This cheap treatment could curb antibiotic use and save millions of lives. So why is it under-prescribed?
A new study examines why oral rehydration salts for diarrhoea are under-prescribed in India, and what to do about it.
- 9 February 2024
- 3 min read
- by Linda Geddes
Each year, more than half a million children die from diarrhoeal diseases. Oral rehydration salts are a simple, cheap, and effective way of combatting the deadly dehydration these diseases cause, and have been hailed as "potentially the most important medical advance of the 20th century".
Yet, a knowledge gap between what health care providers think patients want and what patients actually want may be limiting their use, research suggests.
“Even when children seek care from a health care provider for their diarrhoea, as most do, they often do not receive oral rehydration salts, which costs only a few cents and has been recommended by the World Health Organization for decades.”
– Prof Neeraj Sood, health policy expert, University of Southern California, Los Angeles.
"Even when children seek care from a health care provider for their diarrhoea, as most do, they often do not receive oral rehydration salts, which costs only a few cents and has been recommended by the World Health Organization for decades," said Prof Neeraj Sood, a health policy expert at the University of Southern California in Los Angeles. "Millions of young lives could be saved if we can find ways to increase oral rehydration salt use."
In India, which has the highest number of diarrhoeal deaths in the world, several explanations have been put forward to try and explain this phenomenon. Because the salts are so cheap, health care providers may be less likely to stock or prescribe them, as they can make more money prescribing other treatments instead.
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This includes antibiotics, which are ineffective against viral diarrhoea. Alternatively, doctors may assume their patients do not want them: "Oral rehydration salts are not like a traditional pill – it is a powder that you mix with water – so there could be a perception that the patients don't want [them], or don't think about [them] as real medicine," Sood said.
To investigate, Sood and his colleagues recruited more than 2,000 health care providers across 253 towns in the Indian states of Karnataka and Bihar, selected for their broad socio-economic demographics and varied access to health care. They also trained people to act as patients or caregivers and provided them with scripts to use during unannounced visits to doctors' surgeries, where they requested treatment for symptoms of viral diarrhoea in their two-year-old children.
In some cases, these patients indicated a preference for a certain treatment by showing a photo of an oral rehydration salt or antibiotic packet. In others, they simply asked the doctor for a recommendation – with some of these patients saying they would buy the medicine elsewhere, to control for profit-motivated prescribing.
To measure the impact of potential stock-outs, the researchers also assigned providers in half of the towns to receive a six-week supply of the salts.
The research, published in the journal Science, found that the biggest barrier to use of the salts was an assumption that patients wouldn't want this treatment, accounting for 42% of under-prescribing. If a patient expressed a preference for the salts, this increased the likelihood of them receiving it by 27%. Stock-outs and financial incentives explained only 6% and 5% of under-prescribing, respectively.
"The second surprising thing is that when we surveyed patients, they didn't hold this view; they were fine with oral rehydration salts," said Sood.
The results suggest that efforts to educate health care providers about patients' preferences should be "aggressively explored", as this could substantially increase salts use. Encouraging patients and caregivers to request the salts when seeking treatment for diarrhoeal disease could also increase their uptake, the researchers said.