Study finds care for life-threatening childhood diarrhea limited by healthcare providers’ opinions

In India, young children who suffer from life-threatening diarrhea often receive ineffective treatments because health care providers misunderstand the caregiver’s wishes, according to a groundbreaking new study.

Using actors posing as caregivers to examine the behavior of healthcare providers in two different regions of India, researchers found that the perceived preferences of a child’s caregiver were a more important factor in how a child was treated than the opinions of the health care provider. on the best course of action.

The findings offer possible new avenues to combat a disease that kills more than 500,000 children under the age of 5 worldwide each year, although 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, lead author of the study and an economist at RAND, a non-profit research organization. “But oral rehydration salts were the preferred treatment when we asked caregivers directly about their preferences.

“Interventions aimed at changing provider perceptions of patient preferences for oral rehydration therapy have the potential to increase its use and reduce infant mortality due to diarrhea.”

Diarrhea is the second leading cause of death among children in low- and middle-income countries, although almost all of these deaths could be prevented with oral rehydration salts, a small packet of electrolytes mixed with water before to drink them.

Although it has been hailed as one of the most important medical advances of the 20th century, the use of oral rehydration salts has been underutilized for decades. Currently, almost half of the world’s cases of diarrhea go untreated.

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 underprescribing of oral rehydration salts is driven by perception that patients do not want oral rehydration salts, providers’ financial difficulties, incentives to prescribe other medications, and shortages of oral rehydration salts.

Researchers trained 25 actors to pose as child caregivers so they could visit health providers to seek help for children in distress due to diarrhea. The in-depth two-week training included memorizing a scenario and answers to common questions, as well as hands-on visits with real healthcare providers.

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

The research team also interviewed providers, both when they agreed to participate in the study and shortly after receiving a visit from a caregiver. In addition, approximately 1,200 caregivers were surveyed, answering questions about their treatment preferences, treatment-seeking behavior, and interactions with healthcare providers among those whose children have 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. Ensuring oral rehydration salts were in stock increased treatment prescribing by 7 percentage points.

Removing financial incentives for health providers to prescribe more cost-effective medications did not affect the prescribing of oral rehydration salts on average, but did increase the prescribing of oral rehydration salts in pharmacies.

Researchers estimate that the perception that patients did not want oral rehydration salts explained 42% of underprescriptions, while stock-outs and financial incentives explained only 6% and 5%, respectively.

Before this study, researchers did not know why healthcare professionals did not routinely prescribe oral rehydration salts. There is anecdotal evidence that this is because the treatment does not provide a good profit margin or because patients prefer other treatments due to their poor taste.

Additionally, practitioners may believe that caregivers dislike oral rehydration salts due to a lack of observable symptom relief (they treat and prevent dehydration rather than diarrhea symptoms) and a perceived according to which the treatment is not a “real” medicine compared to a pill or an injection.

“A long-standing conundrum in global health is that providers do not prescribe oral rehydration salts for childhood diarrhea, even though they know it is the standard of care,” said Neeraj Sood, co-author of the study and professor at the Institute. USC Price School of Public Policy.

“This study provides new information that now allows us to pursue interventions that may address this problem.”