Elsevier

Social Science & Medicine

Volume 57, Issue 6, September 2003, Pages 1031-1044
Social Science & Medicine

ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand

https://doi.org/10.1016/S0277-9536(02)00478-1Get rights and content

Abstract

This study explores Thai physicians’ rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians’ case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented.

Introduction

Diarrhoeal disease remains a major cause of death among children throughout the developing world (WHO/CAH, 2001; WHO, 1998; Murray & Lopez, 1996; Ittiravivongs, Songchaitratna, Ratthapalo, & Pattera-arechachai, 1991). In Thailand, the mortality rate for children under 5 years due to diarrhoeal diseases steadily declined between 1990 and 1999, from 20 to 5.2 deaths per 100,000 population (Division of Epidemiology, Ministry of Public Health, Thailand, 2001). However, it remains the sixth major cause of all age mortality (Ministry of Public Health (MOPH), 1994), and contributes significantly to childhood death despite major initiatives undertaken by the Thai Diarrhoeal Diseases Control Program throughout the 1980s and 1990s in line with WHO guidelines (MOPH, 1991; Wongsaroj, Thavornnunth, & Charanasri, 1997; WHO/CDD, 1994; WHO/CDR, 1995). Moreover, surveillance data collected during 1990–1999 suggest increasing prevalence of morbidity from 5.1% to 7.1%; while nearly 40% of all diarrhoea cases and 26% of deaths due to diarrhoea were children aged less than 5 years (Division of Epidemiology, Ministry of Public Health, Thailand, 2001).

WHO treatment guidelines for childhood diarrhoea followed the discovery that dehydration from acute diarrhoea can be treated by oral hydration using a single fluid. Oral Rehydration Salts (ORS) dissolved in water to form ORS solution is absorbed in the small intestine, replacing water and electrolytes lost in the faeces, and is recommended by WHO as a safe and effective treatment which can be administered at home or at medical centres (WHO/CDR, 1995). Thus, a central policy of the Thai Diarrhoeal Diseases Control Program (TCDD) since 1981 has been to promote oral rehydration therapy (ORT), either by ORS solution or other fluids, accompanied by adequate food intake, to reduce dehydration and diarrhoea-related malnutrition (Cao et al., 2000). Specifically, the TCDD recommended every child with diarrhoea be prescribed ORT. A generic form of ORS, called WHO-ORS, was manufactured in the 1990s by the Government Pharmaceutical Organization of Thailand with funding from WHO/UNICEF and supplied free to all regional public hospitals. Several commercial products such as Oreda® and Olyte-dek®, which differ from the generic ORS in taste and ease of preparation, were also available. The TCDD also recommended the establishment of Diarrhoea Treatment Units (DTUs) in public provincial hospitals, and ORT Corners in smaller primary care health facilities to routinely treat acute childhood diarrhoea.

Through these initiatives, the Thai Ministry of Public Health sought to reduce diarrhoea-linked illness and death in children by increasing ORT use to 80% by 1995 (MOPH, 1991). However, between 1978 and 1991 the use of ORT only increased from 27% to 47% (Charanasri, Pornputtkul, & Wongsaroj, 1995), while a more recent survey of household clusters across 12 Thai provinces found that ORS solution use was 26% with other recommended home fluids at 36% (Wongsaroj et al., 1997). Further program evaluations over this period raised significant concerns that health workers were not following government guidelines in diarrhoea case management, did not accept ORS as a principal treatment strategy, and that antimicrobials were over-prescribed leading to treatment failure, increased antimicrobial resistance, higher health care costs and other side effects (Bajalil & Calva, 1994; Charanasri et al., 1995; MOPH, 1991). We undertook intensive fieldwork in Central Thailand to document the prevalence of sub-optimal prescribing and quality of care offered to children admitted as inpatients or outpatients to government hospitals suffering from diarrhoea. Importantly, our investigation sought to explain cultural, clinical and organisational processes influencing management of children with diarrhoea.

Section snippets

Methods

Combined quantitative and qualitative methods were used to collect data on the management of childhood diarrhoea in the two general and eight community hospitals providing residential care in a Central Thailand province. In Phase 1, a prospective clinical audit and structured survey estimated the prevalence of sub-optimal prescribing practices and quality of care using indicators developed by the International Network for Rational Use of Drugs (WHO, 1993). In Phase 2, qualitative methods,

Prescribing audit findings

The prescription audit found that nearly all 424 child cases (91.3%) received ORS. However, ORS was routinely prescribed (94.6%) with other drugs or intravenous fluids in contravention of the standard treatment guidelines. Among 387 patients given ORS, 52% received WHO-ORS. The remainder received a commercial product with the standard ORS formulation. No unacceptable commercial electrolytes or sports drinks that have higher glucose and lower sodium levels than standard ORS formulas were

Personal, inter-personal and contextual influences on ORS prescribing

We now analyse how individual, inter-personal and organisational factors influence the pattern of prescribing described above. Drawing on in-depth interviews, we discuss how socio-cultural, economic, organisational, clinical, and ethical factors affect Thai clinicians’ management of childhood diarrhoea. A major focus is physician ambivalence towards government practice guidelines. Standard practice guidelines are an important clinical resource for physicians and a key quality management tool

Clinical issues

Clearly, numerous influences affect prescribing patterns which seem far removed from the evidence-based clinical considerations underpinning guidelines. However, clinical decision-making, and its theoretical and ethical frameworks, are enormously important. A fundamental issue is whether decisions should be made primarily on the basis of scientific evidence or from multiple evidence sets. This is particularly crucial in situations of diagnostic uncertainty. A contentious issue is the right of

Ethical considerations

In applying standard treatment guidelines and other protocols on behalf of health authorities, physicians arbitrate and judge the best possible course from amongst a range of competing priorities and demands. Physicians must take into account caretaker preferences and act in accordance with their own professional and ethical standards and economic imperatives, whilst contending with pressures from health authorities and their peers to adhere to guidelines and best practice protocols.

Conclusion

Our findings highlight individual, inter-personal, community and system-level influences affecting the management of childhood diarrhoea. The devalued status of ORS was a major problem confronting physicians in the public hospital sector. Our results suggest this might be alleviated by changing the formulation of ORS and the way it is administered to enhance its value and status in the eyes of caretakers. The image of ORS could be transformed if ORT was not administered separately, but strongly

Acknowledgements

Valuable assistance during project fieldwork was provided by Dr. Oratai Rauyajin, Dr. Sayomporn Sirinavin, Dr. Virasak Chongsuwiwatwong, Professor Wandee Varavithya, Dr. Sumaree Srichamorn, Ms Dhammiga Pensrichoti, Ms Bubpha Dumrongkittikul. Dr. Michael Coorey, A/Professor Kate D’Este and Dr. Ann Saul offered statistical and editorial advice, while Mr. John McPhee provided helpful suggestions about the clinical ethics. This investigation received financial support from The Australian Agency for

References (50)

  • R.K Schwartz et al.

    Physician motivations for nonscientific drug prescribing

    Social Science & Medicine

    (1989)
  • R Bajalil et al.

    Antibiotic misuse in diarrhoea. A household survey in a Mexican community

    Journal of Clinical Epidemiology

    (1994)
  • R.N Battista et al.

    Clinical practice guidelinesBetween science and art

    Canadian Medical Association Journal

    (1993)
  • T.L Beauchamp et al.

    Principles of biomedical ethics

    (1989)
  • C.A Berglund

    Ethics for health care

    (1998)
  • P Boonmongkon et al.

    Understanding women's experience of gynecological problemsAn ethnographic case study from northeast Thailand

    (1998)
  • X Cao et al.

    Relationship between feeding practices and weanling diarrhoea in northeast Thailand

    Journal of Health, Population and Nutrition

    (2000)
  • C Cates

    An evidence based approach to reducing antibiotic use in children with acute otitis mediaControlled before and after study

    British Medical Journal

    (1999)
  • U Charanasri et al.

    Evaluating study of case management of diarrhoeal diseases in Thailand

    Southeast Asian Journal of Tropical Medicine and Public Health

    (1995)
  • C Choprapawon et al.

    Cultural study of diarrhoeal illnesses in central Thailand and its practical implications

    Journal of Diarrhoeal Diseases Research

    (1991)
  • N Choudhry et al.

    Relationships between authors of clinical practice guidelines and the pharmaceutical industry

    Journal of the American Medical Association

    (2002)
  • D Cook et al.

    The trials and tribulations of clinical practice guidelines

    Journal of the American Medical Association

    (1999)
  • Division of Epidemiology, Ministry of Public Health, Thailand. (2001). Annual epidemiology surveillance report, 1999....
  • .B Dossetor J

    Psychosocial patient selection criteria in clinical practice guidelinesAn ethical basis for rationing?

    Canadian Medical Association Journal

    (2001)
  • P Dutta et al.

    Impact of zinc supplementation in malnourished children with acute watery diarrhoea

    Journal of Tropical Pediatrics

    (2000)
  • A.G Ellrodt et al.

    Measuring and improving physician compliance with clinical practice guidelines. A controlled interventional trial

    Annals of Internal Medicine

    (1995)
  • Field, M. J., & Lohr, K. N. (Eds.). (1992). Guidelines for clinical practice: From development to use. Institute of...
  • F.B Garfield et al.

    Clinical judgment and clinical practice guidelines

    International Journal of Technology Assessment in Health Care

    (2000)
  • P.J Greco et al.

    Changing physicians’ practices

    New England Journal of Medicine

    (1993)
  • S Hahn et al.

    Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in childrenSystematic review

    British Medical Journal

    (2001)
  • A Haycox et al.

    Clinical guidelinesThe hidden costs

    British Medical Journal

    (1999)
  • C.W Hoge et al.

    Emergence of nalidixic acid resistant Shigella dysenteriae type 1 in ThailandAn outbreak associated with consumption of a coconut milk dessert

    International Journal of Epidemiology

    (1995)
  • Howteerakul, N. (1997). Prescribing patterns and quality of care for children under five years of age with diarrhoea in...
  • B Hurwitz

    Legal and political considerations of clinical practice guidelines

    British Medical Journal

    (1999)
  • A Ittiravivongs et al.

    Effect of low birth weight on severe childhood diarrhoea

    Southeast Asian Journal of Tropical Medicine and Public Health

    (1991)
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