has not percolated down to the extent it should have been. No doubt a considerable time is devoted to discussing these aspects in Pediatric forums; however it would be worthwhile to share the knowl- edge with our general practitioner friends and to involve bodies like IMA in these CME programmes. This would enable the busy practitioner to get an unbiased infor- mation regarding management of diarrhea, the use of anti-microbials and other drugs.

Another aspect that needs consideration is the role of drug industry in promoting

92 THE INDIAN JOURNAL OF PEDIATRICS Vol. 57, No. 1

the indiscriminate use of antibiotics and other drugs. Drug advertisements, which dominate the pages and budgets of medical journals, lend credence to the dubious claims of drug companies. Professional as- sociations and others associated with publi- cation of journals can make a significant contribution by not publishing such advertisements--many such advertisements are projected by the drug companies as an endorsement of the product by the journal or professional association.

Pediatric forums like Indian Academy of Pediatrics should take steps to involve the drug companies, which are marketing ORS. If these companies can be motivated to instruct their medical representatives to

lay more stress on the use of ORS alone, the nation wide network of medical repre- sentatives can be effectively used to reach the RMPs, who are otherwise inaccessible to scientific knowledge.

REn~NOgS

1. Pierce NF, Hirschorn N. Oral fluid-.a simple weapon against diarrhea. WHO Chronicle 1977; 31 : 87-89.

2. Survey of infant and child mortality 1979. Registrar General of India. New Delhi 1983.

3. Report of Workshop on Child Health and Manpower - 2000 AD./AP and WHO : New Delhi 1987.

4. Walia BNS. Presidential address. Indian Pediatr 1983; 20 : 885-892.

OSTEROGEN TREATMENT OF CONSTITUTIONAl t y TlU t GIRLS

Thirty-five constitutionally tall girls (mean age 12.5 years) were treated with ethinyl estradiol, in a dosage of only 0.1 rag/day. Their ultimate heights were compared with those of 23 untreated girls of similar initial ages, bone ages (BAs), and predicted adult heights, and with those of five girls treated with ethinyl estradiol, 0.3 rag/day. The reductions in predicted adult height achieved by estrogen treatment averaged 7.4 cm in girls with BA values > 12.5 Year. The authors concluded that the higher dosage of estrogen offers little, if any advantage over the dosage of 0.1 mg/day.

Abstracted from :

Growth, Genetics and Hormones 1989; Vol. 5, No 2 : 15.