Oral hydration salts (ORS) are a safe, cheap, and widely available treatment for childhood diarrhea but providers often avoid prescribing them in low- and middle-income countries (LMIC) and instead favor antibiotics or other costly treatments, according to a new report in Science.
Diarrhea kills up to 500,000 children globally each year, mainly in LMICs, and most of those lives could be saved by using ORS.
"At the present time, nearly half of diarrhea cases around the world do not receive ORS," the authors explained. "Most health care providers in developing countries know that ORS is a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades and cost millions of lives."
To determine why ORS is underprescribed, a team of US and Indian researchers conducted a randomized controlled trial in India, where 25% of global deaths from childhood diarrhea occur. Actors portraying concerned fathers who have a 2-year-old at home with diarrhea visited 2,282 private healthcare providers across 253 towns in India.
The actors were randomly assigned to express a preference for ORS, a preference for antibiotics, or no preference at all. Without a stated preference, most providers avoided ORS. Only 28% prescribed or dispensed ORS when patients expressed no preference, and 55% prescribed or dispensed ORS when standardized patients expressed an ORS preference.
Stating preference doubled use
Stating a preference for ORS doubled the likelihood of being given the solutions, sold for less than a dollar as small packets mixed with water.
Health care providers’ perception that patients do not want ORS because the medicine tastes bad or is not perceived as effective as antibiotics accounted for 42% of ORS underprescribing, the authors found, while stock-outs (being out of the packets) and financial incentives explained only 6% and 5% of encounters.
"These results suggest that interventions to change provider misperceptions of patients’ ORS preferences should be aggressively explored because they have the potential to substantially increase ORS use," the authors concluded.
Changing provider behavior about ORS prescription remains a huge challenge.
In a press release on the study, corresponding author Zachary Wagner, PhD said, "We need to find ways to change providers’ perceptions of patient preferences to increase ORS use and combat antibiotic resistance, which is a huge problem globally.”
"Changing provider behavior about ORS prescription remains a huge challenge," said co-author Manoj Mohanan, PhD. "The rates of ORS use remain stubbornly low in many countries such as India."