US study used ‘actors’ in Karnataka, Bihar to find out why doctors aren’t prescribing ORS for diarrhoea

ORS plays a critical role in treating diarrhoea, with WHO endorsing its use due to its effectiveness in restoring lost fluids, electrolytes.

ByChetana Belagere

Published Feb 11, 2024 | 8:00 AMUpdatedFeb 11, 2024 | 11:35 AM

US study used ‘actors’ in Karnataka, Bihar to find out why doctors aren’t prescribing ORS for diarrhoea

Despite the availability of a simple and cost-effective remedy for diarrhoea — Oral Rehydration Salts (ORS) — the number of children dying from dehydration caused by this illness continues to rise in India.

A demographic and health survey in 2019-2020 indicated that 45 percent of children with diarrhoea brought to private healthcare providers were not prescribed ORS.

This revelation troubled Zachary Wagner, an economist at RAND, a non-profit research organisation in the US, and so he decided to delve into understanding the reasons for this through a study. The team surveyed 253 towns in Karnataka and Bihar, and made shocking discoveries.

What’s unique was the way the researchers decided to conduct the study — they employed “actors” pretending to be parents of sick children to find out whether doctors were prescribing ORS or not.

Importance of ORS

ORS plays a critical role in treating diarrhoea, especially in children, with the World Health Organization (WHO) endorsing its use due to its effectiveness in replenishing lost fluids and electrolytes, ensuring rehydration.

Its affordability and simple preparation makes ORS accessible, especially in resource-limited settings, significantly contributing to reducing diarrhoea-related mortality among children, a key public health goal of the WHO.

ORS is safe, has minimal side effects, and can be used at home, making it a cornerstone of Oral Rehydration Therapy (ORT), a strategy strongly supported by the WHO for its significant impact on global health by preventing dehydration and malnutrition associated with diarrhoeal diseases.

Also Read: This Hyderabad paediatrician is waging a war against misleading ORSL products

The study

The innovative approach of this study lies in its experimental design and methodology, which sought to uncover the reasons behind the low prescription rates of this cost-effective treatment.

Health economist David Levine, based at the University of California, Berkeley, indicates that this reflects an ongoing problem in which healthcare professionals know the right treatment approach but often do not follow through with it.

To execute the study, the team launched a large experimental intervention in two Indian states, Karnataka and Bihar. The researchers used “actors” to simulate the role of caregivers seeking medical advice for their child’s diarrhoea from over 2,000 private doctors and pharmacists across Karnataka and Bihar, two Indian states.

This approach allowed for a controlled investigation into the dynamics of medical consultations without the complexities and ethical concerns of involving real patients.

The “actors” were instructed to present different scenarios to the healthcare providers, varying their requests and previous treatment experiences, including explicit preferences for ORS, antibiotics, or no prior treatment inclination.

“Each ‘actor’ arrived at a facility unannounced and explained that their child had been experiencing diarrhoea for two days. Some told the healthcare provider that they had previously used ORS to treat their child and asked whether they should use it again,” the study explained.

The authors, explaining the methodology of the study, stated, “Some instead mentioned antibiotics, and others brought up no earlier treatments. Some ‘actors’ noted that they would not be purchasing any medications at the facility and just wanted advice. The researchers also sent a six-week supply of ORS to half of the facilities.”

This method was designed to dissect the influence of patient preferences, financial incentives for selling more expensive treatments, and supply issues on the prescription behaviour of healthcare providers.

What did the study find?

The findings revealed that most private doctors and pharmacists in the study were definitely aware of the benefits of ORS, which has been around for more than half a century.

A survey of more than 1,000 caregivers across the two states, as well as care providers from the clinics and pharmacies, revealed that 48 percent of caretakers believe that ORS is the best treatment for diarrhoea. However, only 16 percent expressed a preference for ORS when seeking care. As a result, care providers think that only 18 percent of their patients want ORS.

The study inferred that patient preferences played a significantly more substantial role in the prescription of ORS rather than the financial motives of the clinics and pharmacies, or the availability of ORS.

The “actors” who had informed doctors that they have used ORS previously or those who questioned if they could use ORS were twice as likely to have it prescribed. The experiment showed a disconnect between caregivers’ belief in ORS’s effectiveness and their communication of this preference to healthcare providers, as well as a misperception among care providers regarding their patients’ desires for ORS.

“The ‘actors’ found that when simulated patients showed a preference for ORS, care providers were more likely to prescribe it, suggesting that many care providers mistakenly believe that patients don’t want ORS,” the study noted.

Improving ORS stock and reducing financial incentives for other medicines had smaller effects. The study suggested that addressing these misperceptions could significantly increase ORS use, potentially saving the lives of many children.

This finding challenges the notion that financial incentives are the primary drivers of healthcare decisions, suggesting that informational barriers play a more role. The core of the problem, as the research suggests, lies in a misperception about patient preferences, creating a barrier that has dire consequences on children’s health.

Also Read: Woman drank water from a waterfall and swallowed a live leech! 

What do Indian doctors think?

Doctors South First spoke to said that while ORS is being prescribed by many of them, the problem lies at the pharmacy-level because ORSL, which are similarly named products, are handed to the caregivers instead of ORS.

Citing this study, Dr Madap Karuna, a paediatric critical care doctor from Hyderabad, opined that a study should be done to know how many people from different localities are being given ORSL products when ORS is prescribed.

“Let’s conduct a study to see how many people from various areas receive ORSL Tetra Paks when we specifically refer to ORS (made based on the WHO formula). By identifying errors in this process, we can strengthen our argument for a name change while also emphasising the importance of ORS. This will highlight how patients might be misled.”

She added, “Moving forward, it’s crucial that scientific research informs policy decisions, rather than relying on legal proceedings to drive change.”

Meanwhile, Dr Sivaranjani Santosh, a lone paediatrician from Hyderabad who is fighting for a name change of ORSL products, agreed that gathering data on this is important. She told South First, “I already have the data of how much WHO-prescribed ORS is sold and how many of the mislabeled drinks are sold in the pharmacies. We must find more.”