Abstract
Diarrhea is a significant health issue in low- and middle-income countries. There is an urgent need to identify and implement actions aimed at reducing the associated mortality and morbidity. The aim of this study was to determine the frequency and determinants of home use of oral rehydration solution (ORS) and antibiotics for the treatment of diarrheal diseases in the Far North and Littoral regions of Cameroon. This was a cross-sectional study using sentinel surveillance data collected from four health facilities in the cities of Kousseri and Douala in Cameroon. The study targeted patients seeking consultations for diarrhea at these health facilities. Patients were selected through consecutive sampling. Data were collected using a questionnaire administered face-to-face by a trained nurse, which included questions about the reason for consultation, socio-demographic characteristics, and prior exposure to ORS and antibiotics before arriving at the health facility. A total of 1,065 patients with diarrhea agreed to participate in the study, including 160 (15.0%) from Kousseri and 905 (85.0%) from Douala. Of the 1,065 participants, 215 (20.2%) and 637 (59.8%) reported using ORS and antibiotics at home as part of their diarrhea treatment prior to arriving at the health facility. The most used antibiotics were metronidazole (31.9%), amoxicillin (3.6%), doxycycline (3.6%), and ciprofloxacin (2.6%).The use of ORS was associated with place of residence (aOR = 0.20; 95% CI [0.10 − 0.40]), and duration of diarrhea (aOR = 0.51; 95% CI [0.33 − 0.78]) were associated with home use of ORS among patients with diarrhea. The city of residence (aOR = 3.06, 95% CI = 1.85 − 5.05) and the absence of ORS use at home (aOR = 2.17; 95% CI = 1.30–3.62); having diarrhea for less than 24 h (aOR = 0.36, 95% CI = [0.24 − 0.54]) and traveling less than one hour to reach the health facility (aOR = 0.44, 95% CI = [0.21 − 0.91]) were associated with home use of antibiotics among patients with diarrhea. The frequency of antibiotic use in the community is significantly high, while the utilization of ORS remains low. More efforts are required to enhance community management of diarrhea effectively.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-026-50743-4.
Keywords: Antibiotics, Treatment of diarrheal diseases, Cameroon
Subject terms: Diseases, Health care, Medical research, Microbiology
Background
Diarrhea is defined as the passage of at least three loose or liquid stools in a single day, or stools that are more frequent than usual for the affected individual1–3. Diarrheal diseases continue to pose a significant public health challenge globally, especially in developing countries, due to the substantial morbidity and mortality they cause1,4–6. With 443,832 deaths worldwide each year, diarrhea is one of the primary contributors to morbidity and mortality among infants and the third leading cause of death among children under five years of age5,7,8,1.
Due to inadequate socioeconomic, health, and nutritional conditions, sub-Saharan Africa continues to bear the highest burden of diarrheal diseases and has the lowest coverage of recommended treatments1,6,9. In Central Africa, in 2020, the incidence of diarrhea was estimated at 114,350 cases per 100,000 population, with a mortality rate of 35.5 deaths per 100,000 among individuals aged over five years and adults10. In Cameroon, the prevalence of diarrhea among children aged 0 to 5 years is estimated to be 12%, according to the most recent Demographic and Health Survey conducted in 201811.
The World Health Organization (WHO) recommends that, in addition to vaccination, hygiene and sanitation measures to prevent diarrheal diseases, oral rehydration solutions (ORS) and zinc supplements should be utilized to treat diarrhea3,6,12,13.
The issue of access to healthcare is predominant in regions where socioeconomic conditions are particularly precarious14. This situation exposes the population to the inappropriate use of antibiotics for diarrhea, despite the proven effectiveness of ORS. This leads to unnecessary antibiotic consumption and contributes to the development of antimicrobial resistance in Cameroon15–18. Additionally, there is a tendency to treat diarrhea as a minor ailment that can be treated through self-medication.
Several studies have investigated the use of antibiotics in managing diarrhea, both in healthcare facilities and within the community through self-medication. These studies indicate that the proportion of antibiotics used to treat diarrhea in Cameroon ranges from 10% to 73%9,19-22. However, these studies were often conducted in hospital settings and did not investigate the determinants of antibiotic use or the home use of ORS.
Understanding the determinants of home use of antibiotics or ORS by patients with diarrhea is essential to provide evidence for the rational use of antibiotics and the appropriate management of diarrheal diseases. This study contributes to understanding the importance of sociodemographic and therapeutic factors in the use of antibiotics and ORS among patients with diarrhea.
Therefore, this study aimed to determine (i) the frequency of home use of ORS and antibiotics among patients consulting for diarrhea in the Far North and Littoral regions of Cameroon, and (ii) identifying the determinants of home use of ORS and antibiotics among these patients using two separate determinants models.
Methods
Study design
This cross-sectional study utilized sentinel surveillance data collected from four health facilities in the cities of Kousseri and Douala, Cameroon between December 2020 and March 2023. This sentinel surveillance was set up locally as part of a cholera surveillance system in selected health facilities across two regions and targeted patients presenting with diarrhea. The study targeted patients seeking consultations for diarrhea at these health facilities. Patients were selected through consecutive samplings. Data were collected using a questionnaire administered face-to-face by a trained nurse, which included questions regarding the reason for consultation, socio-demographic characteristics, prior exposure to ORS and antibiotics, as well as determinants of diarrhea.
Study period and site
Data were collected prospectively and consecutively from December 2020 to March 2023. The data were gathered from four health facilities located in the Far North and Littoral regions of Cameroon. These regions were selected due to their significant impact from epidemics of diarrheal diseases, particularly cholera, in recent years23,24.
In the Far North region, the study was conducted at the Annex Regional Hospital of Kousseri (HRAK), a third-category hospital located in the town of Kousseri that serves as a referral center. This region is affected by ongoing conflict, leading to large-scale population displacement and an influx of refugees, and it also serves patients from neighboring countries such as Chad and Nigeria. Access to healthcare in this region is particularly limited due to geographic barriers and the inadequate resourcing of health facilities25. In Douala, the study focused on the Bonassama District Hospital, New Bell District Hospital, and the Bonamoussadi Council Medical Center. Douala is a cosmopolitan city in the Littoral Region of Cameroon and is regarded as the economic capital of the country. It serves as a hub for trade with all ten regions of Cameroon and attracts people from across the nation. However, the city is prone to frequent flooding and outbreaks of diarrheal diseases, including cholera. Figure 1 presents the map of the targeted health facilities.
Fig. 1.
Map of the targeted health facilities.
Study population
The study population comprised patients of all ages experiencing diarrhea, regardless of severity, at four health facilities in Kousseri and Douala. Patients who declined to participate, those already hospitalized before data collection commenced, individuals unable to provide consent, and those with severe mental conditions were excluded. The case definition of diarrhea was based on the criteria established by the WHO1,6. All eligible patients during the surveillance period were selected using consecutive sampling.
Collection procedure
The enrollment site was the outpatient department of the selected health facilities. All participants who met the eligibility criteria were identified and invited by the research nurse to participate in the study. They were informed about the study procedures, and consenting participants were administered a questionnaire. For each adolescent aged 12 to 17, parental authorization was obtained in addition to their consent before participation in the study. The parental or legal guardian authorization was mandatory for all children under the age of 12 who participated in the study.
After obtaining consent, data on the sociodemographic characteristics of the participants, information regarding the reasons for consultation, and data on antibiotic use were collected through a face-to-face questionnaire (supplementary file 1). This questionnaire was developed for this study. The questionnaire was translated into English and French and then administered in both languages. Prior to the actual data collection, it was tested at two health facilities in the city of Douala.
Study variables
The primary dependent variables in the study were the home use of antibiotics and oral rehydration solution (ORS) prior to hospital admission. Home use of antibiotics was defined as any home use of antibiotic to treat diarrhea within this episode and before the hospital admission. This information was obtained either from the patient’s self-report or from the presentation of the medication packaging, as verified by healthcare personnel. This variable was coded as “yes” if the patient had used antibiotics at home and “no” if they had not. The second dependent variable was the use of ORS at home within the 30 days before hospital admission. ORS intake was based on the patient’s or parent’s self-report and coded as “yes” if ORS had been used at home prior to the patient’s arrival at the hospital, and “no” if not.
The independent variables included the following sociodemographic characteristics: age (in years), sex, region, and the distance between home and the health facility (expressed in hours). Clinical characteristics comprised the duration of diarrhea (in days), presence of fever, presence of abdominal pain, and the state of dehydration. The state of dehydration was assessed according to the World Health Organization’s definition6.
Data analysis
The data were analyzed using SPSS version 26 software. Frequencies and percentages was presented for qualitative variables, while means and standard deviations are provided for continuous quantitative variables. There were two outcome variables: home use of antibiotics and home use of oral rehydration solution.
The chi-squared test and crude odds ratio were employed to compare proportions, and multivariate analysis was conducted using logistic regression. Two separate models were developed, one for the home use of antibiotics and the other for the home use of ORS. Variables with a p-value less than 0.05 were included in the multiple logistic regression analysis. Adjusted odds ratios (aOR) and their corresponding 95% confidence intervals were reported. The significance level was set at 0.05 (p < 0.05). QGIS software (QGIS.org, 2025; QGIS 3.42.3 Geographic Information System API Documentation, QGIS Association) was used to generate the map26.
Ethical considerations
This research was carried out in accordance with the Helsinki Declaration. The data were collected with strict confidentiality; no patient-identifiable information was gathered, and only participants who provided written informed consent were included in the study. The study protocol was submitted to the Cameroon National Ethics Committee for Human Health Research and received ethical approval under the reference No2020/02/1211/CE/CNERSH/SP.
Results
Socio-demographic characteristics of the participants
Of the 1,065 participants contacted, all agreed to participate in the study, resulting in a 100.0% acceptance rate. Among them, 905 (85.0%) resided in Douala, and 160 (15.0%) in Kousseri. The majority of participants were male (53.2%) and aged between 5 and 17 years (60.9%). Most arrived at the hospital by motorcycle (74.2%), typically within an hour of leaving home (92.3%) (Table 1).
Table 1.
Socio-demographic characteristics of the participants.
| Variables | Study sites | Total n (%) |
p Value | |
|---|---|---|---|---|
| Kousseri n (%) |
Douala n (%) |
|||
| Age in years (median [IQR]) | 5 (1.0, 23.5) | 30 (20.0, 43.5) | 28 (15.3, 41.7) | < 0.01 |
| < 2 year | 68 (45.5) | 76 (8.4) | 144 (13.5) | |
| 3–4 years | 33 (20.6) | 77 (8.5) | 110 (10.3) | |
| 5–17 years | 52 (32.5) | 597 (66.0) | 649 (60.9) | |
| 18–49 years | 6 (3.8) | 103 (11.4) | 109 (10.2) | |
| > 50 years | 1 (0.6) | 52 (5.7) | 53 (5.0) | |
| Sex | 0.076 | |||
| Male | 94 (58.8) | 473 (52.3) | 567 (53.2) | |
| Female | 66 (41.3) | 432 (47.7) | 498 (46.8) | |
| Health facility | < 0.01 | |||
| CMC Bonamoussadi | 0 (0.0) | 203 (22.4) | 203 (19.1) | |
| DH Bonassama | 0 (0.0) | 375 (41.4) | 375 (35.2) | |
| DH New Bell | 0 (0.0) | 327 (36.1) | 327 (30.7) | |
| HRAK | 160 (100.0) | 0 (0.0) | 160 (15.0) | |
| Means of transportation used to get here | < 0.01 | |||
| On foot | 1 (0.6) | 13 (1.4) | 14 (1.3) | |
| By motorcycle | 148 (92.5) | 642 (70.9) | 790 (74.2) | |
| By car | 9 (5.6) | 233 (25.7) | 242 (22.7) | |
| Ambulance | 1 (0.6) | 4 (0.4) | 5 (0.5) | |
| By bicycle | 1 (0.6) | 0 (0.0) | 1 (0.1) | |
| Other means | 0 (0.0) | 13 (1.4) | 13 (1.2) | |
| Time to health facility (in hours) | 0.345 | |||
| Less than an hour | 146 (91.3) | 837 (92.5) | 983 (92.3) | |
| 1 to 4 h | 13 (8.1) | 64 (7.1) | 77 (7.2) | |
| 5 to 8 h | 1 (0.6) | 1 (0.1) | 2 (0.2) | |
| More than 8 h | 0 (0.0) | 2 (0.2) | 2 (0.2) | |
| Don’t know | 0 (0.0) | 1 (0.1) | 1 (0.1) | |
Distribution of participants by reason for consultation
Diarrhea was liquid in 871 (81.8%) of the 1,065 participants. Five hundred thirty-five participants experienced diarrhea for approximately 24 h before presenting to the health facility, while 512 (48.1%) had diarrhea lasting between 1 and 7 days. Anorexia, abdominal pain, and fever were the other most common symptoms among patients with diarrhea, affecting 38.1%, 28.9%, and 21.9% of participants, respectively. Four hundred eleven participants (38.6%) reported having at least one episode of diarrhea per year. Regarding their state of dehydration upon arrival at the health facility, 485 of the 1,065 participants (45.5%) exhibited mild dehydration, while 355 (33.3%) experienced moderate to severe dehydration (Table 2).
Table 2.
Distribution of participants by reason for consultation.
| Variables | Study sites | Total n (%) |
p Value | |
|---|---|---|---|---|
| Kousseri n (%) |
Douala n (%) |
|||
| Type of diarrhea | < 0.01 | |||
| Mucus diarrhea | 20 (12.5) | 67 (7.4) | 87 (8.2) | |
| Bloody and mucus diarrhea | 2 (1.3) | 32 (3.5) | 34 (3.2) | |
| Liquid diarrhea | 101 (63.1) | 770 (85.1) | 871 (81.8) | |
| Bloody diarrhea | 28 (17.5) | 30 (3.3) | 58 (5.4) | |
| Watery and bloody diarrhea | 9 (5.6) | 6 (0.7) | 15 (1.4) | |
| Duration of diarrhea | ||||
| 24 h or less | 18 (11.3) | 517 (57.1) | 535 (50.2) | |
| 2–6 days | 133 (83.1) | 379 (41.9) | 512 (48.1) | |
| 7–13 days | 6 (3.8) | 5 (0.6) | 11 (1.0) | |
| ≥ 14 days | 3 (1.9) | 4 (0.4) | 7 (0.7) | |
| Other symptoms | < 0.01 | |||
| Fever | 112 (70.0) | 121 (13.4) | 233 (21.9) | |
| Myalgia | 6 (3.7) | 105 (11.6) | 111 (10.4) | |
| Chills | 6 (3.7) | 46 (5.1) | 52 (4.9) | |
| Loss of appetite | 70 (43.7) | 336 (37.1) | 406 (38.1) | |
| Abdominal pain | 115 (71.9) | 193 (21.3) | 308 (28.9) | |
| Dizziness and lightheadedness | 8 (5.0) | 101 (11.2) | 109 (10.2) | |
| Frequency of diarrhea | 0.013 | |||
| Don’t know | 33 (20.6) | 69 (7.6) | 102 (9.6) | |
| Every day | 2 (1.3) | 14 (1.5) | 16 (1.5) | |
| Once a week | 3 (1.9) | 8 (0.9) | 11 (1.0) | |
| Several times a week | 7 (4.4) | 7 (0.8) | 14 (1.3) | |
| Once a month | 65 (40.6) | 71 (7.8) | 136 (12.8) | |
| Once a year | 43 (26.9) | 368 (40.7) | 411 (38.6) | |
| Less often than once a year | 7 (4.4) | 368 (40.7) | 375 (35.2) | |
| Dehydration status | < 0.01 | |||
| No dehydration | 71 (44.4) | 154 (17.0) | 225 (21.1) | |
| Some dehydration | 66 (41.3) | 419 (46.3) | 485 (45.5) | |
| Severe dehydration | 23 (14.4) | 232 (36.7) | 355 (33.3) | |
Distribution of participants by treatment used at home
Of the 1,065 participants included in the study, 215 (20.2%) reported using ORS at home to treat diarrhea, with 206 (22.8%) from Douala and 9 (5.6%) from Kousseri. A striking and concerning finding concerns the use of antibiotics at home: out of all participants, 637 (59.8%) stated that they had taken antibiotics before coming to the health facility, which is almost six out of ten patients. This behavior was especially common in Douala, where 564 participants (62.3%) reported using antibiotics beforehand, compared to 73 participants (45.6%) in Kousseri. The most commonly used antibiotics among patients with diarrhea were metronidazole (31.9%), amoxicillin (3.6%), doxycycline (3.6%), and ciprofloxacin (2.6%). Thirteen (1.2%) and six (0.6%) participants reported using ceftriaxone and gentamicin, respectively, both parenteral antibiotics, for home treatment of diarrhea. Additionally, 171 participants (16.0%) could not recall the name of the antibiotic they had used (Table 3).
Table 3.
Distribution of participants by treatment used at home.
| Variables | Study sites | Total n (%) |
P value | |
|---|---|---|---|---|
| Kousseri n (%) |
Douala n (%) |
|||
| Used ORS at home | 9 (5.6) | 206 (22.8) | 215 (20.2) | < 0.01 |
| Used antibiotics at home | 73 (45.6) | 564 (62.3) | 637 (59.8) | < 0.01 |
| Antibiotics used at home | ||||
| Metronidazole | 21 (13.1) | 319 (35.2) | 340 (31.9) | |
| Doxycycline | 2 (1.3) | 36 (4.0) | 38 (3.6) | |
| Cotrimoxazole | 6 (3.8) | 5 (0.6) | 11 (1.0) | |
| Ciprofloxacin | 15 (9.4) | 13 (1.6) | 28 (2.6) | |
| Amoxicillin | 3 (1.9) | 35 (3.9) | 38 (3.6) | |
| Chloramphenicol | 0 (0.0) | 3 (0.3) | 3 (0.3) | |
| Ampicillin | 0 (0.0) | 5 (0.6) | 5 (0.5) | |
| Gentamicin | 1 (0.6) | 5 (0.6) | 6 (0.6) | |
| Ceftriaxone | 7 (4.4) | 6 (0.7) | 13 (1.2) | |
| Don’t know antibiotic name | 34 (21.3) | 137 (15.1) | 171 (16.0) | |
Association of sociodemographic and clinical characteristics with home ORS use
Participants residing in the city of Kousseri were 80% less likely to use ORS at home compared to those in Douala (aOR = 0.20, 95% CI [0.10–0.40]). Additionally, participants whose diarrhea lasted 24 h or less were 49% less likely to use ORS than those whose diarrhea persisted for more than one day (aOR = 0.51, 95% CI [0.33–0.78]) (Table 4).
Table 4.
Association of sociodemographic and clinical characteristics with home ORS use.
| Variables | Home use of ORS | Bivariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| No | Yes |
Crude OR, 95% CI |
P value | aOR, 95% IC | P value | |
| n (%) | n (%) | |||||
| Age | ||||||
| 0–14 years | 212 (29.9) | 39 (18.1) | 1.50 [1.02 − 2.19] | 0.036 | 0.84 [0.50 − 1.42] | 0.522 |
| 15 years and more | 638 (75.1) | 176 (81.9) | Reference | |||
| City of residence | ||||||
| Kousseri | 151 (17.8) | 9 (4.2) | 0.20 [0.10 − 0.40] | 0.000 | 0.20 [0.10 − 0.40] | < 0.01 |
| Douala | 699 (82.2) | 206 (95.8) | Reference | |||
| Abdominal pains | ||||||
| No | 248 (49.1) | 74 (59.2) | 0.66 [0.45 − 0.99] | 0.043 | 1.00 [0.65 − 1.54] | 0.983 |
| Yes | 257 (50.9) | 51 (40.8) | Reference | |||
| Type of diarrhea | ||||||
| Liquid | 174 (20.5) | 20 (9.3) | 2.51 [1.54 − 4.09] | 0.000 | 1.83 [0.98 − 3.42] | 0.054 |
| Other | 676 (79.5) | 195 (90.7) | Reference | |||
| Distance from home to health facility | ||||||
| One hour or less | 788 (92.7) | 203 (94.4) | 0.75 [0.40 − 1.41] | 0.377 | ||
| More than a hour | 62 (7.3) | 12 (5.6) | Reference | |||
| Dehydration status | ||||||
| No or mild | 569 (66.9) | 142 (66.0) | 1.04 [0.76 − 1.43] | 0.803 | ||
| Moderate to severe | 281 (33.1) | 73 (34.0) | Reference | |||
| Duration of diarrhea | ||||||
| 0 to 24 h | 406 (47.8) | 124 (57.7) | 0.67 [0.50 − 0.91] | 0.009 | 0.51 [0.33 − 0.78] | < 0.01 |
| More than 24 h | 444 (52.2) | 91 (42.3) | Reference | |||
| Frequency of diarrhea | ||||||
| 2 to 6 episodes per month | 822 (96.7) | 202 (94.0) | 1.89 [0.96 − 3.71] | 0.061 | ||
| One episode per month | 28 (3.3) | 13 (5.0) | Reference | |||
Association Between Sociodemographic and Clinical Characteristics and Home Antibiotic Use
Non-use of ORS was associated with increased odds of home antibiotic use among patients with diarrhea. Specifically, patients who did not use ORS were more than twice as likely to use antibiotics at home compared to those who used ORS at home (aOR = 2.17, 95% CI: 1.30–3.62). Participants residing in Douala were 3.06 times more likely to use antibiotics at home compared to those in Kousseri (adjusted odds ratio [AOR] = 3.06, 95% CI: 1.85–5.05). Conversely, patients with diarrhea lasting up to 24 h were 64% less likely to use antibiotics at home compared to those whose diarrhea lasted more than one day (AOR = 0.36, 95% CI: 0.24–0.54). Additionally, patients living less than an hour’s drive from the health facility were 56% less likely to use antibiotics at home than those whose journey took more than an hour (AOR = 0.44, 95% CI: 0.21–0.91) (see Table 5).
Table 5.
Association between sociodemographic and clinical characteristics and home antibiotic use.
| Variables | Home use of antibiotics | Bivariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| No | Yes |
Crude OR, 95%CI |
P value | Adjusted OR, 95% IC | P value | |
| n (%) | n (%) | |||||
| Age | ||||||
| 0–14 years | 121 (28.3) | 130 (20.4) | 1.54 [1.15 − 2.04] | 0.003 | 1.43 [0.93 − 2.20] | 0.100 |
| 15 years and more | 307 (71.7) | 507 (79.6) | Reference | |||
| City of residence | ||||||
| Kousseri | 87 (20.3) | 73 (11.5) | Reference | |||
| Douala | 341 (79.7) | 564 (88.5) | 1.97 [1.40 − 2.77] | 0.000 | 3.06 [1.85 − 5.05] | < 0.01 |
| Abdominal pains | ||||||
| No | 105 (46.9) | 217 (53.4) | 0.77 [0.55 − 1.06] | 0.114 | ||
| Yes | 119 (53.1) | 189 (46.6) | Reference | |||
| Type of diarrhea | ||||||
| Liquid | 68 (15.9) | 126 (19.8) | 0.77 [0.55 − 1.06] | 0.106 | ||
| Other | 360 (84.1) | 511 (80.2) | Reference | |||
| Duration of diarrhea | ||||||
| 0–24 h | 166 (38.8) | 364 (57.1) | 0.47 [0.37 − 0.61] | 0.000 | 0.36 [0.24 − 0.54] | < 0.01 |
| More than 24 h | 262 (61.2) | 273 (42.9) | Reference | |||
| Distance from home to health facility | ||||||
| 0–1 h | 389 (90.9) | 602 (94.5) | 0.58 [0.36 − 0.93] | 0.022 | 0.44 [0.21 − 0.91] | 0.028 |
| More than 1 h | 39 (9.1) | 35 (5.5) | Reference | |||
| Fever | ||||||
| Yes | 103 (46.0) | 130 (32.0) | Reference | |||
| No | 121 (54.0) | 276 (68.0) | 0.55 [0.39 − 0.77] | 0.000 | 0.80 [0.53 − 1.21] | 0.290 |
| Dehydration status | ||||||
| No dehydration | 272 (63.6) | 439 (68.9) | 0.79 [0.61 − 1.02] | 0.068 | ||
| Some to severe | 156 (36.4) | 198 (31.1) | Reference | |||
| Bloody diarrhea | ||||||
| No | 387 (90.4) | 569 (89.3) | 1.13 [0.76 − 1.70] | 0.563 | ||
| Yes | 41 (9.6) | 68 (10.7) | Reference | |||
| Frequency of diarrhea | ||||||
| 1–6 days per week | 417 (97.4) | 607 (95.3) | 1.87 [0.93 − 3.78] | 0.075 | ||
| Other | 11 (2.6) | 30 (4.7) | Reference | |||
| ORS at home | ||||||
| Yes | 53 (87.6) | 162 (25.4) | Reference | |||
| No | 166 (38.8) | 364 (42.9) | 2.41 [1.72 − 3.38] | 0.000 | 2.17 [1.30 − 3.62] | < 0.01 |
Discussion
The objective of this study was to determine the frequency and determinants of community use of ORS and antibiotics among patients seeking treatment for diarrhea in the cities of Douala and Kousseri, Cameroon. Of the 1,065 participants included in the study, 20.2% reported using ORS at home as part of their diarrhea treatment. The use of ORS was associated with the place of residence and the duration of diarrhea. Regarding antibiotic use at home, 59.8% reported taking antibiotics prior to arriving at the health facility. The most commonly used antibiotics among patients with diarrhea were metronidazole, amoxicillin, doxycycline, and ciprofloxacin. The city of residence and the absence of ORS at home were associated with an increased likelihood of antibiotic use at home among patients with diarrhea. Conversely, having diarrhea for less than 24 h and traveling less than one hour to reach a healthcare facility were linked to a decreased likelihood of antibiotic use in these patients.
When used at home, ORS combined with zinc help prevent dehydration caused by diarrhea27. For this reason, the World Health Organization encourages the use of ORS within communities. Health system managers are urged to educate families on the proper use of these solutions and to enhance their availability6. In this study, the frequency of home use of ORS among patients with diarrhea was found to be 20.2%. This result is consistent with findings from studies conducted in Egypt and India, which reported home use rates of oral rehydration solution (ORS) of 22% and 24.4%, respectively28,29. This indicates that the use of ORS at home remains low among patients experiencing diarrhea in this study setting. Additional efforts are necessary to increase the use of ORS at home among individuals affected by diarrheal diseases.
The results of the multiple logistic regression indicate that patients residing in Kousseri were 80% less likely to use ORS than those living in the city of Douala. Not only was the number of patients residing in Kousseri lower than that in Douala (160 versus 905), but the rate of ORS use was also lower. This imbalance between study sites resulted in fewer participants in Kousseri, thereby reducing the likelihood of ORS use being observed compared with Douala, which had a larger sample size. Additionally, the context of instability, population displacement, and the fragility of the health system may also contribute to the low utilization of ORS in Kousseri. There is a need to implement interventions that improve access to ORS as part of home-based diarrhea management, with efforts intensified in this region. Conversely, patients whose diarrhea lasted less than 24 h were 49% less likely to utilize ORS compared to those whose illness persisted for more than one day. The association between the duration of diarrhea and the use of ORS suggests that patients are more inclined to use ORS if their illness extends beyond 24 h. The findings also indicate that the early use of ORS remains suboptimal. The studies reviewed on the determinants of ORS use focused exclusively on factors different from those examined in this study30–32. This outcome is anticipated, particularly in this study where the determinants are predominantly clinical. In addition to educating the public on the use of ORS at home, it is essential to ensure its availability and affordability to more effectively prevent dehydration in patients with diarrhea.
In general, the use of antibiotics to treat diarrhea is not recommended, except in cases of bloody diarrhea, cholera, severe malnutrition, or diarrhea associated with sepsis33. Appropriate use of antibiotics can help prevent antibiotic resistance, reduce healthcare costs, and minimize the risk of antibiotic-associated diarrhea34,6,1.
In this study, 59.8% of patients utilized antibiotics, with metronidazole, amoxicillin, and doxycycline being the most frequently prescribed medications. This rate of antibiotic use is slightly lower than that observed in a study conducted in India (77.9%) but higher than the rate reported in Nigeria (46.7%)2,35. This difference could be explained by the fact that this study included participants of all ages, whereas the other two studies included only children. These findings are nevertheless consistent with results from a systematic review conducted in Africa36.
These results indicate that nearly 60% of patients use antibiotics at home to treat diarrhea. This high rate of antibiotic use contradicts the recommended guidelines for the appropriate management of diarrheal diseases6,1. This raises questions regarding access to antibiotics, including both sales and availability in pharmacies and beyond, as well as access to care within these establishments. In situations where antibiotics are easily obtained without regulation, this behavior can encourage the development of antimicrobial resistance in the community37. Over time, it may reduce the effectiveness of primary treatments and lead to a higher incidence of difficult-to-treat infections in healthcare settings38. Additionally, it highlights the effectiveness of programs aimed at reducing antibiotic misuse in healthcare facilities and the community. Healthcare leaders must enhance public awareness about the proper use of antibiotics. It should also be noted that injectable antibiotics such as ceftriaxone and gentamicin, which are rarely used for self-medication, were reported as part of the antibiotic treatments administered at home for diarrhea in this study. This indicates inappropriate use of parenteral antibiotics in the home management of diarrheal diseases, with potential implications for antibiotic resistance.
The results of the multivariate analysis indicated that the duration of diarrhea was correlated with the use of antibiotics at home. Specifically, patients experiencing diarrhea for more than 24 h were more likely to self-medicate with antibiotics. This finding is understandable, particularly given that prolonged diarrhea can be distressing for patients. To minimize the unnecessary use of antibiotics, it is essential to initiate rehydration promptly with ORS or other solutions, such as zinc, at the onset of diarrhea33.
Access to healthcare can be influenced by the geographical proximity between households and health facilities39. The closer a health facility is to the population, the more likely it is to be utilized. In light of this, the Cameroon Ministry of Health and the World Health Organization (WHO) recommend a maximum distance of 5 km (approximately a one-hour walk) between households and health facilities40.
This study revealed that the distance from home to the health facility is associated with patients’ self-medication with antibiotics. This result is consistent with the findings of the studies which identified geographic barriers as a factor associated with home-based ORS and antibiotics use32,41. This indicates that patients living less than an hour away from a health facility were 56% less likely to use antibiotics at home compared to those living more than an hour away. It also suggests that the farther patients live from health facilities, the more likely they are to use antibiotics to treat diarrhea. Improving the availability of ORS closer to households should reduce the use of antibiotics in the home management of diarrhea.
The results indicate that the absence of ORS at home increases the likelihood of patients with diarrhea resorting to antibiotic self-medication. ORS are recommended for the treatment of dehydration caused by diarrhea and the prevention of further fluid loss33. We found no studies that investigated the relationship between the home use of ORS and the self-medication with antibiotics. ORS is effective in reducing the frequency, duration, and severity of diarrhea2,3,6,42,43. These beneficial effects of ORS may partially explain the association observed in this study. Improving the availability of ORS could indirectly reduce the inappropriate use of antibiotics in patients with diarrhea. Efforts to enhance household awareness regarding the use of ORS for the home management of patients with diarrhea should be intensified.
Study limitations
The use of a questionnaire in this study may introduce certain biases, particularly recall bias. However, we exclusively recruited patients who sought care at health facilities for diarrhea consultations, which helped us minimize various biases. Defining ORS use within the 30 days preceding the consultation may have introduced recall bias. However, this timeframe captured the current diarrheal episode while allowing assessment of ORS use among patients with multiple episodes during the same period. This health facility-based study includes only patients who attend consultations there. Consequently, the results do not represent the entire community, but only facility-attending patients. Limiting the multivariable analysis to variables with p < 0.05 may have resulted in the exclusion of some important confounders. However, this choice was made to maintain a parsimonious model and to reduce the risk of overfitting given the sample size. Another limitation is the cross-sectional design of the study, which restricts the ability to establish causal relationships.
Conclusion
Home use of ORS is very low, while the home use of antibiotics is very high among patients suffering from diarrhea. The most utilized antibiotics for home treatment of diarrhea included metronidazole, amoxicillin, doxycycline, and ciprofloxacin. Factors such as place of residence and duration of diarrhea were associated with the use of ORS in the community. Regarding antibiotic use, factors including place of residence, duration of diarrhea, distance from home to the health facility, and the use of ORS were linked to the community use of antibiotics among patients with diarrhea. These findings highlight the need for health system managers to: (i) enhance community education on the use of ORS at onset of diarrhea; (ii) improve the availability of ORS and zinc through community health workers, pharmacies, and shops; (iii) strictly enforce regulations on over-the-counter antibiotic sales; and (iv) incorporate these findings into national guidelines for the community-based management of diarrhea.
This study provides actionable evidence for community diarrhea management in Cameroon by highlighting the critical role of ORS availability and accessibility in reducing inappropriate antibiotic use and supporting targeted interventions to improve supply and promote its use as first-line treatment at the community level.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Abbreviations
- ORS
Oral rehydration solution
- WHO
World Health Organization
Author contributions
Design and implementation of the research: AMB, JA; Data analysis: AMB, KHTN; Writing of the manuscript: AMB, KHTN, CBN, EG, RKF, JA, Revision of the manuscript: AMB, KHTN, RKF, and JA. All authors approved the final version of the manuscript.
Funding
With funding from the National Institutes of Health (NIH), the data collection for this study was supported by the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University. The funding bodies played no role in the study design, data collection, analysis, interpretation of results, or in writing the manuscript.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
This research was carried out in accordance with the Helsinki Declaration. The data were collected with strict confidentiality; no patient-identifiable information was gathered, and only participants who provided written informed consent were included in the study. The study protocol was submitted to the Cameroon National Ethics Committee for Human Health Research and received ethical approval under the reference No2020/02/1211/CE/CNERSH/SP.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.World Health Organization. Diarrhoeal disease. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
- 2.Ahmed, F. et al. Management of Diarrhea in Under-fives at Home and Health Facilities in Kashmir. Int J Health Sci (Qassim) 3, 171–175 (2009). [PMC free article] [PubMed]
- 3.Canadian Paediatric Society. Le traitement de la diarrhée. Paediatr. Child. Health. 8, 463–466 (2003). [Google Scholar]
- 4.Lalani, T. et al. Epidemiology and Self-Treatment of Travelers’ Diarrhea in a Large, Prospective Cohort of Department of Defense Beneficiaries. J. Travel Med.22, 152–160 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bitew, B. D., Woldu, W. & Gizaw, Z. Childhood diarrheal morbidity and sanitation predictors in a nomadic community. Ital. J. Pediatr.43, 91 (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.World Health Organization and United Nations Children’s Fund (UNICEF). Clinical management of acute diarrhoea. WHO/FCH/CAH/04.07 (WHO/UNICEF, 2004).
- 7.Nounkeu, C., Kamgno, J. & Dharod, J. Assessment of the relationship between water insecurity, hygiene practices, and incidence of diarrhea among children from rural households of the Menoua Division, West Cameroon. J. Public. Health Afr.10, 951 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lanyero, H. et al. Antibiotic use among children under five years with diarrhea in rural communities of Gulu, northern Uganda: a cross-sectional study. BMC Public. Health. 21, 1254 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Essomba, N., Koum, K., Adiogo, D., Ngwe, D., Coppieters, Y. & M. & Use of oral rehydration therapy in the treatment of childhood diarrhoea in Douala, Cameroon. Malawi Med. J.27, 60–64 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Thystrup, C. et al. Etiology-specific incidence and mortality of diarrheal diseases in the African region: a systematic review and meta-analysis. BMC Public. Health. 24, 1864 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Institut National de la Statistique (INS) and ICF. Cameroon Demographic and Health Survey 2018. Yaoundé, Cameroon and Rockville, Maryland, USA. (2020). https://dhsprogram.com/pubs/pdf/FR360/FR360.pdf
- 12.Efunshile, A. M. et al. Apparent overuse of antibiotics in the management of watery diarrhoea in children in Abakaliki, Nigeria. BMC Infect. Dis.19, 275 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Vierin, Y. N., M’Ella, M. M., Ngoubeyou, M. & Moussavou, A. Prise en Charge Pré Hospitalière de la Diarrhée chez l’Enfant de Moins de 5 Ans à Libreville. 16, (2015).
- 14.McMaughan, D. J., Oloruntoba, O. & Smith, M. L. Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Front. Public. Health. 8, 231 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Mendoza, A. M. B., Maliñana, S. A. A., Maravillas, S. I. D., Moniva, K. C. & Jazul, J. P. Relationship of self-medication and antimicrobial resistance (AMR) in low- and middle-income countries (LMICs): a scoping review. J. Public. Health Emerg.9, 6–6 (2025). [Google Scholar]
- 16.Amin, E. T. et al. Prevalence of antimicrobial self-medication among patients attending two hospitals in the Buea Health District, Cameroon. Archives Community Med. Public. Health. 5, 024–028 (2019). [Google Scholar]
- 17.Ngu, R. C. et al. Prevalence and Determinants of Antibiotic Self-Medication among Adult Patients with Respiratory Tract Infections in the Mboppi Baptist Hospital, Douala, Cameroon: A Cross-Sectional Study. Diseases6, 49 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Massongo, M. et al. Trends of Antibacterial Resistance at the National Reference Laboratory in Cameroon: Comparison of the Situation between 2010 and 2017. Biomed Res Int 9957112 (2021). (2021). [DOI] [PMC free article] [PubMed]
- 19.Yakum, M. N. et al. Health seeking behaviour among suspected cases of cholera in Cameroonian health districts in Lake Chad basin. BMC Res. Notes. 10, 433 (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ateudjieu, J. et al. Health facility preparedness for cholera outbreak response in four cholera-prone districts in Cameroon: a cross sectional study. BMC Health Serv. Res.19, 458 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ateudjieu, J. et al. Profil et antibiosensibilité des bactéries pathogènes associées aux diarrhées chez les patients consultant à l’Hôpital Régional Annexe de Kousseri, Extrême-Nord Cameroun. Pan Afr. Med. J.29, 170 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Yongsi, H. B. N. Recours et Pratiques Thérapeutiques Antidiarrhéiques à Yaoundé, Cameroun.
- 23.Ngwa, M. C. et al. Cholera in Cameroon, 2000–2012: Spatial and Temporal Analysis at the Operational (Health District) and Sub Climate Levels. PLoS Negl. Trop. Dis.10, e0005105 (2016). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ngwa, M. C. et al. Cholera public health surveillance in the Republic of Cameroon-opportunities and challenges. Pan Afr. Med. J.24, 222 (2016). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Geomatic Strategy. Geographical analysis of health coverage in Cameroon: Distribution of health facilities and health workforce workload. No. 002, March/April. (2019).
- 26.Changelog for QGIS 3.42 · QGIS Web Site. https://www.qgis.org/project/visual-changelogs/visualchangelog342/
- 27.World Gastroenterology Organization. Acute diarrhea in adults and children: a global perspective. (2012). [DOI] [PubMed]
- 28.Madkour b, S. M. & Lambrechts c, T. E Sherwin d. Diarrhoeal disease morbidity and home treatment practices in Egypt. Public. Health. 111, 5–10 (1997). [DOI] [PubMed] [Google Scholar]
- 29.Ahmed, M. S., Khanam, S., Kamruzzaman, M. & Morshed, M. S. Prevalence of antibiotic use for diarrhea among 1.3 million under-five years children: A multicounty retrospective analysis from 2006–2018. PLoS ONE. 18, e0289045 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Ahinkorah, B. O. et al. Prevalence and predictors of oral rehydration therapy, zinc, and other treatments for diarrhoea among children under-five in sub-Saharan Africa. PLoS One. 17, e0275495 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Adedokun, S. T. & Yaya, S. Prevalence of oral rehydration solution use and its determinants in the treatment of diarrhea among under-five children in sub-Saharan Africa. PLoS One. 19, e0303193 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Workneh, B. S. et al. Recommended homemade fluid utilization for the treatment of diarrhea and associated factors among children under five in sub-Saharan African countries: a multilevel analysis of the recent demographic and health survey. BMC Pediatr.24, 322 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.World Health Organization (WHO). The treatment of diarrhoea. https://www.who.int/publications/i/item/9241593180
- 34.Bojalil, R. & Calva, J. J. Antibiotic misuse in diarrhea. A household survey in a mexican community. J. Clin. Epidemiol.47, 147–156 (1994). [DOI] [PubMed] [Google Scholar]
- 35.Ekwochi, U., Chinawa, J. M., Obi, I., Obu, H. A. & Agwu, S. Use and/or Misuse of Antibiotics in Management of Diarrhea Among Children in Enugu, Southeast Nigeria. J. Trop. Pediatr.59, 314–316 (2013). [DOI] [PubMed] [Google Scholar]
- 36.Yeika, E. V. et al. Comparative Assessment of the Prevalence, Practices and Factors Associated with Self-medication with Antibiotics in Africa: A Systematic Review and Meta-analysis. 03.24.21254283 Preprint at (2021). 10.1101/2021.03.24.21254283 (2021). [DOI] [PubMed]
- 37.Jani, K., Srivastava, V., Sharma, P., Vir, A. & Sharma, A. Easy Access to Antibiotics; Spread of Antimicrobial Resistance and Implementation of One Health Approach in India. J. Epidemiol. Glob Health. 11, 444–452 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Mouiche, M. M. M. et al. Antimicrobial resistance from a one health perspective in Cameroon: a systematic review and meta-analysis. BMC Public. Health. 19, 1135 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Evans, M. V. et al. Geographic barriers to care persist at the community healthcare level: Evidence from rural Madagascar. PLOS Glob Public. Health. 2, e0001028 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Ministry of public Health of Cameroon. Health Sector Strategy 2001–2015. Yaoundé. (2009).
- 41.Auta, A., Ogbonna, B. O., Adewuyi, E. O., Adeloye, D. & Strickland-Hodge, B. Prevalence and factors associated with the use of antibiotics in non-bloody diarrhoea in children under 5 years of age in sub-Saharan Africa. Arch. Dis. Child.104, 518–521 (2019). [DOI] [PubMed] [Google Scholar]
- 42.Zollner-Schwetz, I. & Krause, R. Therapy of acute gastroenteritis: role of antibiotics. Clin. Microbiol. Infect.21, 744–749 (2015). [DOI] [PubMed] [Google Scholar]
- 43.DeClerque, J., Bailey, P., Janowitz, B., Dominik, R. & Fiallos, C. Management and treatment of diarrhea in Honduran children: Factors associated with mothers’ health care behaviors. Social Science Medicine. 34, 687–695 (1992). [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.