title: Predictors of rational management of diarrhea in an endemic setting: observation from India.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Tanmay
authors: T
authors: Mahapatra
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Sanchita
authors: S
authors: Mahapatra
authors: Department of Data Management, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Barnali
authors: B
authors: Banerjee
authors: Department of General Medicine, Midnapore Medical College & Hospital, Vidyasagar Rd, Medinipur, West Bengal, 721101‎, India.
authors: Umakanta
authors: U
authors: Mahapatra
authors: Department of Pediatrics, Dr. B. C. Roy Memorial Hospital For Children, 111, Narkeldanga Main Road, Phool Bagan, Kolkata-700005, West Bengal‎, India.
authors: Sandip
authors: S
authors: Samanta
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Debottam
authors: D
authors: Pal
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Nandini
authors: N
authors: Datta Chakraborty
authors: Department of Data Management, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Byomkesh
authors: B
authors: Manna
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India; PATH India Office, A-9 Qutab Institutional Area, USO Road, New Delhi, 110067, India.
authors: Dipika
authors: D
authors: Sur
authors: Department of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata-700 010, West Bengal, India.
authors: Suman
authors: S
authors: Kanungo
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D003967:Diarrhea / Q000453:epidemiology / Q000517:prevention & control*; D019468:Disease Management; D005440:Fluid Therapy; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D010818:Practice Patterns, Physicians' / Q000592:standards*
chemical_list: D000900:Anti-Bacterial Agents