quantitative research title about malnutrition

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Prevalence and associated factors of malnutrition among children under-five years in Sindh, Pakistan: a cross-sectional study

• Gul Nawaz Khan 1 ,
• Ali Turab 1 ,
• Mohammad Imran Khan 2 ,
• Arjumand Rizvi 1 ,
• Fariha Shaheen 1 ,
• Asmat Ullah 1 ,
• Amjad Hussain 1 ,
• Imtiaz Hussain 1 ,
• Imran Ahmed 1 ,
• Muhammad Yaqoob 1 ,
• Shabina Ariff 1 &
• Sajid Bashir Soofi 1  

BMC Nutrition volume  2 , Article number:  69 ( 2016 ) Cite this article

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Globally, malnutrition accounts for at least half of all childhood deaths. Managing malnutrition in the community settings involves identifying malnutrition using a universally validated screening tool and implementing appropriate interventions according to the degree of malnutrition. The aim of this study was to estimate prevalence and associated factors that result in malnutrition among children under-five years of age in Thatta and Sujawal districts in Sindh province, Pakistan.

A cross-sectional survey was conducted between May and August 2014. A total of 3964 children under-five years were enrolled in the study. The WHO growth standards height-for-age Z-scores (HAZ), weight-for-height Z-scores (WHZ) and weight-for-age Z-scores (WAZ) were used to measure stunting, wasting and underweight. A structured questionnaire was used to collect data on socioeconomic conditions, family size, maternal education, parity and child morbidity. Multivariable logistic regression was used to determine the risk factors for malnutrition.

The prevalence of stunting, wasting and underweight were 48.2% (95% CI: 47.1–50.3), 16.2% (95% CI: 15.5–17.9), and 39.5% (95% CI: 38.4–41.5), respectively. Stunting was slightly higher (51%) in boys than in girls (45%) ( p  < 0.001). The proportion of wasting ( p  = 0.039) and underweight ( p  = 0.206) was not significantly different between boys and girls. Fifty percent children in the poorest households were stunted as compared to 42% in the wealthiest households. Children in the poorest households were two times more likely to be wasted (20.6%) than children in the wealthiest households (10.3%) (OR 2.33, CI 1.69–3.21, p  < 0.001). A similar relationship was observed between household wealth and underweight in children (43.8% in poorest and 28.8% in wealthiest households (OR 2.18, CI 1.72–2.77, p  < 0.001). Household wealth was significantly associated with stunting, wasting and underweight. Diarrhea was associated with underweight. Factors such as mother’s education, parity and family size were not associated with malnutrition in our study area.

Conclusions

The findings of our study revealed that malnutrition was widespread among the children under-five years of age. The food/nutrient based interventions together with improved hygiene practices and household wealth should be targeted to improve malnutrition situation in the study area and in the country.

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Globally in 2014, an estimated 159 million children under-five years were stunted, 95 million were underweight and 50 million were wasted [ 1 ]. Malnutrition accounts for at least half of all childhood deaths worldwide [ 2 , 3 ]. Despite the economic development, childhood malnutrition still remains a major public health problem in developing countries [ 2 , 4 , 5 ]. Contributing factors in childhood malnutrition are intra-uterine growth retardation, low birth weight, inadequate exclusive breast feeding, inappropriate complementary feeding, maternal education, low nutritional knowledge, insufficient energy and micronutrient intake, birth spacing, parity, socio-economic background, food availability, housing, poor sanitation, health services, vaccination and infectious diseases [ 5 – 15 ].

The Islamic Republic of Pakistan is among the countries in the world with the highest rates of child malnutrition (Stunting 44%, Wasting 15% & underweight 31%) and its progress in child nutrition and health remained slower than in other South Asian countries [ 16 – 18 ]. The data obtained from the National Nutrition Survey (NNS) 2011 indicated little change over the last decade in terms of childhood nutrition indicators. Among children under-five, 44% were stunted in 2011 as compared to 41% in the 2001. Fifteen-percent were wasted compared to 14% in 2001 and 31% were underweight, which has not changed since 2001. The malnutrition rates were relatively lower in urban areas compared to rural areas in Pakistan [ 19 ]. This paper presents the results of baseline data of a large project on effectiveness of food/nutrient based interventions to prevent stunting among children under-five years in districts Thatta and Sujawal, Sindh province, Pakistan.

Study design

A cross-sectional survey design was used to collect data between May and August 2014. The survey was designed to provide baseline information on a representative sample of households in the study area.

Study setting

The study was conducted in 29 Union Councils (UCs) of Thatta and Sujawal districts in Sindh, Pakistan. These districts are located in the southern part of the Sindh province. They are administratively subdivided into 9 Talukas and 55 UCs with a population of 1.5 million.

According to the 2014 Multiple Indicators Cluster Survey (MICS) conducted in Sindh, more than 88% of the population in Thatta and Sujawal have access to improved sources of drinking water, 68% have access to electricity, and 31% of households own agriculture land. Furthermore, few of the households have finished floors (35%), roofing (36%) and walls (40%). Individuals in the poorest wealth quintiles own more than 50% of households, while only 3% of households belong to individuals in the richest wealth quintiles [ 20 ].

Sample size

Sample size was calculated using comparison of two sequential surveys approach to assess the impact of intervention over time as discussed in Micronutrient Initiative (MI) and United States Center for Disease Control (CDC) manual [ 21 ]. Sample size calculation considered the prevalence of stunting in Sindh province at 49% (NNS 2011) and design effect of 2. Total sample size required was 3964 per survey to detect 10% difference with 80% power and 5% level of significance.

Sampling methodology

A two-staged cluster sampling technique was used to select households for interviews. In the first stage, sample size was divided in 29 UCs using a Proportion to Population Size (PPS) design. In the second stage, villages and households with children under-five years were randomly selected for interview.

Data collection

A structured household survey questionnaire was used to collect data through face-to-face interviews from mothers. The information collected included socio-economic and demographic characteristics, food insecurity, morbidity and child anthropometric measurements. Questionnaire was tested during the field testing and changes were incorporated accordingly. The questionnaire was initially designed in English, translated in Sindhi by senior project team member and then back-translated to English by an independent person to check for inconsistencies. Weight, length or height and mid-upper arm circumference (MUAC) were measured using standard anthropometric methods. Seca-874 was used for weight measurement, seca-213 used for height measurement, seca-210 measuring mat for measuring the length and MUAC tape for children with three colours of thresholds at red to 115 mm, yellow 115–125 mm and green from 125 mm was used. We measured length for children <24 months and height for children 24–59 months according to WHO standards [ 22 ]. The measurements were obtained by two trained anthropometrists. The date of birth was reported by the mother and verified by birth certificates and vaccination cards. Sixteen enumerators, 4 team leaders, 2 desk editors and 2 field supervisors were hired, trained and involved in baseline data collection.

Statistical analysis

Three anthropometric indicators were constructed on height-for-age (HAZ), weight-for age (WAZ) and weight-for-height (WHZ) in the form of z-scores using WHO Anthro 2006 software. Each z-score depicts the deviation from the median height or weight of a child of the same age and sex in the reference population. Stunting was defined as height-for- age (Z-score < −2), wasting as weight-for-height (Z-score < −2), and underweight as weight-for-age (Z-score < −2) using child growth standards published by the World Health Organization (WHO) in 2006 [ 22 ]. WHO Anthro 2006 software by default flagged missing data and implausibly high or low observations. Hence total 2.9% of the observations were eliminated due to flagging.

The study population’s characteristics were summarized using means with standard deviations (SD) for the continuous variables and percentages for the categorical variables. Confidence intervals were also reported for inference.

Predictors of childhood malnutrition (stunting, wasting, under-weight and all three) were investigated using logistic regression analysis. A range of child, maternal and household level factors were included in the modelling such as child age and gender, maternal education and parity, family size and wealth index. Wealth index is a composite score constructed with broad range of socio-economic indicators including household construction material, source of drinking water and sanitation facilities, household utilities and assets using principal component analysis. This score further divided in 5 equal categories comprising 20% of the data in each category [ 23 ].

Univariate analysis was conducted to determine independent effect of each predictor on outcomes. Then all predictors were included in multivariate analysis to investigate net effect of each predictor on outcomes adjusting for all other factors in the model. Adjusted OR were calculated to study the predictive power of independent study variables in relation to childhood malnutrition. All statistical analyses were performed using SPSS version 15.0 with the statistical significance set at a p value ≤ 0.05.

Socio-demographic characteristics

Socio-demographic characteristics of the sampled children, their mothers and households are presented in Table  1 . Mother’s educational levels were relatively low and 88% of mothers were not formally educated. We collected data for 3964 children, among them 51% were males and 49% were females. Fifty-two percent children were under the age of two years, while 48% children were between age of 2–5 years. About 40% of children had two or more siblings in the selected households. More than half of households had 6–10 family members, while 9% had more than ten family members.

Prevalence of stunting

The prevalence of stunting in the study sample was 48%, and was slightly higher (51%) in boys than in girls (45%). Similarly, severe stunting rates were slightly higher in boys (25.5%) than in girls (22.3%). Stunting rates gradually increased from 22% in children <5 months old to 62.6% in children 36–47 months old, however it reduced in children 48 to 59 months (43.5%) [Table  2 ].

Prevalence of wasting

The prevalence of wasting in the study area was 16.2%. Proportion of wasting among boys and girls was not prominent. Wasting increased with age, peaking at 20.8% among children in 24–35 months of age. Only 2.5% children were overweight [Table  3 ].

Prevalence of underweight

Overall, 39.5% of children under the age of five years were underweight. Prevalence of underweight for both sexes was almost same. The rates of underweight increased with age, peaking at 51.6% among children in 24–35 months of age, and then dropped to 37.5% among children in 48–59 months of age [Table  4 ].

Association of malnutrition with wealth quintiles

Figure  1 presented comparison of underweight, stunting and wasting rates by wealth quintiles. The prevalence of underweight, stunting and wasting was higher in children of poorest households than in children of wealthiest households. Fifty percent children in the poorest households were stunted compared to 42% in the wealthiest households. Children in the poorest households were two times more likely to be wasted (20.6%) compared to children in the wealthiest households (10.3%). A similar relationship was observed between household wealth and underweight in children (43.8% in poorest and 28.8% in wealthiest households) in the study area.

Comparison of underweight, stunting and wasting by wealth quintiles

Multiple malnutrition (stunting, wasting and underweight) was higher in boys than girls. Children aged between 12 and 23 months were in more risk for being stunted and underweight than in other age groups [Tables  2 and 4 ].

Determinants associated with malnutrition

Determinants related to stunting, wasting and underweight presented in Table  5 . Determinants such as mother’s education, parity and family size was not associated with stunting, wasting and underweight; while gender, age and wealth quintiles was associated with malnutrition. Diarrhea was associated with underweight. The p-value of stunting in boys was highly significant <0.0001 relative to girls, but it was not significant for wasting and underweight in the study area.

This study was conducted to provide baseline results for a large trial for the effectiveness of food/nutrient based interventions to prevent stunting among children under-five years in Thatta and Sujawal districts of Sindh province, Pakistan. The findings of our study revealed that malnutrition was widespread among the children under-five year old, and has not improved since last two decades [ 19 ]. The study data provide critical information on child nutrition, health, household wealth quintiles, family size, parity and food security in the sampled population.

Stunting prevalence found in this study area was 48.2% and is considered as ‘Very High’ public health significance according to WHO standards. The prevalence of stunting was slightly higher (51%) in boys than in girls (45%). These findings are comparable with national results reported in PDHS 2012–13 [ 19 ] and in a meta-analysis for sub-Saharan Africa studies [ 24 ].

The rapid increase in stunting between 6 and 24 months of life (from 34 to 56%) in the study area is particularly concerning. This is the “window of opportunity” as well to prevent stunting during the pregnancy and the first 2 years of life of the child, cumulating a critical period for intervention of 1000 days. Unfortunately, after two years of age, it is extremely difficult to intervene and catch-up growth, leading to irreversible damages in the development of the child.

The results of our study also revealed that there was a highly significant chance for being of stunted, wasted and underweight in children belonging to the lower quintiles as compared to highest quintiles, and almost similar findings were reported in three studies from Africa [ 25 – 27 ].

Research studies had identified maternal education higher than primary school, as one of the main factors of childhood malnutrition [ 27 – 30 ]. As many women in our study area were illiterate and we anticipate that maternal education had limited implications for inter-household differences in nutrition, and similar finding were reported in a study from Democratic Republic of Congo [ 31 ].

Household food insecurity was also positively associated with wasting but not with stunting and underweight in our study area. Food insecurity was associated with higher child undernutrition in Bangladesh, Ethiopia, and Vietnam [ 32 ] but not associated with child undernutrition in a study from rural Cambodia [ 33 ].

The findings of our study revealed that malnutrition was widespread among the children under-five years. Household wealth was highly associated with all three forms of nutritional outcomes. To succeed in the reduction of child malnutrition in the study area and in Pakistan, interventions must target short term nutrition supplements and long term economic empowerments of poor communities. Further research is recommended to investigate potential factors associated with child malnutrition, and interventions to improve nutritional status in children under-five years.

Abbreviations

Center for Disease Control

Confidence intervals

Ethical review committee

Height-for-age z-scores

Micronutrient Initiative

Mid-upper arm circumference

National Bio-Ethics Committee

National Nutrition Survey

Pakistan Demographic Health Survey

Proportion to Population Size

Standard deviation

Union Councils

Weight-for-age z-scores

World Health Organization

Weight-for-height z-scores

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Acknowledgments

We are grateful to the staff of health department and study participants for their time and contribution. We would like to appreciate all staff of the study for their hard work and support provided by DMU, Aga Khan University, Pakistan.

This study was financially supported by World Food Programme (WFP), Pakistan.

Availability of data and materials

Data will be available upon request to corresponding author.

Authors’ contributions

SBS conceptualized the study, its design and analysis plan. SBS, GNK, AT, AU, IH and MY were involved in implementation of the study. GNK wrote first and subsequent drafts, participated in data acquisition and data analysis plan. AR and FS participated in data analysis. AH, IA, AU, SA and GNK involved in data management. MIK and AT edited the manuscript. All authors reviewed and approved the content of the final manuscript.

Competing interests

The authors declare that they have no competing interests.

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Not applicable.

Ethics approval and consent to participate

The study was reviewed and approved by Ethical Review Committee (ERC) of Aga Khan University and National Bio-Ethics Committee (NBC) of Pakistan. Informed written consent was obtained from parents of each study participant to participate in the study and all the data was kept confidential.

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Gul Nawaz Khan, Ali Turab, Arjumand Rizvi, Fariha Shaheen, Asmat Ullah, Amjad Hussain, Imtiaz Hussain, Imran Ahmed, Muhammad Yaqoob, Shabina Ariff & Sajid Bashir Soofi

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Khan, G.N., Turab, A., Khan, M.I. et al. Prevalence and associated factors of malnutrition among children under-five years in Sindh, Pakistan: a cross-sectional study. BMC Nutr 2 , 69 (2016). https://doi.org/10.1186/s40795-016-0112-4

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Received : 07 September 2016

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Published : 24 November 2016

DOI : https://doi.org/10.1186/s40795-016-0112-4

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Conflict and Child Malnutrition: a Systematic Review of the Emerging Quantitative Literature

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Purpose of Review

Reduction of child malnutrition in conflict settings is on top of the international agenda on sustainable development. This association between child malnutrition and conflict has been hypothesised in the academic literature but not rigorously examined empirically till recently. This paper reviews the emerging quantitative literature, including conflict as an explanatory variable to understand the aspects of child malnutrition studied and how violent events are associated with child nutritional status. Limitations are also highlighted.

Recent Findings

Child malnutrition is investigated into its three main dimensions of stunting, wasting and undernourishment computed as z-score. Conflict is mostly studied in terms of duration, number of events, typology and intensity.

The emerging literature generally establishes a significant and negative association between conflict and child malnutrition. However, limitations persist and are mainly due to the type of available data.

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78 Malnutrition Essay Topic Ideas & Examples

🏆 best malnutrition topic ideas & essay examples, 👍 simple & easy malnutrition essay titles, 🎓 good research topics about malnutrition, ❓ research question about malnutrition.

• Child Malnutrition: Term Definition Majority of the people in the globe specifically in the rural areas do not have access to safe drinking water and most of them lack the access of good sanitation.
• Obesity as a Form of Malnutrition and Its Effects Obesity is considered a malnutrition because the extended consumption of nutrients can still lead to the lack macro- and microelements. Overweight and obesity are serious disorders affecting a substantial part of the current population.
• Healthy Nutrition: Case Study of Malnutrition Sofia’s possible malnutrition might be owing to her demanding schedule and lack of prenatal care, which is an important part of a healthy pregnancy.
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• Malnutrition: Criteria and Description of Statement of the Problem Between adequate nutrition programs and malnutrition primary prevention programs, what approach is the most effective to enhance children’s development? What are the dissimilarities between adequate nutrition programs and malnutrition primary prevention programs?
• Obesity and Malnutrition: Who Is at Fault I would like to note that in both the interview and the article Nestle states that malnutrition is not only the responsibility of the consumers.
• Child Malnutrition in the GCC Countries Countries which have faired badly in the recent past include Kuwait and Qatar which saw an increase in their child malnutrition rates from 5% in the 1990s to 10% in the mid-2000s.
• The Issues of Malnutrition and the Healing Process The issues of malnutrition and the healing process are regarded in lots of journals and scientific literature. The nutritional status of the patient previous to and after a surgical procedure is significant for speedy and […]
• Integrated Nursing Practice Addressing Malnutrition The benefits of the specified intervention include an opportunity to reduce the extent of stress experienced by the patient and create the basis for the future patient education.
• Malnutrition in Children as a Global Health Issue The peculiarity of this initiative is not to support children and control their feeding processes but prevent pediatric malnutrition even before a child is born.
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Nutritional status and correlation with academic performance among primary school children, northwest Ethiopia

• Biachew Asmare 1 ,
• Mekuanint Taddele 1 ,
• Sileshi Berihun 1 &
• Fasil Wagnew 1  

BMC Research Notes volume  11 , Article number:  805 ( 2018 ) Cite this article

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This study aimed to determine the association between nutritional status and academic performance among primary school children in Debre Markos Town, northwest Ethiopia, 2017.

The prevalence of stunting, underweight and wasting were 27.5% (95% CI 23.2–31.9%), 20.4% (95% CI 16.5–24.3%) and 8.7% (95% CI 6.2–11.5%), correspondingly. The low level of educational performance was significantly higher (p < 0.05) among the stunted, underweight and wasted children than that of the normal children. In multivariable logistic regression, age of the child (Adjusted Odds Ratio (AOR) = 0.177, 95% CI 0.07, 0.4), monthly income less < 1000.00 birr (AOR = 0.05, 95% Cl 0.02, 0.15), stunted children (AOR = 0.21, 95% CI 0.10, 0.43) and under-weight (AOR = 0.63, 95% CI 0.26, 0.84) were associated with academic performance. This study revealed that indicators of undernutrition were prevalent among school-age children. Thus, collaboration between the health and education sectors is required to alleviate the problem.

Introduction

Quality education plays a pivotal role in the economic, social and political development. Currently, getting children into schools is not enough; government ensure that children attain the basic knowledge and skills needed for personal well-being [ 1 ]. Primary school is an important stage in the development of consciousness and personality of the child [ 1 , 2 ].

Nutrition is also a vital component of human health, life, and brain development through the entire lifespan [ 3 ]. Balanced nutritious is crucial for endurance, physical growth, cognitive development and productivity [ 4 ]. As well, malnutrition is considered a pressing problem that affects the ability of children to learn and causes them to perform at a lower level in school [ 5 , 6 , 7 ]. Undernutrition is a major public health challenging affecting academic school achievement [ 8 ]. Ethiopia is one of the sub-Saharan African countries basically affected by child malnutrition. Previous studies conducted in different areas have shown that under nutrition is common among school-age children; it was reported in the form of stunting range from 11 to 48.7% and underweight from 7.2 to 59.7% [ 9 ]. A study conducted in eastern Ethiopia reported that the prevalence of stunting was 8.9%, of which, 2% had severe stunted among school-aged children [ 10 ]. Though evidence about the prevalence of malnutrition is well studied in Ethiopia, there is insufficient evidence regarding nutritional status allied with academic performance among school-age children [ 9 ]. The association between nutritional status and educational achievement among school-age children in developing countries have not been recognized well [ 9 , 11 ]. Stunting is referred as the best indicator for a chronic type of under nutrition [ 9 ]. Children who are stunted have low ability to learn at school and poor scholastic achievement [ 12 ]. Furthermore, poor feeding practices are associated with stunted and impaired brain development [ 6 , 13 ].

On this background, there is a necessity to overlook the relationship between nutritional status and educational performance among school-age children in the Debre Markos town. This study was aimed to determine nutritional status and correlation with academic performance among first cycle governmental primary school in Debre Markos Town, northwest Ethiopia.

Study area, setting and period

The study was conducted at Debre Markos town primary school. In the town, there were a total of 7473 population. Of them, 3831 were females studying in the school. Debre Markos is a city of East Gojjam Zone which is located 299 km away from Addis Ababa in the North. It had 15 governmental and 8 private primary schools. The study was conducted between January15 to March 17/2018.

Study design and population: An institutional-based, cross-sectional study was employed at primary school in Debre Markos town.

Sample size and sampling techniques: The sample size was determined using double population proportion by considering the following statistical assumptions: prevalence of stunting among school children (p 1 ) is 48% and p 2 is 29% and level of significance (α) = 5%, at 95% level of confidence, power of the study 90% and design effect 1.5. Finally, the overall sample size was found 442.

Sampling procedure: Participants were carefully chosen using a multi- stage sampling technique. Out of 15 primary schools, 4 schools were selected randomly by lottery method at stage one. Students were allocated proportionally at stage two. Then participants from selected schools were selected by systematic random sampling method using students’ name list by calculating ‘k’ value for each class.

Data collection methods: Data were collected using a pre-tested structured questionnaire and translated into the local language (Amharic version) by trained and experienced data collectors. Respondents were parents/caregivers of the children identified in the study schools. After students were systematically selected from the schools, their household address was traced in the students’ parent database. Then data collectors went to the children’s house to interview parents/caretakers. Training on the standard procedures and technique how to collect data were given for the data collectors and supervisors for 2 consecutive days. The contents on questionnaires were briefly described to reduce interviewer bias.

Data processing and analysis: Data were entered into Epi-Data version 3.1 and then exported to SPSS version 20 for further analysis. Emergency Nutrition Assessment (ENA) for SMART software was used to calculate the Z-score of weight-for-age, height-for-age and weight -for-height of the children. Variables which were significant at p-value < 0.2 in the bivariable analyses were candidate for entering into the multivariable logistic regression model to identify the independent predictors for academic performance. Before inclusion of factors, we checked multicollinearity using variance inflation factor (VIF) < 10.

Definition of academic performance

The overall subjects the students were given in the academic year 2017/18 were considered to examine the academic achievements of the students. The annual average score was computed by taking the result of two consecutive semesters of the year. To verify the relationship between nutritional status and academic performance, average marks of the overall subjects the students received were either poor academic achievement or good academic achievement, in accordance with an average mark of 50%. This cut off average point was decided by considering the pass mark set by Ethiopian ministry of education.

Socio-demographic characteristics

A total of 436 children were included in the study with a response rate of 98.6%. Of them, 245 (56.2%) were males. The mean age of the study participants was 8.57 (± 1.12) ranging from 7 to 10 years. Majority of the study participants 398 (90.8%) were located in urban, 389 (89.2%) orthodox and 153 (35.1%) from grade one. Educational status of parents of the study participants showed that 81 (19.5%) mothers and 67 (17.7%) fathers had no formal education (Table  1 ).

Out of the 436 children, 37 (8.5%) were being sick in the last semester and only 140 (32.1%) of school-age children were attending preschool. Majority of study participants 403 (92.44) were traveled to school with in 2.18 km (Additional file 1 : Table S1).

Level of nutritional status in study participants: The overall prevalence of stunting, underweight and wasting were 27.5% (95% CI 23.2–31.9%), 20.4% (95% CI 16.5–24.3%) and 8.7% (95% CI 6.2–11.5%) respectively. The percentage of children having any kind of under nutrition (stunting, wasting and underweight) was 56.2%. The prevalence of stunting was significantly higher in males than females (Fig.  1 ).

Prevalence of under nutrition by gender among children in Debre Markos town, Northwest, Ethiopia, 2017 (n = 436)

Nutritional status and academic performance: In comparison of median t-test analysis revealed that there was significant mean difference in all subject average score between children who were having any kind of undernutrition (Additional file 2 : Table S2).

After adjusting factors, age, family income, nutritional indicators (WAZ and HAZ) had significant positive associations with academic achievement of students ( p  < 0.05). Age of the child (AOR = 0.177, 95% CI 0.07, 0.4), Monthly income less < 1000.00 birr (AOR = 0.05, 95% CI 0.02, 0.15), stunted children (AOR = 0.21, 95% CI 0.10, 0.43) and under-weight (AOR = 0.63, 95% CI 0.26, 0.84) were significantly associated with academic performance. Students those nutritional status had stunted were 79% less likely to score high academic performance as compared with normal. Students whose nutritional status had under-weight were 37% less likely to score high academic performance compared with their counterparts (Table  2 ).

Discussions

The aim of this study was to determine the relationship between nutritional status and academic performance among governmental primary school children. In this study, the prevalence of stunting, underweight and wasting were 27.5%, 20.4%, and 8.7% respectively. This finding was comparable with a study done in Zambia reported that 28.9% of stunted, 14.5% of underweight and 3. 9% of wasted [ 14 ]. In addition, the prevalence of stunting and wasting in this study was also in line with the findings of Sri Lanka among school-age children which indicated that the prevalence of under-nutrition in the central province was 26.6% stunted and 8.5% wasted [ 15 ], and in northwest Ethiopia, 27.1% stunted [ 16 ]. In contrast, this finding was higher as compared to other previous studies conducted in Brazil was found (14.9% stunted and 9.7% wasted) [ 9 ], in Kenya (24% stunted, 14.9% underweight, 9.7% wasted) [ 17 ], in Nicaragua (5% wasted) [ 18 ], in eastern Ethiopia (8.9% stunted) [ 19 ]. The reason for this observed discrepancy might be due to sociodemographic characteristics, area of sampling and study period.

Regarding factors, the present study revealed that age and monthly income were significant factors for academic performance among primary school children. This finding was consistent with a systematic review and meta-analysis showed that there is a strong association between academic performance and socio-economic status including age [ 20 ]. Compromised socio-economic status of a family was statistically associated with poor academic performance in children [ 21 ]. Similarly, other studies done in Southeast Ethiopia [ 22 ] and in Malaysia [ 23 ] reported that minimum wealth indexed score of the family were a positive association with poor academic performance. This might be due to balanced nutritional intake is required for adequate biological functioning affect such complex brain functions as the cognitive processes related academic performance [ 24 ].

Moreover, in developing countries macronutrient and micronutrient deficiencies are a devastating problem. Consequently, this obstacle has been either direct or indirect influence on children future of life [ 25 ]. Improved nutritional status has been exposed to have a positive and direct impact on academic performance of children [ 4 ]. In the current study, under-weight and stunting were associated factors for good academic performance among school-age children. This finding is in line with a study done in Sri Lanka [ 26 ] and in Uganda [ 27 ] which revealed that child with a high score of WHZ and HAZ had good academic performance as compared to their counterparts. Also, marasmic-kwashiorkor children may acquire delay brain development. Chronic types of malnutrition (stunting) had a negative impact on child cognitive development [ 20 ]. Similarly, a study done in Southeast Ethiopia revealed that higher score of HAZ was significantly associated with a higher academic score [ 20 ]. In this study, wasting (WHZ) was not statistical association with child academic performance. This non-significance effect might be due to the fact that wasting is acute malnutrition which implies a temporary nutritional disorder that may not negative substantial impact on academic performance [ 28 , 29 ].

The study revealed that indicators of undernutrition were prevalent among Debre Markos town primary school children. Age, income, HAZ and WAZ scores showed significant association with academic performance. Therefore, the government should paid attention to implement nutrition screening program and intervention strategy to improve academic performance at primary school children.

Limitation of the study

Finally, some important limitations of this study was cross-sectional nature of the study could not establish a cause and effect relationship between the dependent and independent variables. The other limitation of the study is that it was done in an urban areas which may inadequate representative for rural area.

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Authors’ contributions

BA, MT, SB and FW were participated in proposal writing, analyzing the data, and drafting the paper. MT and FW prepared the manuscript for publication. All authors read and approved the final manuscript.

Acknowledgements

The author’s deep gratitude goes to Debre Markos University, college of medicine and health sciences for proper review and approval of this paper. The authors would also like to extend their gratitude to Debre Markos town educational office and primary schools in the town, data collectors, and supervisors for valuable contribution for the success of this study.

Competing interests

The authors declare that they have no competing interests.

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Additional file: data collection tool.

Data set: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The study was carried out after getting approval from Debre Markos University institutional review board (IRB). Written permission was obtained from educational office and administrative leaders of respective schools. The verbal (non-written) consent was obtained because written consent needed a certain level of education to read and sign the consent. Participants had the right to refrain from answering some questions or withdraw from the study process at any time. To maintain confidentiality, each and every one collected data were coded and locked in a separate room prior to enter into the computer. Following entered into the computer all data were protected by password.

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Additional files

Additional file 1: table s1..

General characteristics of study participants in Debre Markos town, March, 2017 (n = 436).

Additional file 2: Table S2.

Prevalence of low educational performance (marks < median of student result of nutritional status of children, Debre Markos, 2017 (n = 436).

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Asmare, B., Taddele, M., Berihun, S. et al. Nutritional status and correlation with academic performance among primary school children, northwest Ethiopia. BMC Res Notes 11 , 805 (2018). https://doi.org/10.1186/s13104-018-3909-1

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MALNUTRITION RESEARCH BY ORYEM JOSEPH

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Polish Annals of Medicine

Taha H Musa

JUNAID ABID

Malnutrition shows a decline in health due to the disproportion of nutrients and energy in the body. Malnutrition is one of the main risk factors related to children's morbidity and mortality. It is estimated that about 52.50% of child mortality is linked to malnutrition and its associated diseases. 1 Malnutrition is a crucial medical problem in approximately every region of the globe and particularly in Southern Asia and Sub-Saharan Africa. In several developing nations, stunting, underweight, and micronutrient deficiencies among children are common due to insufficient nutrition and ABSTRACT Background: Malnutrition is one of the main health issues among children. Malnutrition is more prevalent in developing countries. Malnutrition among children is affected by many factors. These factors are studied in many parts of the world but they are understudied in most the areas of Pakistan. This study aimed to assess the incidence of malnutrition and its associated factors among children in Murree, Rawalpindi, Pakistan. Methods: This descriptive cross-sectional study was carried out among children of Murree, Rawalpindi for about 6 months from August 2021 to January 2022. Simple random sampling along with an established inclusion and exclusion criteria was applied to enroll 316 participants. A self-adapted questionnaire was applied to take data after taking ethical approval from the institutional research board and informed consent from the participants. Results: The incidence of underweight, normal weight, overweight and obesity among school children of study population was 22.80%, 35.40%, 26.90%, and 14.90% respectively. The association between malnutrition and gender (p=0.001), birth weight (p=0.01), supplementation intake (p=0.03), filtered water use (p=0.02), hygiene (p=0.01), vaccination status (p=0.04), recurrent infection history (p=0.02), socioeconomic status (p=0.04), mother education (p=0.04), mother occupation (p=0.03), awareness of parents about balanced diet (p=0.02), and family size (p=0.04) was statistically significant, whereas association between nutritional status and age group (p=0.05) was insignificant. Conclusions: The incidence of underweight, overweight, and obesity was remarkable among children. Many factors such as gender, birth weight, supplementation intake, filtered water use, hygiene, vaccination status, recurrent infection, socioeconomic status, mother education, mother occupation, parental awareness about a balanced diet, and family size were found to associate with malnutrition among children.

Abdul Tauqeer

Eng Abdirahman

Abstract Background: Malnutrition is a severe problem that affects a child’s cognitive and physical development. An adequate, balanced nutrition is crucial for a proper physical, emotional, and mental development. Malnutrition remains one of the most common causes of morbidity and mortality among children under 5 children throughout the World. It is the most important risk factor for the burden of disease causing about 300, 000 deaths per year directly and indirectly responsible for more than half of all deaths in children. Child malnutrition is one of the most serious public health problems in the developing world. Objective: To assess prevalence of malnutrition and associated factors among children aged 5 years at Lasanod district, Sool region, October 2014. Methods: An institution based cross sectional study was done among MCHs under five children found in Lasanod town on October 2014. The sample size of the study was 113. A pretested structured questionnaire and interview guide were employed to obtain the necessary information for this study. The structured questionnaire were originally prepared in English language and then translated into the Somali language and then back to English. The collected data was analyzing using SPSS Version 20.0 and triangulated. Bivariate and multivariate logistic regressions were carried out. Result: The analysis this study revealed that, 57.5%, 25.6.9% and 33.7% of children were underweight ,wasted, and stunted respectively and also revealed that 3.5%, 10.6% and 13.3% of children were severe underweight , severe wasted and severe stunted. The main associated factors of malnutrition were found to be mother’s age at first birth, place of delivery and duration of breastfeeding. Conclusion and recommendation: - This study revealed that, prevalence of malnutrition was high and it was the top list among the health problems in Lasanod district. In Somalia where most mothers do not know nutritional status and nutrient foods, a lot should be done by different sectors. We suggest that under nutrition prevention programs and strategies in the region as well as other regions should target Nutritional status among mothers and their children in extensive way to bring further positive changes related to diet.

Journal of Nutritional Science and Vitaminology

Francis Nkrumah

American Journal of Public Health Research

Irene Sumbele

International Journal Foundation

This is cross-sectional community based study conducted in Angola area in Khartoum State of Sudan during period of 2015-2017. The aim of the study was to assess nutritional status of under five years old children and its associated risk factors using anthropometric measurements, interview of childcare givers, and observation on nutrition status indicators and socioeconomic profile of families. 282 children and their caregivers were selected and investigated using cluster sampling techniques and predesigned questionnaires and checklist. The results revealed that 19.1 of the studied children were severely malnourished, and 4.7 were moderately malnourished with children in age of one to two years were mostly affective with P value of < 0.05. Family size and parent education level also were reported among the major risk factors of malnutrition with P value of < 0.05. 96.6% of the children had episode of diarrhea at least once, and 81.1% had respiratory tract infection at least once. Few were exposed to frequently to those infectious diseases. The study concluded that severe and moderate malnutrition affect almost quarter of the children in the area especially in the age group of one to two years. Poor education and awareness on how to maintain children health generally is the main risk factor especially knowledge and skills on the causes of malnutrition, proper young children food and feeding practices, breastfeeding, and utilization of available health services. The study recommended extensive health education program along with family support through provision of nutrients high density food. Study Area: The area has a total population of the area 56,534 with 10,386 under five year old children according to the area popular committees. Household with children aged 6 to 59 months were selected for the study along with their mothers. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Sample size: 282 children and their mother were selected using the following formula and based on prevalence rate of nutritional deficiency diseases in Khartoum State of which was estimated to be 10% according Khartoum State Ministry of Health, 2009 n = z 2 pq* design defect (d) 2 Where: n = sample size, Z = 1.96, P = prevalence rate of nutritional deficiency diseases= (10%), q = 1-p, d = 0.05, Design defect=2 n =(1.96) 2 X 0.9 X0.X 2 = 138.2976 X 2 = 276.59 (0.05) 2 (14) The number was rounded to 282 children taken into account the refusal which was estimated to be 9%. Cluster sampling techniques was used by dividing the area into 6 clusters, in each 47 children's and their mothers/caretakers were selected randomly (15). Data were collected in predesigned questionnaire and check list through interview with mothers and measuring weight and high of their children. Indicators used during this study were: height –for –age (for chronic malnutrition), weight for weight (for acute malnutrition) and edema (16,17). Weight: The Staler 25kg hanging spring scale marked out in steps 0.1 kg, was used instrument was adjusted to zero before used, the child freed from heavy clothing (16,17). Height: Children up to 2years (23 months 85 cm length) of age were measured on horizontal measuring board. Children over two years of age (or over 85cm) were measured standing on horizontal surface against vertical measuring device. The height was read out as before, to nearest 0.1cm (29) Age: The birth data was entered on the recording form from birth certificates where this document was not available we used date of birth given by mothers Edema: Presence of edema also was recording after examination of children using finger press on the abdomen and legs.

Geleta Asebe

Abdul-Rasheed L Sulaiman , Ahmed Olusi

The road to good health is through good food which depends on the socioeconomic condition of the giver of the food. Numerous studies had been conducted on the causes of child malnutrition among children less than 5 years, that of children between 8 and 16 years with keen interest on the socioeconomic context of the giver has not been well documented. This lacuna is what this paper filled. Cross-sectional household survey was used for the study. 322 respondents were selected using a multi stage cluster sampling design. A well-structured pretested questionnaire was used to elicit the socio-demographic data from the respondents, while the respondents' nutritional status was calculated using the Body Mass Index (B.M.I) method. Chi-square and bivariate logistics regression were used to test the hypotheses. The study discovered that parental education and parental income were the fundamental factors affecting child malnutrition in the study location. Hence, government should ensure that education is made compulsory and affordable to everyone. Also, the menace of poverty should be adequately addressed.

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Nutritional status of children ages 0–5 and 5–10 years old in households headed by fisherfolks in the Philippines

• Mario V. Capanzana 1 ,
• Divorah V. Aguila 1 ,
• Glen Melvin P. Gironella 1 &
• Kristine V. Montecillo 1  

Archives of Public Health volume  76 , Article number:  24 ( 2018 ) Cite this article

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The study aimed to analyze the nutritional status of Filipino children ages 0–60 months (0–5.0 years old) and 61–120 months (5.08–10.0 years old) in households headed by fisherfolks.

The 8th National Nutrition Survey (NNS) data collected by the Food and Nutrition Research Institute, Department of Science and Technology (FNRI-DOST) was used in the study. There were 13,423 young children and 16,398 schoolchildren participants for anthropometry component. The World Health Organization Child Growth Standards (WHO-CGS) was used to assess the nutritional status of the young children while the WHO Growth Reference 2007 was used for schoolchildren. Occupational groups were categorized based on the 1992 Philippine Standard Occupational Classification (PSOC). Descriptive statistics were used for the profiling of the different variables while bivariate analysis, logistic regression and odds ratios were used to correlate the different variables to the nutrition status of the children. Data were analyzed using Stata 12.0.

Results showed that households headed by fisherfolks (HHF) were one of the occupational groups with highest malnutrition among young and school-aged children. The HHF had higher prevalence of malnutrition among young children compared to the overall prevalence of malnutrition among young children in the Philippines, except for overweight. This is also true for schoolchildren, except for wasting. Age of child, sex, household size, age, fishermen and farmer as household head and type of toilet (water-sealed) were correlated to stunting, underweight, overweight and obesity among children.

Conclusions

The high prevalence of stunting, underweight and wasting among young and schoolchildren in this occupational group poses immediate and serious nutrition intervention strategies such as health and nutrition information, health care, sanitation and hygiene, and physical activities. A national policy on the health, nutrition and welfare of households headed by fisherfolks and their children is highly recommended.

Peer Review reports

Fisherfolks consistently top as the poorest sector in the Philippines from 2003 to 2012 based on the report of Philippine Statistics Authority (PSA) on Poverty Incidence of Basic Sectors [ 1 ]. Aside from the uncertainty of income among fishing communities, factors such as land ownership, debt, access to health, education and financial capital, as well as political and geographical marginalization also contribute to why poverty thrives in this sector [ 2 ]. Moreover, fisherfolks often live in places that have particularly high risk of extreme events; flooding, cyclones and tsunamis often visit coastal and floodplain fisheries, while inland fisheries can be significantly affected by droughts and floods. These disasters leave severe damages on infrastructures as well as productive assets such as boat, landing sites, post-harvesting facilities and road among fishing-dependent people. These consequently decrease their harvesting capacity and access to markets, affecting both local livelihood and the overall economy [ 3 ].

These kinds of disasters had also brought severe asset damages among fishing communities in the Philippines. In 2013, Typhoon Yolanda/Haiyan, one of the strongest typhoons that visited the country, affected Eastern Samar, Samar and Leyte. The National Disaster Risk Reduction and Management Council (NDRRMC) estimated that 16 million people were affected and 1.1 million houses were damaged. The livelihood of fisherfolks was also affected in the areas. There were nearly 30,000 small-scale fishing boats damaged while more than 100,000 were lost or destroyed [ 4 ]. Additionally, about 600,000 ha of agricultural land, 33 million coconut trees and 305 km farm-to-market road were damaged, whereas more than 400 health facilities and 1200 provincial, city and municipal and barangay halls and public markets were destroyed in the area [ 5 ].

Disasters, such as typhoon Yolanda/Haiyan, can have serious consequences for food security, nutrition and health. Damaged infrastructures due to extreme events or flooding can cut access to local markets, and consequently reduce the availability of food products and increase the food prices, resulting in higher incidences of malnutrition in communities [ 3 ].

These disturbances in nutrition as a result of inadequacy in food intake, health problems, or a combination of both, invariably affect the growth of children [ 6 ]. Hence, assessments on the nutritional status of children based on their anthropometric indicators of growth has been used not only in generating information on their nutritional and health status, but also in providing an indirect measurement of the quality of life of their community, and thereby as an indicator of the nutritional status and food intake adequacy of all members in that community [ 7 , 8 ].

Thus, this study aimed to focus and analyze the condition of households headed by fisherfolks (HHF) with respect to the nutritional situation by assessing the nutritional status of children ages 0–60 months (0–5.0 years old) and 61–120 months (5.08–10.0 years old), using the 8th National Nutrition Survey data. Factors affecting the nutritional status of the children in HHF were also analyzed to better understand the nutrition situation in the fishing communities in the Philippines.

The study was initiated to estimate the prevalence of malnutrition among young and school-aged children among fishing community as basis in planning and developing nutrition programs that will improve the nutritional situation of this occupational group. It is hoped that this study will provide significant information that can serve as basis for policy makers and program planners in the nutrition and fishery sectors among private or public organizations in drawing future strategies for improving the nutritional situation of the fisherfolks in the Philippines.

Conceptual framework

Malnutrition in children is the result of complex interaction of numerous and multifaceted factors. Thus, in the analysis of this study, the UNICEF’s conceptual framework for the causes of malnutrition was considered (Fig.  1 ). It was expected that factors such as age, gender, household size, occupation, and sanitation facilities were associated with the malnutrition among children in HHF.

UNICEF conceptual framework for the causes of malnutrition (Adapted from Mason, 2003)

The study used the data from 8th National Nutrition Survey (NNS) conducted by the Food and Nutrition Research Institute, Department of Science and Technology (FNRI-DOST) in 2013. The NNS was conducted in 79 provinces, 45,047 households and 172,323 individuals, adopting the 2003 master sample developed by Philippine Statistics Authority (PSA) [ 9 ]. A stratified multi-stage sampling design for household-based surveys covering all the 17 regions, including the National Capital Region was used.

The 2013 NNS used the four subsample or replicates of the master sample for its anthropometry component. There were 13,423 young children ages 0–60 months (0–5.0 years old) and 16,398 schoolchildren ages 61–120 months (5.08–10.0 years old) participated in the survey. The World Health Organization-Child Growth Standards (WHO-CGS) [ 10 ] was used to assess the nutritional status of young children, while WHO Growth Reference 2007 [ 11 ] was used for schoolchildren.

A written informed consent was obtained from all the participants of this study through the mother or guardian. Ethical clearance was provided by the FNRI Institutional Ethics Review Committee (FIERC).

To analyze the nutrition situation of the fisherfolks in the Philippines, the households were categorized into occupational groups based on the 1992 Philippine Standard Occupational Classification (PSOC) of PSA [ 12 ]. Descriptive statistics was employed to summarize data on the prevalence of malnutrition among young children and schoolchildren in different occupational groups including the fisherfolks. Logistic regression and multinomial logistic regression analyses were used to determine the association of variables to underweight, stunting, and overweight or obesity among children 0–5 years and 6–10 years children. Statistical analysis was conducted using Stata version 12.0.

The prevalence of malnutrition among Filipino children ages 0–60 months (0–5.0 years old) by occupational group in the Philippines is summarized in Table  1 . Results showed that stunting (30.3%) was the most prevalent malnutrition among children of this age group in the country, followed by underweight (19.9%). The prevalence of stunting and underweight in this age group are considered high based on the 1995 WHO cut-off for public health significance [ 13 ]. On the other hand, the prevalence of wasting among this age group was 7.9%. The prevalence of overweight was 5.0%.

The young children in household headed by fisherfolks (HHF) had higher prevalence of malnutrition compared to the overall prevalence of malnutrition among young children in the Philippines, except for overweight. The magnitude of underweight (26.4%), stunting (37.7%) and wasting (11.2%) were all alarmingly high and pose as serious public health concerns. The HHF had lower prevalence of overweight (3.2%) compared to the overall prevalence of overweight among young children in the Philippines.

Among the occupational groups, young children in HHF had the highest prevalence of underweight, stunting and wasting next to children belonging to household headed by forestry and related worker. They also had the lowest prevalence of overweight among all occupational groups.

The prevalence of malnutrition among Filipino children ages 61–120 months (5.08–10.0 years old) by occupational group in the Philippines is summarized in Table  2 . Findings showed that stunting (29.9%) is the foremost form of malnutrition that is prevalent among schoolchildren in the Philippines followed by underweight (29.1%). However, unlike the observation on the young children, the prevalence of overweight (9.1%) among schoolchildren was higher compared to the prevalence of wasting (8.6%).

Among HHF, underweight (39.9%) and stunting (39.9%) were the primary forms of malnutrition among schoolchildren. Compared to other occupational groups, schoolchildren in the fishing communities had the highest prevalence of underweight. Furthermore, the prevalence of underweight among fisherfolks was even higher compared to the prevalence of underweight among all schoolchildren in the Philippines (29.1%).

The prevalence of stunting among HHF was also higher compared to the prevalence of stunting among all schoolchildren in the Philippines (29.9%). However, compared to other occupational groups, schoolchildren in HHF had the highest prevalence of stunting next to forestry and related workers (43.3%) and farmers and other plant growers (40.1%).

Moreover, there was the same magnitude of wasting among all schoolchildren in the Philippines (8.6%) and those in fishing communities (8.6%). The magnitude of wasting among schoolchildren in fishing communities was also relatively high compared to the prevalence of wasting in other occupational groups.

Fisherfolks had lower prevalence of overweight among schoolchildren (4.0%) compared to the prevalence of overweight among all schoolchildren in the Philippines (9.1%). They even had the lowest prevalence of overweight among other occupational groups, next to forestry and related workers (2.6%).

With the other variables were held constant, logistic regression indicated that both stunting and underweight were influenced by the same variables. Older children (OR = 1.03; OR = 1.11), male gender (OR = 1.15; OR = 1.08), larger household (HH) size (OR = 1.08; OR = 1.07), and the occupation of the HH head, specifically fishermen (OR = 1.36; OR = 1.44) and farmers (OR = 1.51; OR = 1.32), increases the risk for stunting and underweight respectively. While older age of the HH head (OR = 0.99; OR = 0.99) and the use of water sealed toilet (OR = 0.57; OR = 0.59) manifested a protective effect on the nutrition status. Wasting or thinness was also correlated to gender of child but was not correlated to households headed by fishermen and farmer. For overweight and obesity, older children (OR = 0.93), household size (OR = 0.96), and the occupation of the household head, fishermen (OR = 0.71) and farmer (OR = 0.77) were found to decrease its risk while the use-of water-sealed toilet (OR = 1.29), gender (OR = 1.08) and age of household head increases it. Details were shown in Table 3 .

The present study showed that malnutrition is highly prevalent among children in HHF. Colds and cough, diarrhea, skin infections and asthma, sore eyes and various intestinal parasites are the common illness among children livisdng in coastal rural areas [ 14 , 15 ]. These kinds of illnesses affect the growth and nutritional status of children [ 16 ]. Perhaps, the nutritional status of children in HHF was compromised due to their poor health caused by their living environment.

Another factor that affects the nutritional status of children living in the coastal areas is the high risk of extreme events, such as typhoons and tsunamis [ 3 ]. In the Philippines, many families lost their livelihood, especially the famers and fishers, when typhoon Yolanda/Haiyan visited the country. The typhoon also damaged the means of transportation (i.e. boats) of people living in far flung areas. Because of this, they experienced difficulties going to city proper or mainland where most of the evacuation areas are located and relief goods are distributed making them to go on up to four days without food. As a result, malnutrition among children increased because of difficulties in accessing nutritious foods. It has been reported that 1.5 million children were identified as at risk of acute malnutrition [ 17 , 18 ].

Household socioeconomic status remains to be crucial determinant of nutritional status of children. Children in the poorest quintile had worse nutritional status than the ones from the richest group [ 19 ]. Thus, with HHF being the poorest sector in the country, the prevalence of undernutrition among fisherfolks may be due to their low economic capacity that limits their access to food and nutrition.

However, while poverty is a strong determinant of undernutrition among young children, it may not be true for schoolchildren. A study suggests that poverty is predictive factor to the poor nutrition among young children but not to the nutritional outcomes among schoolchildren [ 20 ]. On the other hand, factors such as household food insecurity, low maternal education and poor health are stronger predictor for the undernutrition of schoolchildren [ 21 ].

Furthermore, women in fishing communities often engage in economic activities to complement men’s decreasing income. In some areas, this results to substantial reduction in breast-feeding when mothers resumed their economic activities soon after delivery. Consequently, the quality of nutrition provided to the young children is compromised [ 22 ]. Moreover, various factors were also observed that are contributing to the nutritional status of schoolchildren. Quality of food intake, food availability, household size, literacy of person in charge of food preparation and household head are some of the factors associated to the nutritional status of schoolchildren. Food availability and nutrition education on balanced diet, food production and consumption are necessary, although not sufficient, to improve the nutritional status of schoolchildren [ 23 ].

Perhaps, in the case of fisherfolk communities in the Philippines, the living condition of this occupational group coupled with poor health, high risk to extreme events, poverty and poor quality of diet may have contributed to the occurrence of various forms of undernutrition among young and school-aged children.

On the other hand, along with high prevalence of undernutrition, overnutrition was also observed among young children in fishing community in the Philippines. Generally, overweight among young children is usually attributed to excessive calorie consumption and low calorie expenditure. The increased consumption of more energy-dense, nutrient-poor foods with high levels of sugar and saturated fats, together with reduced physical activity, have led to obesity rates that have increased three-fold or more since 1980 [ 24 ]. However, these reasons may be unlikely in poor households. A study suggests that overweight among young children in food insecure households may be due to other potential factors linked to obesity, like low activity levels and excessive television watching [ 25 ].

Moreover, overweight among children observed in coastal areas may be due to geographical disparities in terms of income. One study observed that those in coastal area with high economic status exhibited increase in the prevalence of overweight and obesity than those in other areas with less economic development [ 26 ]. Perhaps, in the present study, the overweight children in HHF may be located in coastal areas with high economic status.

Looking into the prevalence of malnutrition among children in HHF, it can be observed that there is a low prevalence of overweight and high prevalence of underweight, stunting and wasting children. This scenario can be attributed to limited access of children to high-calorie snacks and fast food which are hardly affordable. Thus, there are only few who are identified to overweight. Another plausible explanation given is that the children may have been engaged in a more physically demanding activities compared to their contemporaries [ 27 ].

Based on the results of the present study, there is a need for immediate action to intervene in the magnitude of undernutrition among this occupational group with priority on the needs of children. Young children are more prone to poor nutrition and health conditions than adults. Poor nutrition among children of this age could not only contribute to increased likelihood of contracting serious illnesses but may also have a permanent effect on their health and development [ 28 ].

In addition, aside from the direct welfare and financial costs of illness due to poor nutrition, schoolchildren with poor health can also grow up as an adult with poor lower health status with less education which in turn could result to intergenerational transmission of poverty [ 29 ]. Childhood undernutrition exposure has permanent socioeconomic and health consequences. These consequences may include metabolic and cardiovascular diseases, reduced learning ability, lowered years of schooling and intellectual performance in adulthood, reduced working ability, productivity and income, poor quality of life and overall poverty that could be transferred to the future generations [ 22 ].

Thus, investing in the nutritional status of young children and schoolchildren in HHF could break the cycle of poverty in this occupational group. Alleviating the poverty has been a challenge for the longest time now and starting from the poorest of the poor sectors in the country should be a good start.

Findings showed that young children in HHF had higher prevalence of malnutrition compared to the overall prevalence of malnutrition among young children in the Philippines, except for overweight. This is also true for schoolchildren in HHF, except for wasting. It also identified that fisherfolks were one of the occupational groups with highest malnutrition among young and school-aged children. The high magnitude of public health concern in terms of underweight, stunting and wasting among these age groups pose an immediate and serious need for action, prioritizing the nutritional needs of this occupational group.

Various factors could affect the nutritional status of children in fishing communities. Food security, socio-economic capacity, availability of health services, environmental sanitation and geographical disparity in terms of economic development are some of the factors that should be considered in formulating and prioritizing in nutrition programs for children in this occupational group. Possible interventions should include health and nutrition education program that advocates the promotion of children’s nutrition at home, physical activity, capacity building, sanitation and hygiene in the community. A national focus on the health, nutrition and welfare of fisherfolks is highly recommended.

Furthermore, forestry and related workers is another occupational group that exhibited alarmingly high prevalence of malnutrition among young and school-aged children. Perhaps, for future studies, it would be an interesting topic to explore and understand the determining factors of malnutrition in this occupation group.

Abbreviations

Annual Poverty Indicators Survey

FNRI Institutional Ethics Review Committee

Food and Nutrition Research Institute, Department of Science and Technology

households headed by fisherfolks

National Disaster Risk Reduction and Management Council

National Nutrition Survey

Philippine Statistics Authority

Philippine Standard Occupational Classification

World Health Organization-Child Growth Standards

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Acknowledgements

The authors would like to express their sincere gratitude to the children and their parents/guardians for being part of the study. The authors would also like to thank the WorldFish Philippines for funding this study.

This study was funded by the WorldFish Philippines. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Capanzana, M.V., Aguila, D.V., Gironella, G.M.P. et al. Nutritional status of children ages 0–5 and 5–10 years old in households headed by fisherfolks in the Philippines. Arch Public Health 76 , 24 (2018). https://doi.org/10.1186/s13690-018-0267-3

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Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems

Samuelina s. arthur.

1 INDEPTH Network, Accra, Ghana

2 Department of Demography and Population Studies, University of the Witwatersrand, Johannesburg, South Africa

Bongiwe Nyide

3 Library Department, Systems and Technical Services, Mangosuthu University of Technology, Umlazi, Durban, South Africa

4 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa

Abdramane Bassiahi Soura

5 Ouagadougou HDSS, ISSP, University of Ouagadougou, Ouagadougou, Burkina Faso

Kathleen Kahn

6 MRC Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

7 Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

Mark Weston

8 Independent Consultant, Mwanza, Tanzania

Osman Sankoh

9 School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

10 Faculty of Public Health, Hanoi Medical University, Hanoi, Vietnam

Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs).

Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords ‘nutrition’, ‘malnutrition’, ‘over and under nutrition’, we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight papers were identified and reviewed, and 67 were selected for this study.

The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition.

Conclusions

Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

Nutrition has been defined as the ‘science of food, the nutrients and other substances therein, their action, interaction and balance in relation to health and disease, and the processes by which the organism ingests, absorbs, transports, utilises and excretes food substances’ ( 1 ).

In low- and middle-income countries (LMICs) studies of nutrition generally focus on malnutrition, defined by the World Health Organization (WHO) as ‘inadequate or excess intake of protein, energy and micronutrients such as vitamins, and the frequent infections and disorders that result’ ( 2 ). It is estimated that globally 2 billion people suffer from malnutrition ( 3 ), and this has been recognised as a leading cause of death, disability, and ill-health ( 4 ). Malnutrition is consequently the most important risk factor for the burden of disease in developing countries ( 5 ).

The long-term impact of malnutrition cannot be overemphasised ( 6 – 9 ). Such effects have severe consequences for individuals and families, dampening economic growth and poverty reduction. Currently, the commitment by developing countries and international bodies to address the problem of malnutrition – especially child under-nutrition – has never been higher ( 10 , 11 ). Nutrition has consequently been elevated up the global development agenda, as the era of the post-Millennium Development Goals approaches. Synthesised research on key findings is needed to inform researchers and policy-makers of new evidence and knowledge as well as about neglected areas and gaps in nutrition research. This will help inform policy formulation aimed at addressing malnutrition. This paper highlights the contribution made by a longitudinal platform, the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH), to nutrition research in LMICs.

The member centres of INDEPTH have played an important role in their efforts to measure the prevalence of nutritional disorders, understand their determinants and effects, and assess the effectiveness of interventions to tackle the problem ( 12 ). INDEPTH is a network of 49 health and demographic surveillance systems (HDSSs) based in Africa, Asia, and the Pacific region. Its member centres use longitudinal data, collected through regular visits to all households in a geographically defined area, to address the gaps in information on population health in LMICs. The HDSSs monitor new health threats; track population changes via fertility rates, death rates and migration; and measure the impact of policy interventions on communities. They aim to provide information that helps policy-makers to make informed decisions that adapt to changing conditions. While each centre contributes locally or nationally, as a network, INDEPTH has the potential to make global contributions.

In Africa and Asia, the HDSS centres have examined the problem of malnutrition using various methods, including cohort studies, nested surveys, case–control studies, qualitative focus group discussions, key informant interviews, literature reviews, clinical trials, and the testing of diagnostic tools. The centres have also developed and tested measurement and screening tools to facilitate a more accurate diagnosis of nutritional problems and to draw a more robust picture of food intake patterns in low- and middle-income settings.

In this paper, we review studies of malnutrition conducted by HDSSs published in peer-reviewed English language journals, and we outline the key findings reported by INDEPTH member centres and discuss their implications for future nutrition policy. This study includes 67 published papers on malnutrition between 1998 and 2013, covering nine countries in Africa and four in Asia.

Standard systematic review methods by Higgins and Green ( 13 ) and the Centre for Reviews and Dissemination, York, United Kingdom, were used ( 14 ). Relevant publications titles (related to malnutrition studies) from the member research centres of INDEPTH were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords ‘nutrition, malnutrition, and over and under nutrition’, publications were selected that were based only on data generated through research which used the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight papers were identified and independently reviewed by the authors and 67 were selected for this study.

This paper deals with five tropical issues: The problem of malnutrition as manifested in member centres' demographic surveillance areas, including the prevalence of malnutrition and population groups most affected; the biological and social determinants of malnutrition; the effects of malnutrition; the interventions that have attempted to tackle malnutrition; and concludes with discussion and policy and research recommendations ( Fig. 1 ).

Diagram showing how the papers were selected for the study.

The problem of malnutrition

Under-nutrition.

Insufficient or inadequate food intake – be it from lack of quantity or lack of essential nutrients including protein and specific micronutrients – remains a blight across the developing world. Under-nutrition can have effects throughout the life cycle. Physical stunting (defined by the WHO as low height-for-age) can affect cognitive development, increase susceptibility to infection, and impair school attainment and future productivity of survivors as well as of later generations. Deficiencies in iron, iodine, zinc, and vitamins can cause problems ranging from brain damage to blindness, anaemia, and stunted growth. Being underweight makes it harder to fight off infection and recover from illness, and harder to study and work.

Inadequate food intake in the early years of life is particularly damaging. In a cohort survey of children at Nouna HDSS in Burkina Faso, the authors found a reduction in underweight prevalence from 40% in June 1999 to 35% in June 2009 and from 43% in December 1999 to 34% in December 2009. The prevalence for wasting and severe wasting prevalence remained high in under-five children ( 15 ). In a 2010 study by Agincourt HDSS in rural South Africa, stunting was found in approximately 20% of children aged 1–4 years, and in almost one-third of those aged 1 year ( 16 ). In the same area in 2003/04, a case–control study, which aimed to determine risk factors for severe child malnutrition in Agincourt, found that 45% of controls under 5 years were stunted ( 17 ). Despite high levels of HIV in hospitalised cases, the persistence of more traditional risk factors indicated the need for interventions that concurrently target household socio-economic status, food security, education, feeding practices, and access to health and social services.

Being undernourished poses great risk for infants. A cohort study by researchers at the Nouna HDSS in Burkina Faso found that children aged between 6 and 30 months who were malnourished were more than twice as likely to die during the seven-month research period than other children ( 18 ).

Adult under-nutrition receives less attention than under-nutrition affecting children, but a population-based study at the Purworejo HDSS in Java, Indonesia, found that 15% of adult women were classified as suffering from chronic energy deficiency resulting from insufficient food intake ( 19 ). A later study by the same centre found that many women began pregnancy with suboptimal nutritional status and that most did not gain enough weight during pregnancy to avert the risk of adverse health outcomes ( 20 ). Malnutrition in pregnant women can pose problems not only for the women themselves but also for their newborns. A study in West Kiang HDSS, Gambia, showed that nutritional rickets, a disease caused largely by vitamin D deficiency, the effects of which can include cardiac failure and hypoglycaemic seizures, was more prevalent in infants whose mothers had poor vitamin D status during pregnancy ( 21 ).

A study of 457 people aged 60 years and above in rural Bangladesh found that 50% of older adults had chronic energy deficiency, and 62% were at risk of malnutrition ( 22 ). The authors argued that if global targets to reduce world hunger are to be achieved, ‘it is important to recognise that a substantial proportion of the elderly population, particularly in low-income countries, is undernourished’ ( 22 ).

Overweight and obesity

Under-nutrition is not the only form of malnutrition. Overweight and obesity, caused by an over-consumption of calories relative to energy expended, has long been considered a problem only in high-income countries, but in recent years it has begun to emerge as a threat in poorer countries.

As countries grow wealthier, the intake of refined and fatty foods and foods of animal origin increases. In 2002, the WHO ranked being overweight as the fifth most serious risk factor underlying the disease burden in low-mortality developing countries. INDEPTH member centres have begun to track the rise of obesity in developing countries over the past decade and a half. In the study of adult women by the Purworejo HDSS in Indonesia, researchers found an obesity rate in 1997 of 14% and showed that the rate had increased by almost three percentage points over the previous 12 months ( 19 ). Gendered patterns exist in rural South Africa. One study showed that females aged 50 years and older in Agincourt were significantly more obese than males, yet there was no difference in the prevalence of hypertension between men and women ( 23 ).

A 2005 study of 3-year-old children in the Limpopo province of South Africa found that 22% were overweight and 24% were obese. Nineteen percent of children were found to have both stunted growth and obesity ( 24 ). In Agincourt, rural South Africa, Kimani-Murage et al. ( 25 ) investigated adolescent weight status and central obesity (measured by abdominal circumference) and found much higher rates of combined overweight and obesity and of central obesity among girls (15% for each) than among boys (4% of whom had combined overweight and obesity, and 2% central obesity). In that study, risk factors for overweight and obesity included high socio-economic status and a household head who had completed secondary education. For central obesity, the risk factors included age, having a mother aged 50 years or above, and having high socio-economic status. A study at Kanchanaburi HDSS in Thailand found that urban residence, affluence, and possession of a television were associated with higher rates of obesity ( 26 ). Under-nutrition, on the other hand, was associated with poverty. The studies on over-nutrition point to the impact of modernisation in transforming lifestyles and suggest that as countries develop economically, the risk of obesity may increase.

Like under-nutrition, over-nutrition can also have harmful impacts on health. A cohort study of 1,888 rural women in Bangladesh found that those with the highest body mass index (BMI) had a higher mortality risk than those with intermediate BMI ( 27 ). Table 1 displays key findings on under-nutrition and obesity.

Prevalence of under-nutrition and obesity: findings from INDEPTH studies

The determinants of malnutrition

Biological causes.

Under-nutrition does not only come about because of lack of food. Exposure to disease can increase the risks posed to health by under-nutrition.

In a study at the Agincourt HDSS in South Africa, Kimani-Murage et al. ( 28 ) found that children infected with HIV had significantly worse nutritional outcomes than their uninfected peers. In Gambia, HIV-positive children had significantly worse scores in terms of weight-for-age, height-for-age, and BMI than HIV-negative children ( 29 ). In mothers, too, HIV poses problems. Research at the Africa Centre in Kwazulu-Natal found that breastfeeding mothers in South Africa who were HIV-positive had poorer protein and micronutrient status than HIV-negative women ( 30 ). Mean serum concentrations of albumin, pre-albumin, folate, retinol, and haemoglobin were all lower in the group of 92 HIV-positive breastfeeding women than in a control group of 52 HIV-negative women. Filteau et al. ( 31 ) found that providing pregnant women who are HIV-positive with vitamin A supplementation may improve the gut function of their HIV-infected infants. They also found that vitamin A supplementation for HIV-infected infants may decrease gastrointestinal morbidity.

Nyakeriga et al. ( 32 ) found a significant relationship between malaria and subsequent underweight and stunting in children below the age of 2 years at the Kilifi HDSS in Kenya. However, the authors found no association between malaria and subsequent protein-energy malnutrition. A Kisumu HDSS study in Kenya showed that infants who had had malaria were more likely to have stunting, anaemia, and iron deficiency ( 33 ). On the other hand, researchers at Farafenni HDSS in Gambia found no association between malaria and subsequent malnutrition in children below the age of 5 years during the malaria season ( 34 ). In Nouna, Burkina Faso, anaemia was significantly associated with malnutrition but not with the frequency of malaria episodes or its prevalence ( 35 ). A Kilifi HDSS study identified hospital-acquired bacteraemia (nosocomial bacteraemia) as a significant risk factor for severe malnutrition. Nosocomial infections, the study authors wrote, ‘are largely unrecognised or undocumented as a health risk in low-income countries, but they are likely to become public health priorities as awareness of their occurrence increases and as other prominent childhood diseases are progressively controlled’ ( 36 ). Table 2 displays key findings on biological causes of malnutrition.

Biological causes of malnutrition: findings from INDEPTH studies

Social causes

INDEPTH member centres have extensively investigated the social factors that increase the risk of malnutrition in LMICs. Three major contributors have been identified.

The first is wealth. Families themselves recognise this as important. Focus group discussions among mothers in Gambia revealed that poverty is one of the key constraints preventing mothers from putting into practise their knowledge of child health and nutrition ( 37 ). In similar discussions in Kenya, mothers reported that financial constraints were the main cause of severe malnutrition in children, with mothers’ heavy workload and inability to generate income were also reported as key factors. Witchcraft and the violation of sexual taboos were among the other reported causes ( 38 ). Household wealth and community socio-economic status were significantly associated with childhood stunting in Nairobi, Kenya ( 39 ). The authors of this study posited that the community effect occurs because of the availability of social services, physical environment, and the wealth of individuals. In an earlier paper, the same authors showed that neighbourhood characteristics exert an influence on malnutrition independently of household wealth – ‘when basic socio-economic and health services are lacking in the poorest communities’, they observed, ‘families therein can hardly take advantage of their increased means, ability and knowledge in caring for their children’ ( 40 ). In Agincourt, rural South Africa, cases with severe malnutrition were from households with fewer assets and lower incomes, who were less likely to receive a social support grant or to have anyone employed, compared with control groups in the village ( 17 ). In the same area, Kimani-Murage et al. ( 25 ) observed four-fold higher odds of overweight for adolescent girls and two-fold higher odds for participants from households with the highest socio-economic status. The causes of childhood malnutrition have been studied more extensively than those of adult malnutrition, but there is evidence that wealth continues to play a part in nutritional status later in life. As a 1998 study at Matlab HDSS in Bangladesh showed, women aged 35 years and older from wealthier households were less likely to have chronic energy deficiency than poorer women ( 41 ).

Education is a second key factor. Children born to Nairobi mothers who had been educated to primary level had a 94% lower chance of stunting than those born to mothers with no education ( 42 ). In one study in Vietnam, birth weight and growth were statistically significantly and positively associated with economic conditions and the education of the mother ( 43 ). In another study however, mothers’ education level was associated with their children's stunting in early childhood ( 44 ). As with wealth, education continues to have repercussions for nutritional status later in life – in the above-mentioned study in Bangladesh, women over the age of 35 were half as likely to suffer chronic energy deficiency if they had had one or more years of education, than if they had had no schooling ( 41 ).

Linked to both wealth and education is the associated process of urbanisation. Five of the nutrition studies carried out by INDEPTH member centres between 1998 and 2013 demonstrate a link between urban residence and reduced malnutrition. In a study in FilaBavi, Vietnam, Nguyen et al. ( 45 ) found an association between household socio-economic status, education of the mother and birth weight. The Nairobi study ( 39 ) discussed above confirmed this finding, with urban children significantly less likely to be malnourished than rural children, while two studies in Senegal showed that rural adolescent girls who migrated seasonally to urban areas for work had improved nutritional status, as reflected in BMI, compared with girls who remained in villages ( 46 , 47 ). Although urbanisation appears to reduce the risk of under-nutrition, it may increase that of obesity. A study at Kanchanaburi HDSS in Thailand found that urban residence was associated with lower rates of under-nutrition in children, but also with higher rates of obesity ( 26 ). Household wealth was also associated with obesity.

One additional, yet less extensively studied social factor, which also appears to have an impact on nutrition, is paternal involvement in caring for children. Children in a study in South Africa whose fathers did not provide financial support were found to be at higher risk of malnutrition ( 48 ), while in Hanoi, Vietnam, children whose fathers took them to a medical facility to be immunised against childhood diseases were 1.7 times less likely to be underweight and stunted than other children ( 49 ). These points to the need for a multi-pronged response to the problem of malnutrition which has many causes ( Table 3 ).

Social causes of malnutrition: findings from INDEPTH studies

The effects of malnutrition

Obesity is a relatively new threat in LMICs and is, as yet, not generally widespread in these countries. Therefore in researching the effects of malnutrition, HDSS centres have largely focused their attentions on the problem of under-nutrition.

A study by the Kilifi HDSS in Kenya found that among children admitted to a rural district hospital, under-nutrition was a factor in half the in-hospital deaths and half the morbidity from severe diseases such as malaria, gastroenteritis, lower respiratory tract infection, HIV, and invasive bacterial disease ( 50 ). At West Kiang in Gambia, young adults born in the ‘hungry season’ – that is, the non-harvest season between July and December when less food is available – had 10 times higher mortality than those born in the harvest season ( 51 ). Conversely, two studies at Institut de Recherche pour le Developpement IRD HDSS in Senegal found that although child mortality in the rural Casamance region declined sharply between 1969 and 1992, infants’ nutritional status did not improve over the period, suggesting other factors such as vaccination were more important ( 52 , 53 ).

As well as increasing mortality, under-nutrition also impairs the development of those who survive it. In a study in Bangladesh, stunting in early childhood, which is in part the result of a combination of disease and under-nutrition, was found to be a significant predictor of stunting in adolescence ( 54 ). A four-country study covering Ethiopia, India, Peru, and Vietnam found that stunting in early childhood was associated with lower cognitive achievement in 5-year-old children ( 44 ). In infants and young children in Kenya, stunting is also associated with developing severe respiratory syncytial virus-associated pneumonia, and with lower respiratory tract infections from all causes ( 55 ).

The effect of under-nutrition on malaria outcomes is disputed in the literature. In a Kilifi HDSS study, Berkley et al. ( 56 ) found that malnutrition was associated with severe disease due to falciparum malaria. A cohort study at Farafenni HDSS in Gambia calculated that 51% of children with stunting subsequently experienced malaria during the malaria season, compared with 38% of children who were not stunted. The study authors concluded: ‘Our findings suggest that chronically malnourished children may be at higher risk for developing malaria episodes’ ( 34 ). On the other hand, Muller et al. ( 18 ), working at Nouna HDSS in Burkina Faso, found no association between protein-energy malnutrition and malaria morbidity, while a Kilifi HDSS study concluded that children with iron deficiency were less likely than other children to develop mild clinical malaria ( 32 ). Table 4 displays key findings on effects of malnutrition.

Effects of malnutrition: findings from INDEPTH studies

Tackling malnutrition

The role of breastfeeding.

Nutrition in infancy, as we have seen, is important to an individual's prospects of a good life. Breastfeeding has therefore been the subject of much analysis by nutrition researchers, who have assessed its benefits and analysed breastfeeding practices in LMICs.

Working at the Kintampo HDSS in Ghana, Edmond et al. ( 57 ) demonstrated for the first time that there is a causal link between early breastfeeding and declines in infection-specific neonatal mortality in infants aged between 2 and 28 days. Delayed initiation of breastfeeding until after the first day of life led to a 2.6 times higher risk of neonatal mortality as a result of infectious disease, while partial breastfeeding led to a 5.7 times higher risk. Researchers at Bandim HDSS in Guinea-Bissau found that children weaned early for reasons other than ‘being healthy’, including a new pregnancy, had higher mortality ( 58 ). Bahl et al. ( 59 ), meanwhile, found that non-breastfed infants had a 10-fold higher risk of dying than predominantly breastfed and exclusively breastfed infants, although there was no significant difference in risk between the latter two groups. This finding suggests that in areas where most women already predominantly breastfeed, breastfeeding promotion efforts should be directed at those who chose not to breastfeed or who partially breastfed. A case–control study by Saloojee et al. in rural South Africa ( 17 ) also found that risk factors for severe malnutrition included poor weaning practices.

The positive effects of breastfeeding have also been demonstrated in older children. Vohr et al. ( 60 ) found that extremely low birth weight babies who ingested breast milk while in the neonatal intensive care unit (NICU) had significantly higher scores in cognitive and behaviour tests at 18 months of age than similar non-breastfed NICU infants.

However, breastfeeding is not universally practised. Researchers at Nanoro HDSS in Burkina Faso who conducted a multi-centre study of women infected with HIV, highlighted the size of the task facing those engaged in breastfeeding promotion efforts. In sub-Saharan Africa, fluids other than maternal milk are often introduced within the first six months of life, notwithstanding WHO guidelines that recommend exclusive breastfeeding for the first six months (including where the mother is HIV-positive). Although 53% of women in the Nanoro study saw exclusive breastfeeding as the preferred feeding method, only 11% reported exclusively breastfeeding after previous pregnancies ( 61 ). Conversely, some mothers choose to prolong breastfeeding beyond the recommended duration, which has been found to be associated with reduced nutritional status and impaired growth. However, as Simondon and Simondon ( 62 ) and Simondon et al. ( 63 ) found in two studies conducted in Senegal, these consequences are a result not of prolonged breastfeeding itself, but of the fact that women prolong breastfeeding beyond 12 months for children who are undernourished and tend to wean well-nourished children. The authors surmised that this is a result of mothers’ awareness of the mortality risks to children following weaning.

Prevention efforts

A number of interventions to prevent or cure malnutrition have been tested by HDSS sites. The vast majority of the trials have focused on infants, children and women of childbearing age.

Efforts to tackle malnutrition in infants and children have met with mixed success. Studies by the Bandim HDSS in Guinea-Bissau of malnutrition campaigns during that country's 1998 civil war found that vitamin A supplementation for children ( 64 ) and a supplementary feeding programme for children ( 65 ) helped to reduce mortality during the conflict. Compared with the 3-year period before the war, the authors reported that children offered vitamin A at home during the war had a 12% reduction in mortality, whereas the overall impact of the war was an 89% increase in mortality.

In a randomised controlled trial in Vietnam, fortification with multiple micronutrients of biscuits provided in schools was found to reduce the risk of anaemia and of iron and zinc deficiencies by 40% ( 66 ). At Nouna HDSS in Burkina Faso, on the other hand, a randomised controlled trial to assess the effects of zinc supplementation on the growth of young children in an area with high rates of malnutrition found no significant impact on height-for-age, weight-for-age, and weight-for-height scores. The study authors concluded that zinc supplementation does not have an effect or public health importance on growth in West African populations of young children with a high prevalence of malnutrition, and that multi-nutrient interventions are likely to be more effective ( 67 ).

The effectiveness of vitamin A supplementation has also been questioned. Although it appeared to be beneficial in the above-mentioned trial in Guinea-Bissau, researchers at Kintampo HDSS in Ghana found no positive effect of vitamin A supplements in combination with vaccines during the first few months of life ( 68 ). This finding echoes the findings of similar trials in Peru and India. Fish oil supplementation, too, appears to have limited effects for infants. A study in Gambia found that fish oil had no effect on growth, intestinal integrity, morbidity, or cognitive development ( 69 ).

Only two studies investigated methods to treat children suffering from severe malnutrition. Current guidelines for treating children who develop shock as a result of severe malnutrition recommend using low-dose hypotonic fluid resuscitation. Working at the Kilifi HDSS in Kenya, Akech et al. ( 70 ) tested the safety and efficacy of this recommendation and found ‘universally poor’ outcomes in terms of persistent shock, oliguria, and high case fatality. The authors concluded that the low recommended dose was insufficient to correct shock and suggested that for future guidelines to be more effective, clinical investigation is needed to determine the appropriate volume and rate of dosage of isotonic fluids. Researchers at Agincourt HDSS, meanwhile, found that the introduction of WHO guidelines in two hospitals strengthened the management of malnutrition. The authors concluded that implementation of WHO guidelines on severe malnutrition was feasible, affordable, and sustainable ( 71 ).

Studies of malnutrition prevention campaigns for women of childbearing age also had mixed results. In Ghana, vitamin A supplementation was found to increase liver reserves of mothers during the postpartum period, with the effects persisting for at least five months ( 72 ). A study at Niakhar HDSS in Senegal found that providing high energy, nutrient-dense food supplements to infants aged between four and seven months contributed to decreased postpartum weight loss in their mothers ( 73 ). The supplements reduced the intake of breast milk and therefore the energy costs of lactation on mothers. It also increased the interval between births, thereby potentially having effects on fertility. As with supplements for children, a number of studies – all conducted at the West Kiang HDSS in Gambia – found that supplements of individual nutrients for women were ineffective. Hawkesworth et al. ( 74 ) found that nutrient supplementation during pregnancy had little effect on infants’ risk of cardiovascular disease. Another study found that protein-energy supplementation during pregnancy had no effect on the blood pressure of their children in adolescence ( 75 ), while a third study found that calcium supplementation for pregnant mothers had no effect on foetal and infant growth ( 21 ). A fourth West Kiang study found that calcium supplements could be harmful – women given calcium supplements while pregnant were found to have lower bone mineral content, bone area, and bone mineral density at the hip during the 12-month lactation period than other women. The authors surmised that such supplements may disrupt metabolic adaptation ( 76 ).

Two studies conducted by INDEPTH members in South Africa and Bangladesh addressed the problem of implementing nutrition programmes. In the first, at Dikgale HDSS, the majority of people with type 2 diabetes had poor glycaemic control and were obese or had high blood pressure. Quantitative and qualitative research showed that these patients were often given incorrect and inappropriate dietary advice by health educators ( 77 ). In the second study, researchers showed that agencies working to tackle a flood disaster in Bangladesh in 1998 had mixed results in terms of meeting international disaster response standards. Compliance with standards was variable. Preliminary nutritional analysis was one of the areas in which agencies performed poorly in this regard ( 78 ).

The state of research

Over the past 15 years, INDEPTH member centres have expanded the global knowledge base on nutrition. They have shown how under-nutrition continues to plague children and adults of all ages in LMICs and they have highlighted the emergence of obesity as a growing threat. In some areas, combined under-nutrition early in life with overweight and obesity in adolescence and adulthood, warns of rapidly escalating risk for cardiometabolic disease. The HDSS centres have demonstrated how malnutrition early in life continues to have effects on physical and mental development throughout the life-cycle. They have examined links between disease and malnutrition, and shown how wealth, education, and urbanisation all reduce the risks of under-nutrition but at the same time can increase the risks of obesity. The double burden of malnutrition in LMICs is of major concern to the World Bank, the WHO, and other international bodies.

In terms of tackling malnutrition, INDEPTH members have demonstrated the importance of breastfeeding for infant nutrition and health, and for the health of the infants as they grow older, and they have assessed the reasons why some women choose not to breastfeed or to wean infants too early or too late. Interventions such as micronutrient supplementation for children and their mothers can have beneficial impacts on child health and survival, with some studies suggesting that multiple micronutrient supplementation may be more effective than supplementation with single micronutrients ( Table 5 ).

Tackling malnutrition – prevention efforts: findings from INDEPTH studies

Nutrition is something of an under-researched field; however, over the period 1999–2013, INDEPTH member centres produced almost four times as many published papers on HIV/AIDS as they did on nutrition. Many issues remain unresolved – for example, the impact of malaria on malnutrition and of malnutrition on susceptibility to malaria. There was little attention paid to nutrient supplements or to education and information campaigns to help families improve their diet, while activism campaigns to encourage companies to label foods accurately or to reduce sugar or fat content received no attention from HDSS centres. Likewise, the economic benefits of nutrition interventions also received little attention from HDSSs. One study by the Africa Centre calculated the costs of adding nutritional supplementation to the management of HIV-infected children ( 79 ), but studies on the cost-effectiveness of nutrition programmes were lacking.

Policy implications

In this review, we noted the importance of adopting a multi-pronged approach to tackling malnutrition. Countries including Vietnam and South Africa have had some success in reducing malnutrition in recent years. Researchers at Kaya HDSS in Burkina Faso carried out a nine-site study to assess the impact of United Nations Millennium Project guidelines to reduce child stunting. This holistic approach incorporated nutrition-specific, health-based interventions with food system and livelihood-based approaches, and its adoption reduced stunting in children by up to 43% over 3 years ( 80 ). Programmes in Vietnam to increase nutrition, particularly via animal-source foods, have also been successful in reducing under-nutrition in children and chronic energy deficiency in women ( 81 ), but otherwise investigations of nationwide or multi-pronged nutrition programmes have not been extensively studied by HDSS centres. Lessons from other countries on how to reduce malnutrition may be a useful guide for policy-makers who are attempting to tackle the problem in their own countries.

Although a small number of studies have examined the success of efforts to implement nutrition programmes, there is a need for further investigation in this area. How to effectively change dietary habits, how to educate individuals in LMICs about the availability of healthy natural foods, how to improve compliance with food supplementation programmes, and how to train health workers to provide useful nutrition advice and effective treatment for nutrition problems, are just a few of the many implementation challenges that remain.

The INDEPTH HDSSs have unearthed important findings over the past decade and a half – for example, the vital role of breastfeeding in promoting infant and child health, the benefits of multiple micronutrient supplementation, the under-appreciated prevalence of malnutrition in adults and the elderly, and the rise of obesity in lower-income settings. Although much knowledge generation has already been achieved, there is broad scope for future research to inform policy-makers and researchers on ways to tackle the double burden of malnutrition in order to have a major impact on policy and on the lives of people living in LMICs.

Acknowledgements

We thank all INDEPTH member centres for submitting to the Secretariat all their published papers that are based on the HDSS platform for the period 1998–2013.

Conflict of interest and funding

Samuelina S. Arthur is a research fellow at INDEPTH Network; Bongiwe Nyide was a librarian at INDEPTH Network during the time this paper was written; Abdramane Bassiahi Soura is a member of the INDEPTH Network Board of Trustees and the leader of Ouagadougou HDSS in Burkina Faso, a member of INDEPTH Network; Kathleen Kahn is a scientist at Agincourt HDSS in South Africa, a member of INDEPTH Network; and Osman Sankoh is the executive director of the INDEPTH Network. Osman Sankoh is funded by core support grants from Sida/Research Cooperation Unit, The Wellcome Trust, and The William and Flora Hewlett Foundation. Samuelina S. Arthur is funded by INDEPTH Sexual and Reproductive Health project supported by The William and Flora Hewlett Foundation.

Authors' contributions

All the authors contributed to drafting, analysing, reviewing, and finalising this manuscript.

A qualitative study on malnutrition in children from the perspectives of health workers in tumpat, kelantan

Affiliation.

• 1 Department of Community Medicine and Public Health, Universiti Malaysia Sarawak.
• PMID: 22692186

Underlying causes of most nutrition related problems are diverse, including biological, social, cultural, and economic factors. Qualitative approaches complement quantitative methods in identifying the underlying meanings and patterns of relationships involved in managing malnutrition. This study examined perceptions regarding malnutrition among health workers from 7 clinics (community and health clinics) in Tumpat, Kelantan. A total of 18 nurses and 2 doctors, who were involved in monitoring child health and nutrition, were included in the study. These health workers were interviewed using a semi-structured questionnaire adapted from Sastry's framework on malnutrition (Sastry, 1996). The questionnaire included biological, behavioral and environmental factors that influence child health and nutrition. All the health workers perceived that mothers/caregivers play the main role in improving the health of malnourished children. The quality of childcare was rated as moderately satisfactory by the health workers. Most of the affected families who were given the Food Baskets did not fully use all the items for the malnourished child. Child feeding practice was based on the needs of the whole family rather than according to the target child's needs. Most of the mothers preferred processed cereals than rice porridge because the former is easier to prepare for the child. Although they were from a low socioeconomic background, most of the mothers were not earning additional income for the family. The qualitative methodology provided information that can be used as a basis for the designing of quantitative questionnaires to assess malnutrition among children. The induction characteristic of qualitative methods was used to gain an understanding of the underlying reasons or phenomena such as behaviours that are directly observable.

This paper is in the following e-collection/theme issue:

Published on 6.6.2024 in Vol 26 (2024)

Physician Perspectives on Internet-Informed Patients: Systematic Review

Authors of this article:

• Qianfeng Lu 1 , MSc   ; 
• Peter Johannes Schulz 1, 2, 3 , PhD  

1 Faculty of Communication, Culture and Society, Università della Svizzera italiana, Lugano, Switzerland

2 Department of Communication & Media, Ewha Womans University, Seoul, Republic of Korea

3 Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore, Singapore

Corresponding Author:

Peter Johannes Schulz, PhD

Faculty of Communication, Culture and Society

Università della Svizzera italiana

Via Buffi 13

Lugano, 6900

Switzerland

Phone: 41 586664724

Email: [email protected]

Background: The internet has become a prevalent source of health information for patients. However, its accuracy and relevance are often questionable. While patients seek physicians’ expertise in interpreting internet health information, physicians’ perspectives on patients’ information-seeking behavior are less explored.

Objective: This review aims to understand physicians’ perceptions of patients’ internet health information-seeking behavior as well as their communication strategies and the challenges and needs they face with internet-informed patients.

Methods: An initial search in PubMed, Scopus, CINAHL, Communication and Mass Media Complete, and PsycINFO was conducted to collect studies published from January 1990 to August 1, 2022. A subsequent search on December 24, 2023, targeted recent studies published after the initial search cutoff date. Two reviewers independently performed title, abstract, and full-text screening, adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines. Thematic analysis was then used to identify key themes and systematically categorize evidence from both qualitative and quantitative studies under these themes.

Results: A total of 22 qualifying articles were identified after the search and screening process. Physicians were found to hold diverse views on patients’ internet searches, which can be viewed as a continuous spectrum of opinions ranging from positive to negative. While some physicians leaned distinctly toward either positive or negative perspectives, a significant number expressed more balanced views. These physicians recognized both the benefits, such as increased patient health knowledge and informed decision-making, and the potential harms, including misinformation and the triggering of negative emotions, such as patient anxiety or confusion, associated with patients’ internet health information seeking. Two communicative strategies were identified: the participative and defensive approaches. While the former seeks to guide internet-informed patients to use internet information with physicians’ expertise, the latter aims to discourage patients from using the internet to seek health information. Physicians’ perceptions were linked to their strategies: those holding positive views tended to adopt a participative approach, while those with negative views favored a defensive strategy. Some physicians claimed to shift between the 2 approaches depending on their interaction with a certain patient. We also identified several challenges and needs of physicians in dealing with internet-informed patients, including the time pressure to address internet-informed patient demands, a lack of structured training, and being uninformed about trustworthy internet sites that can be recommended to internet-informed patients.

Conclusions: This review highlights the diverse perceptions that physicians hold toward internet-informed patients, as well as the interplay between their perceptions, communication strategies, and their interactions with individual patients. Incorporating elements into the medical teaching curriculum that introduce physicians to reliable internet health resources for patient guidance, coupled with providing updates on technological advancements, could be instrumental in equipping physicians to more effectively manage internet-informed patients.

Trial Registration: PROSPERO CRD42022356317; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=356317

Introduction

The internet has become a common resource for people seeking health-related information [ 1 , 2 ]. It offers a vast array of health information that was previously accessible mainly through physicians. Over the past decade, attention to internet health information–seeking behavior among patients has grown. The idea of patients searching for information on the internet can be traced back to Ferguson [ 3 ], who coined the term e-patients in 2007 for those seeking health information on the internet.

People seeking health information on the internet may have different purposes [ 4 ]. Before seeing a physician, they might search on the internet to determine if a medical appointment is necessary. Once a consultation is scheduled, some patients look for background information to better prepare for their appointments [ 5 ]. After consultations, some turn to the internet to clarify and supplement the physician’s information, such as details about medication indications and side effects [ 6 ]. These patients seek internet health information to better understand their diagnosed condition and manage their treatment [ 7 ]. Being equipped with knowledge from the internet, they are often referred to as internet-informed patients [ 8 ].

Some patients intentionally avoid information from the internet. For instance, information avoidance among cancer patients has been frequently explored by researchers [ 9 , 10 ]. However, several systematic reviews from patients’ perspectives conclude that patients often feel more confident discussing their health with physicians and feel more empowered to manage their conditions after searching for information on the internet [ 11 - 13 ]. Internet health information allows patients to transition from being passive and uninformed recipients to empowered and informed consumers [ 14 , 15 ].

However, searching for health information on the internet poses challenges for both patients and the health care system. The vast amount of internet health information can be overwhelming for laypeople, who might find it difficult to sift through and identify relevant and accurate content. Consequently, patients may end up learning mis- and disinformation or become confused by conflicting information they encounter on the internet [ 16 , 17 ]. Seeking internet health information can exacerbate patients’ anxiety about their health [ 18 , 19 ]. In contrast, physicians can provide accurate and personalized information, which can reassure patients. This becomes particularly vital in cases where patients, having been misinformed by internet sources, are taking active steps to manage their health [ 20 ].

Although the internet has become a popular source for accessing health information, consultations with physicians remain the primary influence on patients’ medical decisions [ 21 ]. Patients have various strategies for addressing the internet health information they gather before a consultation. They might either implicitly or explicitly share this information, hoping the physician will consider it in their judgment [ 22 ]. However, some may withhold it, fearing it might upset their physician [ 13 ]. A significant barrier to such disclosure is the concern that the physician might perceive it as a challenge to their expertise [ 23 ]. Many patients are cautious about revealing internet information to their physicians to avoid causing offense [ 24 ]. As a result, they often assess the physician’s potential reactions to such information before deciding whether to share it [ 25 ]. Research has shown that dialogue about internet information between patients and physicians can improve patient satisfaction and their relationships. This improvement is particularly noticeable when physicians acknowledge the patients’ efforts and take their internet-sourced information seriously [ 26 ].

The physician-patient relationship is dyadic, meaning it is built on mutual trust and efficient communication at its core [ 27 ]. Patients often access health information through the internet and approach physicians with a desire to seek clarification and advice [ 28 ]. Discussing internet health information offers a new communication opportunity, allowing for physicians to better understand their patients’ preferences and concerns and for patients to deepen their trust in their physicians. To maximize this communication opportunity, understanding the perspectives of both parties, that is, physicians and internet-informed patients, is crucial. However, while much of the literature focuses on internet-informed patients, there is less emphasis on physicians’ perspectives [ 29 ]. Several reviews have explored patients’ internet health information–seeking behavior and its impact on the physician-patient relationship [ 11 , 13 , 14 , 30 , 31 ]. Nonetheless, these reviews primarily focused on patients, with evidence collected mainly from the patient’s viewpoint.

To the best of our knowledge, this is the first systematic review focusing on physicians’ perspectives. We aimed to explore physicians’ views on patients’ internet information–seeking behavior and their experiences with internet-informed patients. Our research questions (RQs) are elaborated as follows:

• RQ1: how do physicians perceive patients’ internet health information–seeking behavior?
• RQ2: what communicative strategies do physicians use in interacting with internet-informed patients? In this context, the term strategies refers to physicians’ actions and responses to internet-informed patients.
• RQ3: what difficulties and needs do physicians encounter when dealing with internet-informed patients?

Search Strategy

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [ 32 , 33 ].

To identify the appropriate search algorithm, we undertook 3 steps. In the first step, we conducted an exploratory search using various combinations of terms such as physician , communication strategies , internet-informed patients , and physician-patient communication . Upon reviewing the reference lists of several primary articles identified from the exploratory search, we discerned 12 articles that were deemed relevant to this review. In the second step, we structured 3 blocks of keywords, each representing a facet of the RQs: physicians as the target population (block 1), patients’ health information behavior (block 2), and physicians’ perspectives or communication strategies with internet-informed patients (block 3; Textbox 1 ). Each block encompasses a set of synonyms and related Medical Subject Heading (MeSH) terms tailored to represent the aspect of the RQs under consideration. For instance, the patients’ health information behavior (block 2) includes terms like internet-informed patients , health-related internet use , e-patients, internet information , eHealth , health information search , internet health information , and online health information . Within each block, synonymous terms and related MeSH terms were amalgamated using the OR operator. The 3 blocks were then combined with the AND operator. We used truncations to widen our search and set abstract or title limiters to circumvent the retrieval of an overwhelming number of results in several databases. This combination of terms was used across several platforms: PubMed, Scopus, CINAHL, Communication and Mass Media Complete, and PsycINFO.

Block 1: physicians

physicians, doctors

Block 2: patients’ health information behavior

internet-informed patients, health-related internet use, e-patients, internet information, eHealth, health information search, internet health information, online health information

Block 3: physicians’ perspectives or communication strategies with internet-informed patients

doctor–patient relation, physician-patient relation, physician-patient communication, doctor–patient communication, experience, attitude, strategy, belief

The first search was conducted in August 2022, and we initially restricted our search to the time frame from January 1, 1990, to August 1, 2022. All search outcomes were cataloged in a data set for subsequent screening. Before this screening, we assessed the effectiveness of our search algorithm by seeking out the 12 articles initially pinpointed from the exploratory search. All 12 articles were successfully located via our search algorithm, affirming its adequacy. We then performed a second search on December 24, 2023, using the same combination of keywords in the 5 databases used for the first search. The second search was conducted to collect studies published after August 1, 2022, the cutoff date for the first search. Multimedia Appendix 1 provides a detailed overview of the search algorithm and the total number of results obtained from each database.

Inclusion and Exclusion Criteria

We included empirical qualitative, quantitative, and mixed methods studies that assessed physicians’ perspectives on patients’ internet health information–seeking behavior and their communication with internet-informed patients. A physician is defined as a medical doctor, either a specialist or a general practitioner (GP). This review focuses on physicians attending to physical health conditions. Studies had to be published in a peer-reviewed journal after 1990 and be written in English. We chose 1990 as the starting year because public access to the internet was not available before then. We did not consider the impact factor of the journals or their peer-review process. If a study covered multiple populations, such as physicians, nurses, and patients, we only considered those presenting the results for physicians separately from other groups. Textbox 2 lists the inclusion and exclusion criteria.

Inclusion criteria

• Study topic: physicians’ perspectives regarding patients’ internet health information–seeking behavior
• Study populations: medical doctors who are attending to physical health conditions
• Study type: empirical studies using qualitative, quantitative, or mixed methods
• Language: written in English
• Publication year: published after the year 1990

Exclusion criteria

• Study topic: physicians’ perspectives in contexts unrelated to patients’ internet health information seeking, such as telemedicine, digital devices, electronic health records, and physicians’ own internet information–seeking behavior and social media use
• Study populations: nonmedical doctors or psychiatrists specializing in areas other than physical health
• Study type: reviews, evidence syntheses, study protocols, reports, book chapters, or any forms of gray literature
• Language: written in languages other than English
• Publication year: published before the year 1990

Studies Identification

The first author (QL) and a research assistant independently assessed the titles and abstracts of these articles based on the inclusion and exclusion criteria. Any disagreements in selection were discussed with another author until a consensus was reached. Full-text screenings were performed by 2 authors independently, and any discrepancies were resolved through discussion.

Data Analysis

A thematic analysis was conducted to identify prominent themes and to systematically organize the literature under these themes. This method permits the combination of qualitative and quantitative evidence [ 34 ] and has been used in previous reviews concerning physicians’ internet health information needs and their role in cancer care [ 35 , 36 ]. Both authors (QL and PJS) of the present review analyzed data from the included studies and synthesized them into themes and subthemes. The qualitative results of the included articles were used to describe the themes by using specific quotations that offer direct evidence of physicians’ experiences and perspectives. Quantitative results from survey studies were used to validate and support the identification of themes. For instance, if a theme emerged from the qualitative data suggesting that “physicians perceive that patients’ internet health information seeking boosts patients’ confidence in participating in their healthcare,” quantitative data were used to indicate the percentage of physicians who echoed the perspective that internet health information seeking boosts patient confidence. Our analysis focused solely on the raw data and results of the included articles, extracting direct evidence without incorporating the interpretations or conclusions drawn by the authors of the included studies. We did not use specialized qualitative software for data analysis. Instead, we created 2 structured tables (Tables S1 and S2 in Multimedia Appendix 2 [ 22 , 29 , 37 - 56 ]) in Microsoft Word (Microsoft Corp) to systematically list, organize, and synthesize all themes and subthemes alongside their associated qualitative and quantitative evidence. This approach facilitated clear organization of qualitative quotations and the corresponding survey evidence.

Quality Assessment

Two tools were used by the first author to evaluate the risk of bias in the included studies. The Critical Appraisal Skills Program (CASP) checklist assessed the quality of qualitative research, while a tool developed by Hoy et al [ 57 ] evaluated quantitative research. Both tools comprise 10 questions that assess the study’s objectives, methodology, sampling, ethical considerations, and other aspects. A quantitative study was considered to have a moderate risk of bias if it satisfied 4 or 5 out of the 10 criteria and a low risk of bias if it met 6 to 8 criteria. The CASP does not categorize qualitative research as “high,” “medium,” or “low” quality; instead, it appraises the strengths and limitations of its methodology. It has been widely used in health-related qualitative evidence syntheses [ 58 ].

Overview of the Articles

Figure 1 illustrates the article selection process for this review in accordance with the PRISMA guidelines. Using the search algorithm described in the Search Strategy section, 2856 records were initially identified, which ultimately yielded 2159 (75.6%) unique articles after removing duplicates. After screening titles and abstracts, 32 (1.48%) articles remained for full-text assessment. In total, 10 (31%) articles that did not meet the inclusion criteria were excluded: 4 (40%) that focused on telemedicine and technological health devices; 3 (30%) with an incorrect sample (1 each targeting patients with cancer and caregivers, the general population, and nurses); 1 (10%) study that focused on physicians’ social media use; 1 (10%) study on physicians’ view of patient family members’ information seeking; and 1 (10%) study for which the full article was inaccessible. Ultimately, 22 (69%) articles were included in this review.

Of the 22 included articles, 11 (50%) used qualitative methods, including focus groups, interviews, and analysis of audio-recorded clinical consultations. Another 11 (50%) articles adopted a quantitative approach using survey data. Furthermore, 2 (18%) of the quantitative articles also incorporated a qualitative method through open-ended survey questions [ 37 , 38 ]. A total of 4 (18%) studies exclusively collected data from family physicians or GPs, 2 (9%) studies focused solely on oncologists, 1 (5%) study focused on dermatologists, while the remaining studies (n=15, 68%) encompassed physicians from various specialties. Most of the included studies were conducted in North America and Europe, encompassing the United States (n=4, 18%), Canada (n=2, 9%), Germany (n=4, 18%), the Netherlands (n=1, 5%), the United Kingdom (n=2, 9%), Switzerland (n=2, 9%), and Norway (n=1, 5%). Other countries featured in the studies included Israel (n=3, 14%), Oman (n=1, 5%), Brazil (n=1, 5%), and South Korea (n=1, 5%). One study interviewed physicians from 7 different countries: Australia, Israel, France, the United States, the Philippines, New Zealand, and Hungary. Table 1 provides an overview of the included articles.

a GP: general practitioner.

b Only study results and quotations from physicians, including GPs and specialists, are considered.

In the quality assessment, all the qualitative studies (11/22, 50%) received “yes” responses to the first 5 questions on the CASP checklist. This indicates that these studies provided clear descriptions of their research aims and used appropriate methodologies, sampling procedures, and data collection techniques. Moreover, each study received positive responses to at least 8 out of the 10 questions. The primary area of concern, as denoted by negative responses, pertained to the following question on the checklist: “Has the relationship between the researcher and participants been adequately considered?” This suggests that many studies did not critically examine the researcher’s role, its associated potential bias, and influence during the research process. Furthermore, 2 (9%) articles that used mixed methods were evaluated with the tool for quantitative studies, as most of their results were presented numerically. Most of the included quantitative studies (7/11, 64%) exhibited a low risk of bias, while the remainder (4/11, 36%) displayed a moderate risk. Multimedia Appendix 3 [ 22 , 29 , 37 - 56 ] details the quality check for each study.

Synthesis of the Studies

Overview of categories.

A total of 5 main categories were identified through the coding of evidence from the included articles. Two primary categories, “impacts on patients’ health and health management” and “Impacts on physician-patient relations and health care services,” represent physicians’ perceptions of patients’ internet health information seeking in terms of its effects on patients' health and health management, as well as on their relationships with physicians and on health care systems, respectively. These categories address RQ1. Two additional categories, “participative strategy” and “defensive strategy,” summarize a series of communication actions physicians take in response to internet-informed patients, thereby addressing RQ2. The final category, “physicians’ difficulties and needs,” addresses RQ3 by delving into the challenges and needs that physicians perceive when dealing with internet-informed patients. Multimedia Appendix 2 provides a detailed list of all subthemes, accompanied by their qualitative quotations and supporting quantitative survey evidence.

In the following sections, we first offer a brief description of each primary category, accompanied by its corresponding subthemes highlighted in italics. We then delve deeper into physicians’ perceptions, their choices regarding communicative strategies, and their identified difficulties and needs. Furthermore, we outline the antecedents of, or connections between, these categories. Direct qualitative quotations and survey evidence are provided to reinforce our observations.

Impacts on Patients’ Health and Health Management

Physicians believe that seeking health information on the internet can inform/educate patients about their health conditions and enhance patients’ confidence in participating in health care. The internet can also provide social support by connecting patients with their peers. However, physicians express concern that the internet might misinform patients with inaccurate information and some patients lack the capability to interpret internet information appropriately. Internet searches can potentially trigger patients’ negative emotions , such as anxiety or confusion. Moreover, physicians view patients’ self-diagnosis and self-treatment based on internet searches, conducted before medical consultations, in a negative light.

Impacts on Physician-Patient Relations and Health Care Services

Physicians believe that internet information seeking can improve physician-patient relations, as internet-informed patients are more empowered and informed in managing their health. Such searches also encourage patients’ participation in decision-making . Moreover, internet-informed patients can improve the efficiency of medical consultations , potentially shortening the duration when patients have already informed themselves about their conditions. However, there have been reports from physicians about nonadherent patients who disregard medical advice due to their internet searches. Some physicians sense feelings of distrust from internet-informed patients and feel that their medical authority is being challenged by them. They also sometimes experience negative emotions, such as anxiety and uneasiness, when interacting with internet-informed patients. Furthermore, physicians note increased time and information demands , as well as inappropriate medical requests made by internet-informed patients.

Participative Strategy

Physicians appreciate internet searches when patients bring internet information to consultations. They help patients examine the information and acknowledge their limited expertise on specific topics. They clearly explain the diagnosis and treatment plan to patients and strive to understand patients’ emotional needs , such as concerns about their health and motivations for conducting internet searches. Furthermore, physicians seek to build ongoing relations with internet-informed patients and instruct patients on appropriate internet use , including teaching them how to recognize appropriate information sources and recommending reliable internet sites.

Defensive Strategy

Physicians decline to discuss internet health information by displaying resistance or deferring patients to other specialists. They also discredit the internet as an unreliable information source and devalue the internet health information brought by patients.

Physicians’ Difficulties and Needs

Physicians face extra responsibility as information interpreters or examiners beyond their traditional professional practices, adding pressure on an already overwhelmed health system. Physicians desire training to manage internet-informed patients, stay updated with technology, and be informed about reliable internet sites that they can recommend to patients.

Physicians’ Perceptions of Internet-Informed Patients

Diverse views on internet-informed patients existed among physicians. These views can be seen as a continuous spectrum of opinions ranging from positive to negative. In qualitative studies, a group of digitally engaged physicians who were active on social media generally held positive perceptions toward internet health information, regarding its impact on physician-patient communication and patients’ health [ 39 ]. In contrast, interviews with 11 GPs from the United Kingdom revealed generally negative perceptions [ 40 ]. Another interview study in Norway showed physicians with these 2 opposite opinions [ 41 ]. Between these 2 polarized views, a larger number of physicians expressed balanced perspectives on patients’ internet searches. In survey studies, many physicians held neutral opinions regarding the impact of internet searches on physician-patient relations [ 42 , 43 ]. These physicians recognized both the beneficial and detrimental effects of internet information on patients’ health [ 38 , 42 , 44 ]. Interview studies also showed that physicians’ views on internet-informed patients varied based on their interactions with individual patients [ 41 , 45 ]. In other words, they did not approach all patients with a singular attitude; rather, they often held more nuanced or balanced perceptions.

Physicians with positive perceptions valued the more equal physician-patient relationship fostered by internet-informed patients [ 39 ]. For instance, an interview study from Switzerland found that physicians with positive perceptions believed that internet-informed patients, by searching on the internet, become more informed about their health conditions and thus feel encouraged and more confident to engage collaboratively with their physicians in health care [ 46 ]. Similarly, physicians from Israel mentioned in interviews that internet-informed patients had assisted them in making diagnoses and pinpointing referrals, thereby making medical encounters more efficient [ 29 ]. The following quotations exemplify this positive perspective:

Because of the Internet, social media and technology, my patients were coming to me with more information and they weren’t looking to me to just solve a problem. They wanted to be involved in this problem. [ 39 ] [Male physiotherapist aged 36 years]

I’d say spontaneously that it gives them [internet-informed patients] more right to have a say in a matter. They have, let’s say, more empowerment to join in the conversation. They then already have an opinion, and don’t come here thoroughly blank. [ 46 ] [Male physician, obtained medical degree in 1983]

Physicians with negative perceptions expressed unpleasant feelings toward internet-informed patients. They felt that their authority was challenged by these patients [ 40 ]. Notably, 3 survey studies from South Korea, the United States, and the Netherlands showed that approximately 20% of physicians felt that internet-informed patients challenged or undermined their authority as medical professionals [ 38 , 42 , 43 ]. Furthermore, they perceived themselves as being devalued and distrusted by internet-informed patients [ 40 , 47 ]. Their views are expressed as follows:

For me that was the irritation, that the patient had far more trust in the computer and what they found on the web than in what I was trying to explain. [ 40 ] [female GP]

I see a very big danger in the fact that the patient gets into a kind of tunnel through his/her constant search on the internet and then, in the end, is no longer receptive to the doctor’s advice. Again and again, I experience those patients who constantly feel misunderstood and do doctor hopping. [ 47 ] [female GP]

In contrast, many physicians hold mixed perceptions of internet-informed patients, which are influenced by their interactions with individual patients. For instance, 2 qualitative studies conducted in Canada and Norway have revealed that physicians differentiate between patients who use the internet for self-education and those who use it for self-diagnosis and self-treatment [ 41 , 45 ]. Physicians tend to view patients who use the internet for self-education in a favorable light. These patients often bring internet information to the physician for confirmation and remain receptive to the physicians’ suggestions. In these cases, the internet serves as a helpful tool. In contrast, when patients use the internet to self-diagnose or self-treat, specifically, those who have already made up their minds before consulting a physician, they are often perceived as “challenging” patients. Physicians have reported feeling the need to defend their diagnosis or treatment plan, and this can evoke negative emotions, ranging from frustration to anger, when dealing with such self-diagnosing or self-treating patients [ 45 ]. Furthermore, physicians recognize the importance of established relationships with patients in shaping their perspectives. A positive prior relationship leads them to view the internet as beneficial [ 38 ]. Some physicians described it as follows:

I think there’s one situation where the Internet is useful. If the person has the diagnosis, and they want to find out more, educate themselves,... I find that’s actually helpful in cases where...it’s not time-consuming for me.

If they’re, however, using it to diagnose, then I think that’s where the problem lies... [ 45 ] [A focus group of family physicians]

If the relationship is good, Internet use is not a problem. The biggest problem is with new patients with whom no relationship has yet been forged and who arrive with a certain assertivity or suspicion. [ 38 ] [Not available]

Quantitative data also support the observation of physicians holding more neutral or balanced perceptions. A survey study of 406 US physicians who had previously encountered internet-informed patients during consultations found that 38% of the physicians consider the internet information brought by the internet-informed patients to benefit their relationship, 8% consider it harmful to the physician-patient relationship, and 54% provided neutral answers [ 43 ]. Another survey study involving 493 South Korean physicians found that 16.6% believed that discussing internet information with patients positively impacted their relationships. In contrast, 25.6% indicated that it had negative impacts, while 42.6% chose a neutral response, indicating that they perceive it as having no significant impact on the physician-patient relationship either way [ 42 ]. In alignment with these 2 studies, the proportion of physicians with varying perceptions do not show significant differences across other survey studies from the Middle East, South America, and Europe [ 38 , 48 - 50 ]. Overall, most physicians hold neutral perceptions.

In addition, physicians’ general perceptions of internet-informed patients appear to differ between different cultures, ages, and specializations. Focus groups involving 48 Canadian family physicians revealed that senior physicians felt a stronger sense of challenged authority than younger medical graduates [ 45 ]. In a survey of 108 surgeons, German surgeons were less content with internet information than their Omani counterparts [ 49 ]. Another survey from the Netherlands involving 238 oncologists and rheumatologists found that oncologists were less positive about internet use than rheumatologists [ 38 ]. However, these associations lack substantial evidence, as few studies have verified them.

Physicians’ Communicative Strategies: How Do Physicians With Negative Perceptions Respond to Internet-Informed Patients?

Physicians’ communicative strategies were mostly observed in qualitative studies. When physicians develop negative perceptions, they are likely to adopt specific actions or strategies aligning with these perceptions. For instance, an interview study with 38 GPs revealed that physicians who viewed themselves as the primary “decision-making and instructing authority” actively discouraged patients from internet searches, believing that other sources of information that might conflict with their own should be eliminated. In contrast, GPs who did not emphasize their authoritative role chose to collaborate with internet-informed patients, recommending reliable internet information sites and jointly examining internet information without seeking to prevent patients from further internet search [ 47 ].

Being identified in several studies [ 45 , 47 ], defensive actions have been termed by scholars as resistance [ 51 ] or negative mediation [ 44 ]. Defensive actions can be categorized into 2 types. The first type involves refusing to discuss internet information, which can manifest as resistance to discussing such information, terminating the physician-patient relationship by referring patients to other specialists, or even suggesting an additional charge for discussing internet-based information. The second type is about devaluing internet health information. This includes actions like discrediting the internet as a source, devaluing the health information that patients obtain from the internet, and correcting patients’ misbeliefs with the implication that they should stop searching on the internet for health information [ 41 , 44 , 45 , 47 , 51 ]. Some physicians described this approach as follows:

When patients tell me, “yes, but on the Internet,”... I always cut short: “On the Web you find everything and its opposite, so forget it all and listen to what I’m saying, which is the standard.” [ 51 ] [Male gynecologist aged 63 years]

If they come in and it’s too much and it’s too specialized.... I let them slug it out with the specialist. They’re paid very special money to do this kind of work. [ 45 ] [A focus group of family physicians]

Physicians have claimed to take defensive actions to reduce the risk of internet health information for their patients [ 51 ]. A survey of 104 American physicians indeed showed that their negative assessment of the quality of internet information was positively correlated with more defensive actions [ 44 ]. However, another survey study of 1050 American physicians found that their perception of the potential harm of internet information to health was positively associated with their feelings of challenged authority [ 43 ]. Hence, the defensive strategy can be seen as coping mechanism that helps physicians defend themselves from the challenges and potential emotional unpleasantness posed by internet-informed patients.

Physicians’ Communicative Strategies: How Do Physicians Collaborate With Internet-Informed Patients?

Physicians who have a positive perception of their patients’ internet searches tend to work with their patients more collaboratively [ 44 , 51 , 52 ]. Their actions with internet-informed patients promote physician-patient relations by making the best use of the internet. These physicians believed that patients can also provide information and negotiate health care decisions, and they acknowledged the value of internet information brought by patients to the consultation [ 29 ]. As stated by the physicians, they would show interest in the information that patients bring, make patients feel respected and listened to, and examine patients’ information. In addition, they believed that recommending reliable internet health information sites is an excellent way to guide patients in using internet information more effectively [ 39 , 52 , 53 ]. They also emphasized that the internet will never replace the human touch that physicians offer. They claimed to provide internet-informed patients with holistic care and to build ongoing relationships based on trust and familiarity [ 29 ].

While participative physicians acknowledged the risks associated with internet information, they regarded the internet as a powerful and legitimate health information source. Thus, they saw it as an opportunity for patients and believed that physicians should guide them in using this medium appropriately [ 51 ]. These actions can be categorized as the participative strategy, as opposed to the defensive one. Physicians take participative actions to “join in” with internet-informed patients in a way that allows them to guide and help patients navigate the internet with physicians’ professional expertise. The participative approach is described as follows:

Yeah for me, for instance, the use of sites, I know patients when they come to you and you have to provide information they usually get shocked first to get a diagnosis and second to start treatment. And so I give them readings. I print some information for them and tell them if they have more questions to go to these sites and then you come back with me and we can discuss it if you want. [ 52 ] [Male physician and scientist, 29 years in practice]

Often people find information you don’t have. Why? We’re doctors, we’re constantly being updated, [but] we’re not up to date on everything. We don’t know everything about everything.... I actually like it when someone comes and tells me something I know nothing about, and I leave his room, and I go straight to the computer...and start reading about what they said. And if it’s relevant, I can sometimes find myself incorporating [it] into my work. Definitely.... They come, they tell you something, I’ve never heard about it, I’m willing to check. And then after you check, you become a slightly better doctor. Because you know more. [ 29 ] [Cardiologist]

Apart from physicians’ self-claims, 1 study analyzed audio-recorded real clinical consultations between oncologists and patients with breast cancer in Switzerland [ 22 ]. The authors observed a series of participative actions with internet-informed patients, including physicians encouraging patients to use the internet, acknowledging the internet as an information tool, helping patients identify reliable internet information sources, providing detailed information to clarify patients’ internet information, and admitting their limited knowledge on the topic being discussed. These actions align closely with the participative approaches that physicians claimed in other studies [ 22 ].

Similar to physicians' mixed perceptions of internet-informed patients, some physicians have reported shifting between different communication strategies. An interview study with 17 Swiss physicians revealed that they would shift between participative and defensive strategies depending on their interactions with individual patients [ 51 ]. They tended to be cautious toward internet information when the patients demonstrated a low level of health literacy, as judged by the patient’s or the family member’s education level and the quality of information that the patient had brought. Furthermore, patients’ disrespect for physicians’ expertise and their reluctance to consider physicians’ suggestions also prompted defensive actions from physicians [ 51 ]. This characterization of patients who provoke a defensive response coincides with the description of self-diagnosing or self-treating patients given by physicians who maintain more neutral or balanced perceptions regarding patients’ internet searches. Physicians’ communication strategies, much like their perceptions, are not strictly limited to being participative or defensive. They adapt their communication approaches to suit individual patients. One physician illustrated his adaptability between different patients as follows:

You need to do the right thing with the right person. With some people you take the time to look at the information together, to evaluate it together. But there are also situations where you say no, I don’t want to go into it. You have to consider, evaluate and grade, you need to weed some things out and to keep others...

A few times, when I was really exasperated, I have said: “Time is up!” Those people were arrogant, and I have said “Time is up!” Two of them then left really pissed, but after the third repetition of the same thing.... Some patients do not want to understand: They have their idea and they want me to agree with it. [ 51 ] [Male urologist, aged 53 years]

With the introduction of internet information to medical consultations, physicians have frequently expressed in interview studies that their traditional roles have expanded to include responsibilities as internet information interpreters or examiners [ 39 , 41 , 45 , 46 , 52 , 53 ]. Two survey studies indicated that physicians believed patients brought internet information to consultations largely to seek physicians’ opinions on that information [ 42 , 43 ]. Internet-informed patients are typically perceived as more demanding in terms of information and time compared with regular patients [ 49 , 54 , 55 ]. Furthermore, while physicians with negative views of internet-informed patients are often reluctant to assume this new responsibility [ 45 ], even proactive physicians have expressed time constraints when addressing internet-informed patients within an already burdened health system [ 39 ].

In addition, some physicians highlighted challenges in dealing with extreme cases [ 47 ]. Interviews with UK family physicians revealed feelings of being “left alone” when dealing with patients who exhibit intense health anxiety and excessive internet information searches. These physicians felt ill-equipped, both in terms of psychological expertise and time, to handle such situations. They favored the development of structured training that aids in identifying such extreme cases. Another group of digitally engaged physicians expressed a need for an updated medical curriculum to assist them in better establishing relations with internet-informed patients [ 39 ]. However, the studies included in this review provide limited details on the specific training needs of physicians, preventing a detailed exploration of their preferred curriculum.

Several studies highlighted the physicians’ desire to stay updated with emerging technologies and trustworthy internet information sources for patient reference [ 38 , 45 , 47 , 48 ]. For example, a survey study of 118 family physicians revealed that 58% saw a need for training on internet use [ 48 ]. In another mixed methods study, 53% of physicians expressed difficulty in staying informed about credible internet health sites [ 38 ]. One physician illustrated it as follows:

It is imperative that doctors are trained in internet usage. I rarely know which website to recommend to patients. [ 38 ] [Not available]

Principal Findings

This review has examined physicians’ perceptions of patients’ internet health information–seeking behavior and their communication experiences with internet-informed patients. We included a mix of qualitative and quantitative studies, which enabled us to gain a deeper understanding from physicians’ perspectives and explore connections between physicians’ perceptions and their communicative approaches.

We first identified a diversity of perceptions among physicians regarding patients’ internet searches. These perceptions can be viewed as a continuous spectrum of opinions ranging from positive to negative. While some physicians hold more positive or negative views on patients’ internet searches, a greater number of physicians expressed balanced views toward internet-informed patients. They acknowledge the benefits of internet health information but also raise concerns. The findings indicate that physicians, in general, are not entirely resistant to interacting with internet-informed patients. Their potential in educating and empowering patients to manage their health in this digital age should be further investigated and emphasized. For instance, scholars have drawn attention to the role of physicians in addressing internet misinformation. They have argued that although laypeople lack the medical expertise to distinguish the quality of internet material, the internet can become an extremely helpful tool with the collaboration of physicians [ 17 ].

Discrepancies exist when comparing the perceptions of physicians and patients. Previous reviews have concluded that patients tend to believe that internet searches make their consultations with physicians more effective [ 13 ]. However, our review found that physicians generally perceive their experiences with internet-informed patients as more time-consuming and demanding [ 42 ]. Physicians are also commonly concerned about the risk of misinformed patients [ 52 , 54 ]. Their concerns are not only about the poor quality of internet information but also about the patient’s capability to process a large volume of information. The divergences between patients’ and physicians’ perspectives highlight the importance of understanding both parties’ viewpoints. Future policy makers and researchers should consider these differences while investigating internet use and physician-patient communication.

We also identified 2 types of communicative strategies that physicians adopted to deal with internet-informed patients. These strategies include the defensive approach and the participative approach, each containing a series of specific communicative actions. Physicians’ perceptions are linked to their strategies: positive perceptions toward internet-informed patients lead to a participative approach, while negative perceptions lead to a defensive approach. The 2 strategies were primarily identified through interview studies with physicians and are, therefore, based on their self-claims. Future research should build on our findings and delve into the interaction process between physicians and patients. This exploration will provide a better understanding of how physicians implement these strategies in actual medical consultations and how various strategies impact both the patients’ use of internet material and the physician-patient relationship.

Furthermore, physicians shift between the 2 strategies based on their interaction with specific patients. The identification of neutral physicians and physicians’ shift between the 2 communicative strategies emphasizes the dyadic nature of physician-patient relations. On the one hand, patients are cautious about disclosing internet-sourced information to their physicians and constantly evaluate the possible reactions of physicians to their information [ 23 , 25 ]. On the other hand, physicians adopt different attitudes and communicative approaches based on their interaction with that particular patient [ 51 ]. The communication process between the patient and the physician plays an essential role in determining whether patients will introduce internet information and how the information will be responded to by the physician during a consultation.

This study also identified physicians’ difficulties and needs with internet-informed patients. The most common difficulty is the time pressure to address information and time demands from internet-informed patients. The medical systems in many countries are already overwhelmed [ 59 ]; therefore, the time issue could be difficult to address. Other common needs include training on new technologies and being informed of reliable internet sites that can be recommended to patients [ 38 , 48 , 53 ]. Some physicians also raised a need for training to help them address extreme cases of patient internet searches and form a more satisfying relationship with internet-informed patients [ 39 , 47 ]. This finding provides new insights into the medical teaching curriculum. Introducing special training that showcases trustworthy medical websites recommended for patients to reference could better equip physicians for medical encounters with internet-informed patients.

However, it is important to note that these training needs were primarily demonstrated in studies where physicians held more positive views of the internet [ 38 , 39 , 48 ]. Therefore, the expressed training needs primarily come from physicians who are receptive to internet information and tend to adopt a participative strategy toward internet-informed patients. Their motivation for such training programs likely revolves around enhancing their collaborative skills with internet-informed patients. Future research should take into account the perspectives of physicians with negative views, as they might have different concerns and might not be in favor of training specifically designed to enhance communication with internet-informed patients. Nonetheless, it is worth noting that newer medical graduates are more receptive to internet-informed patients compared with senior physicians [ 45 ]. Some medical educators have considered implementing communication training to prepare medical students for future consultations with internet-informed patients [ 60 ], and it has been observed that such training boosts the competency of medical students [ 61 ].

Limitations

Our review has certain limitations. First, the specialization of physicians may influence their perspectives on internet-informed patients; however, we could not draw concrete conclusions regarding the differences among medical specialists, as only a few of the included studies had examined them. In addition, some included studies focused solely on GPs or oncologists, which might skew the prevalence of their perspectives in this review and potentially diminish the applicability of our results to other specialists.

Second, most of the included studies are from Europe and North America, with few focusing on physicians from Eastern countries, such as South Korea and Israel. This makes it challenging to draw further comparisons between different cultures. Particularly, in some East Asian cultures dominated by Confucianism, strong hierarchies between physicians and patients still exist [ 62 ]. The impact of internet information on changing physician-patient relationships in these cultures was found to be limited [ 24 ]. Physicians from such Eastern cultures might exhibit different perceptions and communicative actions toward internet-informed patients compared with their Western counterparts, where the concept of an equal physician-patient relationship is more common.

Third, the data used to observe communicative strategies primarily originated from qualitative interviews with physicians. Using quantitative data and observations from real-life consultations could strengthen our results, which are currently based on physicians’ self-claims.

Conclusions

This review underscores the varied perceptions physicians hold toward internet-informed patients. Physicians’ choice of communication strategies, whether adopting a participative or defensive approach, is intricately linked to their perceptions and their interactions with individual patients. Incorporating a medical teaching curriculum that introduces reliable internet sites to physicians for patient reference and provides updates on technology can potentially assist physicians in better coping with internet-informed patients.

Acknowledgments

The authors wish to extend their deepest appreciation to Professor Peter Salmon for his invaluable comments and insights on this review. The authors received no financial support for the research, authorship, or publication of this review.

Conflicts of Interest

None declared.

Keyword combinations and databases.

Description of themes and supporting evidence.

Quality assessment.

PRISMA checklist.

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Abbreviations

Edited by A Mavragani; submitted 27.03.23; peer-reviewed by K Masters, R Poss-Doering, R McMullan; comments to author 09.09.23; revised version received 01.10.23; accepted 27.02.24; published 06.06.24.

©Qianfeng Lu, Peter Johannes Schulz. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.