Volume 99, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Diarrhea remains a leading cause of morbidity and mortality in patients worldwide. The objective of this study was to determine the relative inter-rater reliability and usability of standard and Mobile health (mHealth)-supported World Health Organization (WHO) algorithms for dehydration assessment in patients with acute diarrhea in a rural, low-income country hospital. Two nurses blinded to each other’s examinations assessed dehydration status on patients soon after hospital arrival using either the standard WHO algorithm printed on a laminated card or an mHealth-supported WHO algorithm downloaded onto a smartphone. The assignment of assessment tool was based on odd or even enrollment date. The inter-rater reliability for dehydration assessment between the two nurses was calculated using Cohen’s K statistic for each study group. A total of 496 patients (< 5 years = 349, > 5 years = 147) were enrolled in the study; 132 (27%) had some or severe dehydration, and 364 (73%) had no dehydration on arrival. Cohen’s K statistic demonstrated greater reliability for the mHealth-supported dehydration assessment (0.59) compared with the standard assessment (0.50) in the overall population ( < 0.0001), as well as in the pediatric (0.43 versus 0.37, < 0.0001) and adult (0.79 versus 0.57, < 0.0001) populations individually. This is the first study to show that mHealth can improve the reliability of nursing dehydration assessment in patients with acute diarrhea and the first to report on the reliability of the WHO algorithm in adult patients specifically. Future studies should focus on the impact of mHealth-supported dehydration assessment on patient-centered outcomes and examine its reliability in different settings worldwide.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. GBD 2015 Mortality and Causes of Death Collaborators, 2016. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388: 14591544. [Google Scholar]
  2. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators, 2016. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388: 15451602. [Google Scholar]
  3. Liu LOS, Hogan D, Perin J, Rudan I, Lawn JE, Cousens S, Mathers C, Black RE, , 2015. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 385: 430440. [Google Scholar]
  4. GBD 2013 Mortality and Causes of Death Collaborators, 2015. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 385: 117171. [Google Scholar]
  5. Fischer Walker CL, Sack D, Black RE, , 2010. Etiology of diarrhea in older children, adolescents and adults: a systematic review. PLoS Negl Trop Dis 4: e768. [Google Scholar]
  6. Lamberti LM, Bourgeois AL, Fischer Walker CL, Black RE, Sack D, , 2014. Estimating diarrheal illness and deaths attributable to Shigellae and enterotoxigenic Escherichia coli among older children, adolescents, and adults in south Asia and Africa. PLoS Negl Trop Dis 8: e2705. [Google Scholar]
  7. Kotloff KLN, 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet 382: 209222. [Google Scholar]
  8. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI, , 2003. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 9: 565572. [Google Scholar]
  9. Bartsch SM, Lopman BA, Ozawa S, Hall AJ, Lee BY, , 2016. Global economic burden of norovirus gastroenteritis. PLoS One 11: e0151219. [Google Scholar]
  10. Truninger K, , 2014. Diarrhea in the elderly. Ther Umsch 71: 545550. [Google Scholar]
  11. Fischer Walker CL, Perin J, Aryee MJ, Boschi-Pinto C, Black RE, , 2012. Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review. BMC Public Health 12: 220. [Google Scholar]
  12. Green A, , 2017. Cholera outbreak in the horn of Africa. Lancet 389: 2179. [Google Scholar]
  13. Parker LA, 2017. Adapting to the global shortage of cholera vaccines: targeted single dose cholera vaccine in response to an outbreak in South Sudan. Lancet Infect Dis 17: e123e127. [Google Scholar]
  14. Freedman SB, Vandermeer B, Milne A, Hartling L, Pediatric Emergency Research Canada Gastroenteritis Study Group; , 2015. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr 166: 908916.e1-6. [Google Scholar]
  15. Steiner MJ, DeWalt DA, Byerley JS, , 2004. Is this child dehydrated? JAMA 291: 27462754. [Google Scholar]
  16. Hooper L, 2015. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev 4: CD009647. [Google Scholar]
  17. Armstrong LE, Kavouras SA, Walsh NP, Roberts WO, , 2016. Diagnosing dehydration? Blend evidence with clinical observations. Curr Opin Clin Nutr Metab Care 19: 434438. [Google Scholar]
  18. World Health Organization, 2005. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. Geneva, Switzerland: World Health Organization.
  19. Pringle K, Shah SP, Umulisa I, Mark Munyaneza RB, Dushimiyimana JM, Stegmann K, Musavuli J, Ngabitsinze P, Stulac S, Levine AC, , 2011. Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea. Int J Emerg Med 4: 58. [Google Scholar]
  20. Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Atika B, Rege S, Robertson S, Schmid CH, Alam NH, , 2016. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study. Lancet Glob Health 4: e744e751. [Google Scholar]
  21. Colaci D, Chaudhri S, Vasan A, , 2016. mHealth interventions in low-income countries to address maternal health: a systematic review. Ann Glob Health 82: 922935. [Google Scholar]
  22. ICT Data and Statistics Division, International Telecommunication Union, 2016. ICT Facts and Figures 2016. Available at: http://www.itu.int/en/ITU-D/Statistics/Pages/stat/default.aspx. Accessed June 8, 2017.
  23. Haque F, 2017. Evaluation of a smartphone decision-support tool for diarrheal disease management in a resource-limited setting. PLoS Negl Trop Dis 11: e0005290. [Google Scholar]
  24. Khatun F, Heywood AE, Ray PK, Bhuiya A, Liaw ST, , 2016. Community readiness for adopting mHealth in rural Bangladesh: a qualitative exploration. Int J Med Inform 93: 4956. [Google Scholar]
  25. ICDDR B, 2016. Health and Demographic Surveillance System-Matlab. Registration of Health and Demographic Events 2014. Scientific Report No. 133 Dhaka, 49.
  26. Modi P, Nasrin S, Hawes M, Glavis-Bloom J, Alam NH, Hossain MI, Levine AC, , 2015. Midupper arm circumference outperforms weight-based measures of nutritional status in children with diarrhea. J Nutr 145: 15821587. [Google Scholar]
  27. James WP, Mascie-Taylor GC, Norgan NG, Bistrian BR, Shetty PS, Ferro-Luzzi A, , 1994. The value of arm circumference measurements in assessing chronic energy deficiency in Third World adults. Eur J Clin Nutr 48: 883894. [Google Scholar]
  28. Walter SD, Eliasziw M, Donner A, , 1998. Sample size and optimal designs for reliability studies. Stat Med 17: 101110. [Google Scholar]
  29. Diggins KC, , 2008. Treatment of mild to moderate dehydration in children with oral rehydration therapy. J Am Acad Nurse Pract 20: 402406. [Google Scholar]
  30. Fonseca BK, Holdgate A, Craig JC, , 2004. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 158: 483490. [Google Scholar]
  31. Kabakyenga J, 2016. A demonstration of mobile phone deployment to support the treatment of acutely ill children under five in Bushenyi district, Uganda. Afr Health Sci 16: 8996. [Google Scholar]
  32. Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, Shah SP, , 2014. External validation and comparison of three pediatric clinical dehydration scales. PLoS One 9: e95739. [Google Scholar]
  33. Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Rege S, Chu C, Schmid CH, Alam NH, , 2015. Empirically derived dehydration scoring and decision tree models for children with diarrhea: assessment and internal validation in a prospective cohort study in Dhaka, Bangladesh. Glob Health Sci Pract 3: 405418. [Google Scholar]
  34. Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O’Brien KL, Campbell H, Black RE, , 2013. Global burden of childhood pneumonia and diarrhoea. Lancet 381: 14051416. [Google Scholar]

Data & Media loading...

  • Received : 15 Aug 2017
  • Accepted : 03 Apr 2018
  • Published online : 14 May 2018

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error