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

Christa L Fischer Walker; Sunita Taneja; Amnesty LeFevre; Robert E Black; Sarmila Mazumder

doi:10.9745/GHSP-D-14-00209

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FIGURE 1.
Flowchart of Private Provider Survey Participants
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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.
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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.

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TABLE 1. Characteristics of Health Care Providers in 4 Districts of Gujarat, India

	ASHAs (n=165)	AWWs (n=165)	ANMs (n=66)	MOs (n=33)	PPs (n=190)
Age, mean (SD), y	29.4 (6.4)	39 (8.2)	39.6 (9.3)	34.3 (7.4)	43.2 (13.8)
Female, No. (%)	165 (100)	165 (100)	66 (100)	6 (18.2)	5 (2.6)
Years of education, mean (range)	10 (4, 17)	10 (4, 17)	12 (10, 19)	NA^a	16 (9, 22)
Years practicing in current position, median (range)	3 (1, 18)	13 (1, 32)	19 (1, 28)	3 (1,24)	10 (1, 45)
Providers who have received training/drug-detailing visits for diarrhea treatment in last 6 months, No. (%)	138 (83.6)	144 (87.3)	55 (83.3)	29 (87.9)	168 (88.4)
Providers who had any zinc in stock, No. (%)	93 (56.4)	81 (49.1)	42 (66.7)	21 (63.6)	69 (36.3)
Providers who had any ORS in stock, No. (%)	108 (65.5)	94 (57.0)	51 (77.3)	31 (93.9)	105 (55.3)

Abbreviations: ASHAs, Accredited Social Health Activists; AWWs, Anganwadi workers; ANMs, accredited nurse-midwives; MOs, medical officers; ORS, oral rehydration salts; PPs, private providers; SD, standard deviation.
↵a All MOs were trained physicians who had passed their medical examinations successfully.

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TABLE 2. Diarrhea Management Knowledge and Reported Prescribing Behaviors Among Public and Private Providers, Gujarat, India

	Public-Sector Providers
	ASHAs (n=165)	AWWs (n=165)	ANMs (n=66)	MOs (n=33)	PPs (n=190)
No. (%) reporting a child with diarrhea should:
Increase fluid intake^* (correct response)	106 (64.2)	118 (71.5)	49 (74.2)	24 (72.7)	147 (77.4)
Maintain usual fluid intake	48 (29.1)	40 (24.2)	17 (25.8)	9 (27.3)	40 (21.1)
Reduce fluid intake^*	11 (6.7)	7 (4.2)	0 (0)	0 (0)	3 (1.6)
Maintain usual or increase breastfeeding/food intake^* (correct response)	146 (88.5)	150 (90.1)	59 (89.3)	28 (84.8)	136 (71.6)
Reduce food intake^*	19 (11.5)	15 (9.1)	7 (10.6)	5 (15.2)	54 (28.4)
No. (%) recalling ≥ 2 signs/symptoms requiring referral to higher-level facility^*^a	141 (85.5)	154 (93.3)	65 (98.5)	30 (90.9)	162 (85.3)
No. (%) recalling ≥ 4 signs/symptoms requiring referral to higher-level facility^*^a	40 (24.2)	56 (33.9)	26 (39.4)	5 (15.2)	44 (23.2)
No. (%) reporting usually recommending zinc treatment^*	137 (83.0)	146 (88.5)	63 (95.5)	29 (87.9)	117 (61.6)
No. (%) correctly stating the dose and duration of zinc syrup or tablet
Duration of 14 days^*	140 (85.0)	144 (87.0)	63 (95)	31 (94)	90 (47.0)
Correct dose for children 2–5 months old (10 mg/day, i.e., 1/2 tablet or 5 mL)^*^b	60 (36.0)	53 (32.0)	47 (71)	20 (61)	33 (17.0)
Correct dose for children 6–59 months old (20 mg/day, i.e., 1 tablet or 10 mL)^*^b	88 (53.0)	84 (51.0)	49 (74)	22 (67)	47 (25.0)
Refused to answer/did not know correct dose^a	18 (11.0)	10 (6.0)	0 (0)	0 (0)	146 (77.0)
No. (%) reporting routinely recommending ORS^*	164 (99.4)	164 (99.4)	66 (100)	32 (97.0)	170 (89.5)
No. (%) correctly describing how to prepare ORS (i.e., 1 L packet in 1 L water or 200 mL packet in 1 cup of water) ^*	157 (95.7)	153 (93.3)	62 (93.9)	33 (100)	114 (67.5)

Abbreviations: ANMs, accredited nurse-midwives; ASHAs, Accredited Social Health Activists; AWWs, Anganwadi workers; MOs, medical officers; ORS, oral rehydration salts; PPs, private providers.
↵* Signifies differences in response by provider type using chi-squared test for multiple proportions (P<.05).
↵a Signs/symptoms included: unconscious, lethargic, convulsions, unable to drink or breastfeed, persistent diarrhea, sunken eyes, skin pinch goes back slowly, irritable/restless, blood in stool, signs of mild dehydration, fast breathing, difficulty breathing, and vomiting.
↵b Government and training documents state infant dosing is from 2 months and up to 6 months of age. We considered 2–5 months and 2–6 months as correct responses. For this reason, we also accepted 6 or 7 months as the lower bound of the older age category. Zinc should be given until 5 years of age, and thus 59 or 60 months were accepted as the upper bound for the older age category.

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TABLE 3. Demographic and Training Variables Associated With Knowledge and Reported Practice Indicators for Diarrhea Treatment With Zinc and ORS by Type of Provider,^a Gujarat, India

Demographic and Training Variables	Knowledge and Reported Practice Outcome Variables
	Reported routinely recommending zinc		Knew correct duration of zinc treatment		Knew correct zinc dose for 2–5‐ month-old child		Knew correct zinc dose for 6–59‐ month-old child		Reported routinely recommending ORS		Knew correct ORS preparation
	OR	P value	OR	P value	OR	P value	OR	P value	OR	P value	OR	P value
ASHAs (n = 165)
Years of education	0.88	.25	1.05	.68	1.01	.94	1.03	.65	NA^b		1.28	.27
Years practicing as ASHA	0.87	.13	0.92	.40	1.00	.59	0.94	.45	NA^b		2.60	.02
Received training in diarrhea treatment in last 6 months	9.04	<.001	4.85	<.001	3.45	.04	4.80	<.001	NA^b		1	NA
Zinc in stock	4.98	.02	7.20	.01	0.00	.99	3.52	.05	NA^b		7.10	.09
ORS in stock	0.38	.22	0.73	.64	0.00	.99	0.37	.14	NA^b		0.15	.13
AWWs (n = 165)
Years of education	0.93	.58	1.04	.73	1.04	.56	1.03	.65	NA^b		1.14	.35
Years practicing as AWW	1.01	.71	1.00	.94	1.03	.17	0.99	.82	NA^b		1.10	.06
Received training in diarrhea treatment in last 6 months	16.05	<.001	5.68	<.001	2.80	.13	4.85	.01	NA^b		1.51	.61
Zinc in stock	1.94	.48	34.82	<.001	2.16	.36	1.18	.81	NA^b		6.84	.05
ORS in stock	0.72	.70	0.15	.01	0.47	.37	1.21	.78	NA^b		0.27	.13
PPs (n = 190)
Years of education	1.24	<.001	1.20	<.001	1.17	.06	1.16	.04	1.44	<.001	0.98	.72
Years practicing as PP	1.01	.57	0.99	.68	1.01	.47	1.00	.86	1.02	.42	0.98	.18
Received drug-detailing visit for diarrhea medications in last 6 months	3.95	.01	1.96	.21	3.77	.21	2.79	.19	3.86	.04	0.55	.25
Zinc in stock	7.00	<.001	2.51	.01	1.98	.12	2.29	.03	5.55	.12	1.82	.10
ORS in stock	0.57	.14	0.99	.98	1.05	.91	0.84	.64	4.12	.03	1.11	.75

Abbreviations: ASHAs, Accredited Social Health Activists; AWWs, Anganwadi workers; NA, not applicable; OR, odds ratio; ORS, oral rehydration salts; PPs, private providers; RMP, rural medical practitioner.
↵a Results are from a multiple logistic regression (MLR) analysis. Statistically significant results at P≤ .05 are shown in boldface.
↵b Not applicable in the MLR analysis because 99.4% of ASHAs and AWWs reported routinely recommending ORS for the treatment of diarrhea.