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Table 3 Beliefs, motivations, and context related to harmful practices by region and country

From: Harmful practices in the management of childhood diarrhea in low- and middle-income countries: a systematic review

Author, Year [reference] Country Study design: methods (number conducted), study population Source of information on diarrhea treatment Expected effect of treatment Restriction of specific food or fluid Treatment specific to type or cause of diarrhea Drug specific: strength/effectiveness Drug specific: and source/availability Other
 Hudelson et al., 1994 [44] Bolivia Qualitative study: Indepth interviews IDIs (65), hypothetical case scenarios (10), and observation (5) of mother and health workers, El Alto 1993, Mothers of children <5 years and health workers   Food: Mothers worry increasing food intake could worsen episode   General: Type of treatment sought is dependent on perceived cause of the illness    Feeding: Diet is already poor so doesn’t vary much during episode
Food: Some may offer less food to reduce stool output Drugs: Drugs are used to treat “diarrea por infeccion” Food: Reduction in intake due to loss of appetite. Caregivers unaccustomed to encouraging feeding.
 Larrea-Killinger et al., 2013 [113] Brazil Qualitative study: IDIs (29) and observations, Salvador 1997–2004, Mothers and grandmothers of children <5 years      Combination of ORS and antibiotics believed to reduce severity of episode   
 McLennan et al., 2002 [49] Brazil Qualitative study: IDIs (29) and observations, Salvador 1997–2004, Mothers and grandmothers of children <5 years    Feeding: 1/3 mothers reported restricting some foods     Drugs: 73 % mothers believe child should be given antibiotic for episode
Feeding: 95 % believe at least one food item should be restricted
Food: 38 % believe all solid foods should be restricted
BF: Few (3 %) believe BF should be suspended
 Granich et al., 1999 [114] Dominican Republic Quantitative study: Structured interviews (582), Periurban Santo Domingo 1996, Mothers of children <5 years        Drugs: 71 % of caregivers would give pill or injection for hypothetical episode of diarrhea
 Ecker et al., 2013 [115] Peru Quantitative study: Structured interviews (1200), Periurban Lima (year not specified), Caregivers of children <5 years        Drugs: 65 % of caregivers believe antibiotic is necessary to treat hypothetical case of non-dysenteric diarrhea
Eastern Mediterranean          
 Ali et al., 2003 [50] Pakistan Quantitative study: Self-administered questionnaire (400), Karachi 2000, Adult females attending clinic Food: Most caregivers reported receiving information on food restriction from mother or grandmother   Food: Heavy foods, bread, meat commonly restricted     
Food: 2 % of women believe all food items should be restricted
 Agha et al., 2007 [116] Pakistan Quantitative study: Structured interview (647), Gambat, Singh Province (year not specified), Caregivers of children 6–59 months    Fluid: 12 % of caregivers believe less fluid is required during episode     
Food: 44 % believe less food is required
 Rasheed et al., 1993 [117] Saudi Arabia Quantitative study: Structured interview (240) and self-administered questionnaire (589), Eastern Province 1990, Mothers of children attending government health center and girls attending government high school        Feeding: Fewer mothers than female students believe fluid and foods should be restricted during episode
Drugs: Compared to students, more mothers preferred drugs as treatment
 Kaltenthaler et al., 1996 [30] Botswana Qualitative study: Focus group discussions FGDs (4) and IDIs (12), KIIs (7) and observations, North-east Botswana 1991–1992, Caregivers of young children, health providers and traditional healers     BF: Pogwana (severe diarrhea with sunken fontanel) is an “African illness” and should be treated with breast feeding cessation and should go to health facility or traditional healer    General: Mothers report using multiple sources of treatment if episode doesn’t improve
 Nkwi et al., 1994 [34] Cameroon Mixed-method study: Structured interviews (256) and hospital observations, 3 provinces in Cameroon, Caregivers of children <5 years     BF: Some diarrhea thought to be caused by “bad breastmilk” - mothers are given herbs to improve quality of milk    
 Almroth et al., 1997 [36] Lesotho Qualitative study: FGDs (19) and IDIs (43), 3 geographically different locations 1991–1992, Mothers and grandmothers of children and nurses General: Mothers received conflicting advice from grandmothers and nurses Food: Believe food should be given because it “strengthens the bowels” Food: Believe you should adjust diet for individual child, if a specific food makes diarrhea worse     Food: Mothers coax children to eat during and after diarrhea
Feeding: Caregivers report providers still advise caregivers to restrict feeding General: Mothers report using any treatment that works, sometimes multiple treatments
 Munthali et al., 2005 [35] Malawi Qualitative study: IDIs and KIIs (sample size not specified), Rumphi 2000–2002, Old and young men and women and health providers     BF: Perceived causes of diarrhea include contaminated breast milk requires weaning Drugs perceived to useful in treatment of all illnesses   
General: Diarrhea due to teething is perceived as requiring no treatment
 Ellis et al., 2007 [78] Mali Mixed methods study: Structured interviews (352), illness narratives (14), and IDIs (42), Bougouni District 2003, Caregivers of children <5 years with illness in past 2 weeks or seeking care and health providers General: Mothers-in-law play important role initiating traditional treatment     Combining several different medicines/therapies is viewed as most efficacious Treatment of diarrhea typically begins in the home with traditional medicines and/or antibiotics from nearby vendors  
 Ikpatt et al., 1992 [19] Nigeria Quantitative study: Self-administered questionnaire (561), Cross River and Akwa Iborn State (year not specified), Household representative    BF: 19 % mothers believe BF should be discontinued     Drugs: 53 % of mothers reported antibiotic and 15 % reported antidiarrheal as treatment for diarrhea
Fluid: 15 % believe fluid should not be offered during episode
Food: 17 % believe solid foods should be withdrawn
 Jinadu et al., 1996 [48] Nigeria Mixed method study: Structured interview (335) and FGD (4), Rural Yoruba communities of Osuo State (year not specified), Mothers of children <5 years     Fluid: More mothers believe fluids should not be given for watery diarrhea (65 %) compared to bloody diarrhea (55 %)    
 Ogunbiyi et al., 2010 [29] Nigeria Mixed method study: Structured interviews (250) and FGDs (2), Ibadan 2003–2004, Mothers of child <1 year attending sick baby/immunization clinic of 2 health facilities BF: “Cultural” reasons for BF restriction - passed from generations Food: Foods withdrawn because thought to prolong the duration of diarrhea in the child (86 %) and induce vomiting/loss of appetite (14 %) Food: Indigenous foods rich in protein withdrawn because believed to aggravate diarrhea BF: Overconsumption of BM thought to cause some diarrhea – therefor reduce BF frequency during episode    
Feeding: 71 % believe some food, fluid, or breast milk should be withdrawn during episode Food: Withdrawal of other foods also linked to mother’s perception of cause of diarrhea
 Olakunle et al., 2012 [56] Nigeria Quantitative study: Structured interview (186), Ilorin West Local Government Area (year not specified), Mothers of children <5 years Feeding: Majority said food restriction was based on personal view, but some said received information on food restriction from nurses   Feeding: 46 % of mothers believe “some food” should be restricted during episode     Drug: 17 % of mothers believe child should be treated with antibiotic during episode
 Kauchali et al., 2004 [32] South Africa Qualitative study: IDIs (16), FGD (1), Case histories (13) and card sorting, Rural Kwazulu-Natal 2001, Caregivers of young children, grandmothers, CHWs     BF: Perceived causes of diarrhea include “dirty” breast milk requires temporary stop in breastfeeding    
 Friend du Preeze et al., 2013 [72] South Africa Mixed method study: IDIs (17), FGDs (5) and structured interviews (206), Johannesburg and Soweto 2004, Caregivers of children <6 years in longitudinal study and health providers        Drugs: Health care workers reported that mothers commonly use non-prescribed antibiotics
Drugs: Demand for modern medicines is high
 Mwambete et al., 2010 [118] Tanzania Qualitative study: Semi-structured interviews (88), Dar es Salaam 2007, Mothers of children <5 years      35 % of mothers reported metronidazole as most effective chemotherapeutic agent for treating diarrhea   Drugs: Metronidazole (43 %) and Erythromycin + Metronidazole (12 %) were cited as commonly used “therapeutic agents” for diarrhea treatment
South East Asia          
 Mushtaque et al., 1991 [55] Bangladesh Qualitative study: “Socioanthopologic methods,” Central Bangladesh (year not specified), villagers    Food: Certain types of diarrhea require withholding foods that are normally part of the diet General: Treatments considered appropriate depend on the local classification of the diarrhea    
BF: Injection of breast milk into woman used to correct “polluted” breast milk
 Singh et al., 1994 [43] India Quantitative study: Structured interviews (208), Jaipur District (year not specified), Mothers of children <5 years    Feeding: Mothers believe intestine becomes weak and child unable to digest heavy foods (roti and milk) during episode     
Feeding: Tea water and banana believed to help reduce frequency of diarrhea
 Chandrashekar et al., 1995 [25] India Qualitative study: Semi-structured interviews (300), Rural South India 1991, Mothers of children age 3 days - 17 months Feeding: Elderly relatives are source of information on feeding practices       BF: Some caregivers believe breastfeeding should be restricted when mother is experiencing diarrhea or respiratory infection
 Buch et al., 1995 [119] India Quantitative study: Structured interview (1600), Kashmir 1992, Caregivers of infants with acute diarrhea attending hospital pediatric OPD    Feeding: 19 % of caregivers believe child should have complete dietary restriction     Drugs: 55 % of caregivers believe diarrhea should be treated with antidiarrheal & antispasmodic drugs, while 32 % should be treated with drugs and ORT
Fluid: 77 % believe milk should be restricted
 Bhatia et al., 1999 [54] India Quantitative study: Structured interview (120), Rural Chandigarh 1996, Mothers of children <5 years    Feeding: 47 % of mothers believe certain foods/fluids should be restricted including chapatti, milk and pulses     
 Datta et al., 2001 [120] India Quantitative study: Structured interview (75), Rural Maharashtra 2000, Caregivers of children <5 years attending hospital pediatric OPD    BF: 16 % of caregivers not aware child has to be given breastfeeding during episode of diarrhea     
 Vyas et al., 2009 [121] India Quantitative study: Structured interview (380), Ganhinagar district (year not specified), Women of reproductive age (15–44)    BF: 52 % of women did not know breastfeeding should be continued during episode     
Food: 50 % did not know other foods should be continued
 Bolam et al., 1998 [122] Nepal Quantitative study: Structured interview (105), Kathmandu 1994–1996, Women delivering at Kathmandu General Hospital    BF: 3 months postpartum, 53 % of mothers did not know to continue BF during episode     
 Adhikari et al., 2006 [123] Nepal Quantitative study: Structured interview (510), Kathmandu 2005, Married women age 18–38 from 2 village development committees   BF: 7 % of women believe breastfeeding aggravates diarrhea      
 Ansari et al., 2012 [24] Nepal Qualitative study: FGDs (2) and IDIs (8), Morang 2010, Mothers of children <45 months with diarrhea in the previous 6 months General: Elders recommend traditional treatment practices   Food: Spicy, oily and rotten food commonly believed to be harmful General: Certain types of diarrhea are perceived to be manageable with ORS/SSW, while others require traditional/spiritual methods.    
BF: Breast milk sometimes considered harmful
 Baclig et al., 1990 [58] Thailand Mixed method study: FGDs (2) and structured interviews (98), Tambon Korat and Koongyang (year not specified), Mothers and grandmothers of children <5 years     Feeding: Mothers believe no changes should be made to the child’s diet to manage poh (a mild self-limiting diarrhea)    
 Pylypa et al., 2009 [18] Thailand Qualitative study: Semi-structured interviews (200) as part of ethnographic study, Rural Northeast Thailand 2000–2001, Caregivers of children <5 years, traditional healers, and health providers General: Grandmothers and elders are important sources of information for classifying/managing diarrhea Fluid/BF: Some mothers restricted water or breast milk out of concern that it would make diarrhea worse, belief child could not drink much because he was small, or would vomit   Food: Most mothers didn’t change quantity/type of food given for diarrhea occurring in normal developmental stages (not illness) although expected children would eat less in than normal   Medicines were frequently obtained from health workers – most clinicians consulted gave antibiotics routinely for watery diarrhea, and for diarrhea with fever Drugs: Some mothers took the medicines themselves to pass to infants through breast milk
Drugs: Medicines were commonly administered for childhood diarrhea considered illness
Western Pacific          
 Okumura et al., 2002 [70] Vietnam Quantitative study: Structured interviews (505), 4 Provinces of Vietnam 1997, Mothers of children <5 years       Antibiotics to be stocked at home (55 % of households) for various anticipated symptoms as if they were panaceas  
 Le et al., 2011 [69] Vietnam Qualitative study: IDIs (5) and FGDs (4), Ha Tay province (year not specified), Mothers of children <5 years and health workers/drug sellers Drugs: Drugs bought on drug seller recommendation or previous prescriptions     Western medicine considered necessary but more dangerous than traditional therapy Drugs are available without prescription and small amount can be purchased to give for 2–3 days  
 Rheinlander et al., 2011 [67] Vietnam Qualitative study: Semi-structured interviews (43), FGDs (3), and observations, Ethnic minorities in Lao Cai 2008, Caregivers of children <7 years with diarrhea in the past month General: Elders are in charge of deciding, preparing, and administering treatment for a sick child    Drugs: Medicines chosen based on perceived compatibility with the child and the disease Antibiotics perceived as very powerful and potentially harmful compared to natural medicines   Drugs: common to receive 2–4 prescribed drugs for diarrhea
Drugs: To limit intake and harm of western drugs, caregivers gave smaller doses than prescribed, or shifted from one drug to another if recovery was slow
  1. Beliefs, motivations, and context related to:
  2. BF: Breastfeeding
  3. Fluid: Fluid restriction
  4. Food: Food restriction
  5. Feeding: Fluid, breastfeeding, and food restriction, or non-specific as to type of feeding
  6. Drug: Use of modern medicines
  7. General: Decision making around treatment or perception of diarrhea not specific to one of the harmful practice