Care for life-threatening child diarrhea limited by health providers’ views

Young children in India who suffer from life-threatening diarrhea frequently are given ineffective treatments because health providers misperceive the wishes of a child’s caregiver, according to a novel new study.

Using actors posing as child caregivers to examine the behavior of health providers in two divergent regions in India, researchers found that the perceived preferences of a child’s caregiver was a more important factor in the way a child was treated than the views of the health care provider about the best course of action.

The findings offer possible new pathways to address an illness that annually kills more than 500,000 children under age 5 around the world, even though most could be successfully treated with inexpensive oral rehydration salts.

The study is published by the journal Science.

“We found that providers avoided prescribing oral rehydration salts because they thought caregivers wanted something different for their child,” said Zachary Wagner, the study’s lead author and an economist at RAND, a nonprofit research organization. “But oral rehydration salts were the most preferred treatment when we asked caregivers directly about their preferences.

“Interventions to change providers’ perceptions of patients’ preferences about oral rehydration therapy have the potential to increase its use and reduce child mortality from diarrhea.”

Diarrhea is the second leading cause of death for children in low- and middle-income

countries, despite the fact nearly all such deaths could be prevented with oral rehydration salts -- a small package of electrolytes that is mixed with water before drinking.

Although it has been lauded as one of the most important medical advances of the 20th century, use of oral rehydration salts has been underutilized for decades. At present,

nearly half of diarrhea cases around the world do not receive the treatment.

Researchers from RAND, the University of Southern California, Duke University and the Indian Institute of Management used a unique approach to estimate the extent to which the underprescription of oral rehydration salts is driven by perceptions that patients do not want oral rehydration salts, providers’ financial incentives for prescribing other medications, and oral rehydration salts being out of supply.

Researchers trained 25 actors to pose as child caregivers so they could visit health providers to seek help for children in distress with diarrhea. The extensive two-week training included memorizing both a script and responses to common questions, as well as practice visits with real health care providers.

The actors visited 2,282 private health providers across 253 medium-sized towns in the Indian states of Bihar and Karnataka, presenting a case of a 2-year-old child who had been having uncomplicated diarrhea for two days. Half the actors presented a moderate case and the other half a severe case, with both types of cases being severe enough to require oral rehydration salts.

The research team also surveyed the providers, both when they agreed to participate in the study and shortly after they were visited by an actor caregiver. In addition, about 1,200 child caretakers were surveyed, answering questions about their treatment preferences, treatment-seeking behavior, and provider interactions for caretakers among those whose children had a recent case of diarrhea.

The study found that when patients expressed a preference for oral rehydration salts, prescribing of the treatment increased by 27 percentage points. Assuring that oral rehydration salts were in stock increased prescribing of the treatment by 7 percentage points.

Removing financial incentives for health providers to prescribe higher-profit medicines did not affect prescribing of oral rehydration salts on average, but did increase oral rehydration salts prescribing at pharmacies.

Researchers estimate that perceptions that patients did not want oral rehydration salts explained 42% of underprescribing, whereas being out of stock and financial incentives explain only 6% and 5%, respectively.

Prior to this study, researchers did not know why health practitioners do not routinely prescribe oral rehydration salts. There was anecdotal evidence that it was because the treatment does not provide a good profit margin or because patients prefer other treatments because of its poor taste. In addition, practitioners may believe that caregivers do not like oral rehydration salts because of a lack of observable symptom relief (it treats and prevents dehydration rather than diarrhea symptoms), and a perception that the treatment is not “real” medicine as compared to a pill or a shot.

“A long-standing puzzle in global health has been that providers do not prescribe oral rehydration salts for child diarrhea, even though they know it is the standard of care,” said Neeraj Sood, coauthor of the study and a professor at the USC Price School of Public Policy. “This study provides new insights that now allow us to pursue interventions that can address this problem.” 

Support for the study was provided by the National Institute of Diabetes and Digestive and Kidney Diseases. Other authors of the study are Manoj Mohanan of Duke University, Rushil Zutshi1 of RAND, and Arnab Mukherji of the Indian Institute of Management Bangalore.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.