Nigerian Journal of
Paediatrics 2011;38 (4)159 - 164
ORIGINAL
Esezobor C I
Adeniyi OF
Knowledge, Acceptance and Practice of
Ekure EN
Zinc
Therapy in Acute Diarrhoea Among
Paediatric Doctors in Nigeria
Received: 22nd May
2011
Abstract
Background: WHO
and
part of Nigeria
(70.8%). About half
Accepted: 29th
September 2011
UNICEF recommend zinc
therapy
(44.3%) of the
respondents
in children with acute
diarrhoea,
managed more than 10
diarrhoeal
Esezobor C I (
)
however
adherence
to
the
cases every month. All
except one
Adeniyi OF, Ekure
EN
recommendation varies
from
respondent (84 of 85)
agreed with
Department of
Paediatrics, College country to country.
t h e
W H O / U N I C E
F
of Medicine, University
of Lagos, Objectives:
To determine the
recommendation and
86.9% (73 of
PMB 12003, Lagos ,
Nigeria
knowledge, acceptance
and
85) reported
prescribing zinc for
E-mail
:esezobor@gmail.com
practice of zinc use in
childhood
acute diarrhoea in the
past year;
Tel:
+2348058440582
diarrhoea among
paediatric
67.1% (49 out of 73)
prescribed it
doctors in
Nigeria.
always for acute
diarrhoea.
Methods:
Every third
sitting
Knowledge of the
effects of zinc on
participant during the
42
n d
acute diarrhoea was
high.
There
Paediatric Association
of Nigeria
was no significant
difference
Conference was
requested to
between the paediatric
residents
complete a
questionnaire if they
and the consultants in
both
were either a
paediatric resident
knowledge and practice
of zinc
doctor or consultant
working in
therapy.
Nigeria.
Conclusion: The
use of
zinc as
an
Results: Of
the 153
questionnaires
adjunct in the
management of acute
distributed, 93 (60.8%)
were
diarrhoea is acceptable
and
returned and 85 met the
study
practised by most
paediatric
criteria. Over half
(57.6%) of the
residents and
consultants in
respondents were
consultant
Nigeria.
paediatricians and
84.7% (49 of
85) practise in
tertiary or teaching
Key
Words:
acute diarrhoea,
hospitals, mostly in
the southern
knowledge, practice,
WHO, zinc
Introduction
recommendations, many
countries have developed
guidelines on the
management of acute diarrhoea
which include zinc
However, it has been observed
8
Diarrhoea remains a
leading cause of mortality and
morbidity in the
paediatric population globally, and
that that adherence to
treatment guidelines for the
also in Nigeria.
1,2
Most diarrhoeal deaths
result from
management of common
childhood illnesses such as
dehydration and take
place at home or soon after
diarrhoea is low
worldwide.
8-10
In Sudan,Cheragili et
11
arrival at the
hospital. To combat this trend, WHO
al noted
that the
adherence of
prescribers to
standard
recommended the use of
oral rehydration
treatment guidelines
for treating diarrhoea in the
solution including
continued oral feeding. Based on
public hospitals ranged
between 45-64%. Similarly,
the reports of several
studies
3-6
confirming the
arecent study in India
found that only 22% of 843
beneficial effects of
zinc therapy in acute watery
prescriptions for acute
diarrhoea included zinc.
9
diarrhoea, the WHO and
UNICEF, in 2004,
recommended its use for
10-14 days in children with
There appears to be
little published information
acute diarrhoea. Since
the publication of the
7
available on the use or
prescription of this vital
160
Supplement for children
with diarrhoea by
In diarrhoea where the
options provided were 'Yes',
paediatricians in
Nigeria. Thus this study aims to
'No' and 'Not sure', if
none of the options was ticked it
describe the knowledge
and practice of the use of
was assumed the
respondent was not sure of the
zinc in the treatment
of acute watery diarrhoea by
correct answer.
Continuous variables were tested for
paediatric residents
and consultants in the country.
normality and presented
as mean (SD) or median
(IQR) as appropriate.
Categorical variables were
presented as
percentages. Test of differences in the
knowledge and practice
of the residents and the
Materials and Methods
consultants was
compared using odds ratio. The level
of statistical
significance was set at 5%.
nd
The study was carried
out during the 42 Annual
Paediatric Association
of Nigeria Conference
(PANCONF), held in
Abuja, Nigeria between 12
th
and 14
th
January 2011. PANCONF
is the largest
Results
annual gathering of
paediatricians, paediatric
residents and other
health practitioners in the
Of the 153
questionnaires distributed 93 were
practice of child
health in Nigeria. It attracted over
returned (60.8%). Eight
questionnaires were
500 participants from
Nigeria and the rest of the
discarded because they
were completed by nurses (3),
world. A sample size of
158 was calculated using the
did not include the
state where practice is located (3),
Cochran's formula with
correction for finite
did not see any child
with diarrhoea in the past one
population and a
reported adherence of 75% from a
year (1) and was
incompletely filled (1); leaving 85
previous study.
12-13
To increase the
geographical
questionnaires for
analysis. The median time since
spread of the survey
and diversity of the participants,
graduation from medical
school was 13 years and 45
every third sitting
participant was recruited, because
(52.9%) of the
respondents were females. Most of the
participants that share
the same interests and location
respondents work in
tertiary or teaching hospitals
of practice tend to sit
togetherduring meetings.
(84.7%) located in the
southern region of Nigeria
(70.8%). Consultants
made up 57.6% (49 out of 85)
The questionnaire
included sections on the
of the respondents with
a median time since
demographics of the
respondents such as gender,
attainment of
fellowship of 4
years. About
half
time since medical
school graduation and fellowship
(44.3%) of the
respondents attend to more than 10
in paediatrics,
practice type and location; number of
diarrhoeal cases every
months Table 1.
diarrhoea cases seen
per month; agreement with the
WHO guidelines on the
use of zinc for acute watery
All the respondents
except one (84 out of 85) agreed
diarrhoea; zinc
prescription pattern; and knowledge
with the WHO
recommendation that zinc should be
about the function of
zinc in acute diarrhoea. To
given to children with
acute diarrhoea and 86.9% (73
encourage completion,
each question except the
out of 85) prescribed
zinc for acute watery diarrhoea
ones on time since
graduation or fellowship and
in the past 1 year. Of
those who prescribed zinc in the
practice location had 3
or more options to choose
past one year, 67.1%
(49 out of 73) prescribed it all
from. To maximize
retrieval, the questionnaires were
the time they managed a
child with acute diarrhoea
distributed on the
first day of the conference. Only
Table 2. Of the 88
respondents who agreed with the
questionnaires from
resident doctors in paediatrics
WHO recommendation,more
than 75% responded
and consultant
paediatricians were analyzed.
that zinc in acute
watery diarrhoea should be given
I n c o m p l e t e l
y
f i l l e d
q u e s t i o n n a i r
e s
o r
for 10-14 days, that it
reduces diarrhoea duration,
questionnairesfilled
byparticipantspractising
replaces body stores of
zinc and re-epithelizes the
outside Nigeria were
excluded
intestine. A smaller
proportion (60.7%) agrees that it
reduces stool
frequency. In contrast, less than half
The data was entered
into Microsoft Excel 2007 and
(45.2%) reported that
zinc reduces stool volume.
analyzed using EPI info
version 3.4.3. One of the
There was no
significant difference in the knowledge
authors checked the
entered data for errors by going
and practice of
paediatric residents and consultants
through all the
questionnaires again. For
concerning zinc use in
acute diarrhoea (Tables 2 and
theknowledge-based
section on the benefits of zinc
3).
161
Table 1: Description of the studied
population
Descriptors
All
Residents
Consultants
n=85 (%)
n=36 (%)
n=49 (%)
Gender
Males
40 (47.1)
15 (41.7)
25 (51.0)
Females
45 (52.9)
21 (58.3)
24 (49.0)
Time since medical
school graduation, median(IQR), years
13 (12)
8 (4.5)
17 (11)
Time since fellowship,
median (IQR), years
NA
NA
4 (8)
Practice location:
North-west
13 (14.6)
9 (25.0)
4 (8.2)
North-central
9 (10.1)
2 (5.6)
7 (14.3)
North-east
1 (1.1)
1 (2.8)
0 (0.0)
South-west
24 (27.0)
7 (19.4)
17 (34.7)
South-south
19 (22.5)
12 (33.3)
7 (14.3)
South-east
19 (21.3)
5 (13.9)
14 (28.6)
Practice Type:
General
hospitals
8 (9.4)
3 (8.3)
5 (10.2)
Tertiary/Teaching
Hospitals
72 (84.7)
32 (88.9)
40 (81.6)
Private/NGOs
5 (5.9)
1 (2.8)
4 (8.2)
Diarrhoea cases/month:
1-10
49 (55.7)
19 (52.8)
30 (61.2)
11-20
20 (23.9)
10 (27.8)
10 (20.4)
>20
16 (20.5)
7 (19.4)
9 (18.4)
19.NA: not
appropriate
Table 2: Practice of zinc use in acute watery
diarrhoea
Practice
Variables*
All
Residents
Consultants
Odds Ratio
P value
n (%)
n (%)
n (%)
Agrees with WHO
0.00
0.58
recommendation
84 (98.9)
36 (100.0)
48 (98.0)
Yes
1 (1.1)
0 (0.0)
1 (2.0)
No
Teach student use of Zinc
1.09 (0.30-
0.57
Yes
67 (85.9)
29 (85.3)
38 (86.4)
3.93)
No
11 (14.1)
5 (14.7)
6 (13.6)
Prescribed zinc in the past
1.03 (0.25-
0.62
year
73 (86.9)
32 (88.9)
41 (85.4)
4.13)
Yes
9 (10.7)
4 (11.1)
5 (10.4)
No
How
often is zinc prescribed
1.47 (0.54-
0.45
All the times
49 (67.1)
23 (71.9)
26 (63.4)
4.00)
Rarely/Sometimes
24 (32.9)
9 (28.1)
15 (36.6)
Duration zinc is prescribed
2.05 (0.49-
0.26
(days)
10 (13.7)
3 (9.4)
7 (17.1)
8.67)
5
62 (84.9)
29 (90.6)
33 (80.5)
10-14
*The total respondents
for each practice variables differs
162
Table 3: Knowledge of the Function of Zinc
in Acute Diarrhoea
Knowledge
Variables*
All
Residents
Consultants
Odds Ratio
P value
n (%)
n (%)
n (%)
95%CI
Does zinc reduce stool
1.06 (0.44-2.52)
0.90
volume
38 (45.2)
16 (44.4)
22 (45.8)
Yes
46 (54.8)
20 (55.6)
26 (54.2)
No/not sure
Does zinc reduce
diarrhoea duration
1.24 (0.43-3.61)
0.70
Yes
67 (79.8)
28 (77.8)
39 (81.3)
No/not sure
17 (20.2)
8 (22.2)
9 (18.8)
Does zinc reduce stool
0.79 (0.33-1.93
0.61
frequency
51 (60.7)
23 (63.9)
28 (58.3)
Yes
33 (39.3)
13 (36.1)
20 (41.7)
Not/not sure
Does zinc re-epithelize
0.53 (0.12-2.22
0.30
the
intestine
74 (88.1)
33 (91.7)
41 (85.4)
Yes
10 (11.9)
3 (8.3)
7 (14.6)
Not/not sure
Does zinc replace body
1.27 (0.45-3.54)
0.65
store
65 (77.4)
27 (75.0)
38 (79.2)
Yes
19 (22.6)
9 (25.0)
10 (20.8)
Not/not sure
*knowledge variables
for the 84 respondents who agree with the WHO/UNICEF recommendation
Discussion
found to be lower than
adherence inferred from self
report.
1 4
With widespread
awareness of a
In this study an
attempt was made to determine,
recommendation among
health workers, adherence is
expected to increase ;
hence the difference in study
13
using self-report, the
level of adherence to the WHO-
UNICEF recommendation
concerning the use of
periods could also have
contributed to the varied
zinc in acute
diarrhoea. All but one of the
adherence rates.
participating
respondents agreed with the
recommendation with
over 80% prescribing zinc for
The high prescription
rate for zinc in the present study
acute diarrhoea in the
past year. Of those who
may be explained by the
demographics of the
prescribed zinc in the
past one year, two-thirds
respondents. All the
respondents were either
prescribed it all the
time they managed a child with
specialist
paediatricians or paediatric residents
acute diarrhoea. The
high practice rate in this study is
practicing in tertiary
or teaching hospitals with a
similar to the findings
of two retrospective studies in
median duration since
graduation from medical
India which reported
that 65% of the children with
schools of 13 years.
Because most of the respondents
acute diarrhoea
received a prescription of
indicated that they
teach students about diarrhoea, it
is expected that they
were more likely to be current in
zinc. Inontrast, the
prescription rate in the present
13
the knowledge and
practice of common childhood
study is much higher
than the 22% reported by
Pathak
et al in another region in
India.
9
medical
conditions
compared
to
general
practitioners. The
small number of respondents in
facilities other than
teaching/tertiary hospital did not
The higher rate in the
present study compared to that
allow for comparison in
the present study. Moreover,
of Pathak
et al may be due to several
factors. While
since about half of the
respondents manage more than
the study by
Pathak et
al involved mostly general
10 cases of acute
diarrhoea per month, it is likely that
practitioners the
present study involved
this would have
contributed to their knowledge and
paediatricians and
paediatric residents whose
practice of the
standard management of acute
knowledge of the
current management of diarrhoea
diarrhoea.
is expected to be
higher. Secondly, the huge
difference in adherence
rates to the WHO
The majority of the
respondents reported that
recommendation could
also be due to the methods
prescribing zinc in
acute diarrhoea was associated
used to access
adherence. As expected, adherence
with shorter diarrhoea
duration, fewer stool
measure by actual
observation is commonly
frequency and helps in
the re-epithelization of the
163
Intestinal mucosa. The
high proportion of the
Association of Nigeria.
Like in most c ountries where
respondents with the
correct knowledge of the
effects of zinc on the
course of acute diarrhoea may
the recommendations
have been implemented,
have contributed to the
high zinc prescription rate
support by paediatric
associations has been important
to the
implementation.
8
(elicited by
self-report) documented in the present
study. In contrast,
less than half of the respondents
reported that zinc use
leads to reduction in stool
The findings of the
present study may not be
volume. This low
response may be due to the
extrapolated to the
general population of paediatric
conflicting findings
from various studies on the
doctors in Nigeria,
because the respondents may be a
effect of zinc on stool
volume.
15-17
selection bias of
doctors that are abreast with current
medical practice.The
lower sample size may also have
In agreement with the
WHO recommendation, the
reduced the
generalizability of our findings. However
vast majority of the
respondents in the present study
the conference provided
an opportunity to improve
reported prescribing
zinc for 10-14 days to children
response rate and
coverage to a country-wide study.
with acute diarrhoea;
about 14%, most of whom are
For unknown reason(s)
respondents from the north
consultant
paediatricians, prescribed zinc for 5 days.
east region of Nigeria
were poorly represented in the
Plausible explanation
for the practice of zinc
study. However we are
not aware of any reason why
prescription for 5 days
was not explored in the study
their acceptance and
practice of zinc use in acute
but may be due to
reports of studies supporting than
diarrhoea should be
significantly different from the
zinc therapy for less
than 10-14 days was equally
results of the present
study. Because the questionnaire
with the instruction
'for doctors only' was handed to
effective.
3,18
For instance, in a
randomized
every third sitting
participant, some of whom may not
community trial in
Bangladesh a 5-day regimen was
be medical doctors, the
response rate in this study
not different from a
10-day regimen when the
could be higher than
the 60% response rate recorded.
primary outcome was
incidence and duration of
We were not able to
comment on the demographics of
diarrhoea over the
subsequent 90 days.
18
those who did not
return the questionnaires.
In terms of knowledge
and practice of zinc use in
acute diarrhoea, there
was no significant difference
between the resident
doctors and consultant
Conclusion
paediatricians. This
finding is not unexpected for
several reasons. Being
a fairly common childhood
The use of zinc in the
management of acute diarrhoea
condition both the
residents and consultants would
is acceptable and
practiced by most paediatricians and
have had ample
opportunities to participate in the
paediatric resident
doctors in Nigeria, most of whom
management of acute
diarrhoea and as a result
posses the correct
knowledge about the effects of zinc
improve knowledge and
practice. Also, as most of
on the clinical course
of a bout of acute diarrhoea.
the respondents are
from teaching/tertiary hospitals
they are exposed
regularly to academic activities that
Author's contribution: ECI
and AOF
conceived the
provide opportunities
to update knowledge and
study but all the
authors participated in the design and
practice of common
health conditions including
implementation of the
study. In addition all the
diarrhoea.
authors approved the
submitted manuscript.
Conflict of interest: none
declared
The 42 PANCONF provided
a unique opportunity
nd
Role
of funding source: No
funding was
received for
to determine knowledge
and practice of zinc use, not
this work
only in one centre or
region, but among paediatric
doctors from all the
regions of Nigeria. Our findings
support a country-wide
practice of the prescription
Acknowledgement
of zinc during a bout
of acute diarrhoea in children,
although the north east
region was sparsely
We wish to thank the
resident doctors from Lagos
represented in the
sample. The result of the present
University Teaching
Hospital who helped in the
study implies
acceptance of the recommendations of
distribution and
retrieval of the questionnaires during
WHO and UNICEF
concerning the use of zinc in
PANCONF. We are also
grateful to Dr Oladepo for
acute diarrhoea to most
members of the Paediatric
entering the data into
Microsoft Excel software.
164
References
1. Black RE, Cousens
S,
6. Bhandari N, Bahl
R, Taneja S,
13. Balasubramanian S,
Ganesh R.
Johnson HL, Lawn JE,
Rudan
Strand T, Molbak K,
Ulvik
Prescribing pattern of
zinc and
I, Bassani DG, et al : Global,
RJ, Sommerfelt H, Bhan
MK:
antimicrobials in
acute
regional, and national
causes
Substantial reduction
in
diarrhea.
Indian Pediatr. 2008;
of child mortality in
2008: a
severe diarrheal
morbidity by
45(8):701.
systematic
analysis. Lancet
daily zinc
supplementation in
14. Farley J, Hines S,
Musk A,
2010, 375(9730):1969-1987.
young north Indian
children.
Ferrus S, Tepper
V.
2. Bryce J,
Boschi-Pinto C,
Pediatrics2002, 109(6):e86.
Assessment of adherence
to
Shibuya K, Black RE.
WHO
7. Clinical
management of acute
antiviral therapy in
HIV-
estimates of the causes
of
diarrhoea(WHO/FCH/CAH/0
infected children using
the
death in children. Lancet.
4.07). Geneva & New
York:
Medication Event
Monitoring
2005;365(9465):1147-52.
World Health
Organization &
System, pharmacy
refill,
3. Baqui AH, Black RE,
El
United Nations
Children's
provider assessment,
caregiver
Arifeen S, Yunus
M,
Fund; 2004.
self-report, and
appointment
Chakraborty J, Ahmed
S, et
8. Fischer Walker CL,
Fontaine
keeping.
J Acquir Immune
al. Effect of zinc
O, Young MW, Black
RE.
DeficSyndr. 2003;33(2):211-8.
supplementation
started
Zinc and low osmolarity
oral
15. Patel A, Mamtani M,
Dibley
during diarrhoea on
morbidity
rehydration salts
for
MJ, Badhoniya N,
Kulkarni H.
and mortality in
Bangladeshi
diarrhoea: a renewed
call to
Therapeutic value of
zinc
children: commun ity
action.
Bull World Health
supplementation in
acute and
randomised trial. BMJ 2002,
Organ. 2009; 87(10):780-6.
persistent diarrhea:
a
325(7372):1059.
9. Pathak D, Pathak
A, Marrone
systematic review. PLoS One.
4. Bhutta ZA, Bird
SM, Black
G, Diwan V, Lundborg
CS.
2010;5(4):e10386.
RE, Brown KH, Gardner
JM,
Adherence to
treatment
16. Lukacik M, Thomas
RL,
Hidayat A,
et al : Therapeutic
guidelines for acute
diarrhoea
Aranda JV. A
meta-analysis of
effects of oral zinc in
acute
in children up to 12
years in
the effects of oral
zinc in the
and persistent diarrhea
in
Ujjain, India--a
cross-
treatment of acute
and
children in
developing
sectional
prescription
persistent
diarrhea. Pediatrics .
countries: pooled
analysis of
analysis.
BMC Infect Dis .
2008;121(2):326-36.
randomized controlled
trials.
2011;11:32.
17. Patro B, Golicki D,
Szajewska
Am
J ClinNutr2000,
10. Hoekstra JH.
Acute
H. Meta-analysis:
zinc
72(6):1516-1522.
gastroenteritis
in
supplementation for
acute
5. Sazawal S, Black
RE, Bhan
industrialized
countries:
gastroenteritis in
children.
MK, Jalla S, Sinha
A,
compliance with
guidelines
Aliment PharmacolTher. 2008;
Bhandari N: Efficacy of
zinc
for treatment. J
28(6):713-23.
supplementation in
reducing
PediatrGastroenterolNutr.
18. Alam DS, Yunus M,
El Arifeen
the incidence and
prevalence
2001;33 Suppl 2:S31-5.
S, Chowdury HR, Larson
CP,
of acute
diarrhea--a
11. Cheraghali AM,
Idries AM.
Sack DA, Baqui AH,
Black
community-based,
double-
Availability,
affordability, and
RE: Zinc treatment for
5 or 10
blind, controlled
trial. Am J
prescribing pattern
of
days is equally
efficacious in
ClinNutr1997, 66(2):413-418 .
medicines in
Sudan. Pharm
preventing diarrhea in
the
World Sci 2009;31(2):209-
.
subsequent 3 months
among
15.
Bangladeshi
children. J
12. Cochran WG.
Sampling
Nutr.2011, 141(2):312-315.
nd
techniques, 2 Ed.,
New
York: John Wiley and
Sons,
Inc. 1963