The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda
Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and...
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| description | Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and what can be done to increase use. We hypothesized that price and inconvenience are important barriers to ORS use and tested whether eliminating financial and access constraints increases ORS coverage.
In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and lim |
| doi_str_mv | 10.1371/journal.pmed.1002734 |
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In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability.
Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context.
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In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability.
Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context.
Trial registry number AEARCTR-0001288.</description><subject>Access control</subject><subject>Adult</subject><subject>Biology and Life Sciences</subject><subject>Care and treatment</subject><subject>Child, Preschool</subject><subject>Childhood diarrhea</subject><subject>Children</subject><subject>Children & youth</subject><subject>Clinical trials</subject><subject>Community</subject><subject>Community Health Workers - statistics & numerical data</subject><subject>Diarrhea</subject><subject>Diarrhea - economics</subject><subject>Diarrhea - therapy</subject><subject>Diarrhea, Infantile - economics</subject><subject>Diarrhea, Infantile - therapy</subject><subject>Drug Costs</subject><subject>Economics</subject><subject>Female</subject><subject>Fluid Therapy - economics</subject><subject>Fluid Therapy - statistics & numerical data</subject><subject>Funding</subject><subject>Handbooks</subject><subject>Health</subject><subject>Health insurance</subject><subject>Health Services Accessibility - 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statistics & numerical data</topic><topic>Diarrhea</topic><topic>Diarrhea - economics</topic><topic>Diarrhea - therapy</topic><topic>Diarrhea, Infantile - economics</topic><topic>Diarrhea, Infantile - therapy</topic><topic>Drug Costs</topic><topic>Economics</topic><topic>Female</topic><topic>Fluid Therapy - economics</topic><topic>Fluid Therapy - statistics & numerical data</topic><topic>Funding</topic><topic>Handbooks</topic><topic>Health</topic><topic>Health insurance</topic><topic>Health Services Accessibility - economics</topic><topic>Health Services Accessibility - organization & administration</topic><topic>Households</topic><topic>Humans</topic><topic>Infant</topic><topic>Insecticides</topic><topic>Intervention</topic><topic>Laws, regulations and rules</topic><topic>Low income groups</topic><topic>Male</topic><topic>Market prices</topic><topic>Medical personnel</topic><topic>Medical research</topic><topic>Medicine and Health Sciences</topic><topic>Mortality</topic><topic>Oral rehydration fluids</topic><topic>People and Places</topic><topic>Polls & surveys</topic><topic>Private sector</topic><topic>Profits</topic><topic>Public health</topic><topic>Rehydration</topic><topic>Research and Analysis Methods</topic><topic>Retirement benefits</topic><topic>Salts</topic><topic>Social Sciences</topic><topic>Towns</topic><topic>Uganda</topic><topic>Workers</topic><topic>Zinc</topic><topic>Zinc (Nutrient)</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Wagner, Zachary</creatorcontrib><creatorcontrib>Asiimwe, John Bosco</creatorcontrib><creatorcontrib>Dow, William H</creatorcontrib><creatorcontrib>Levine, David I</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Canada</collection><collection>Gale In Context: Science</collection><collection>ProQuest Central (Corporate)</collection><collection>Neurosciences Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><collection>PLoS Medicine</collection><jtitle>PLoS medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Wagner, Zachary</au><au>Asiimwe, John Bosco</au><au>Dow, William H</au><au>Levine, David I</au><au>Tumwine, James K.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda</atitle><jtitle>PLoS medicine</jtitle><addtitle>PLoS Med</addtitle><date>2019-01-24</date><risdate>2019</risdate><volume>16</volume><issue>1</issue><spage>e1002734</spage><epage>e1002734</epage><pages>e1002734-e1002734</pages><issn>1549-1676</issn><issn>1549-1277</issn><eissn>1549-1676</eissn><abstract>Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and what can be done to increase use. We hypothesized that price and inconvenience are important barriers to ORS use and tested whether eliminating financial and access constraints increases ORS coverage.
In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability.
Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context.
Trial registry number AEARCTR-0001288.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>30677019</pmid><doi>10.1371/journal.pmed.1002734</doi><orcidid>https://orcid.org/0000-0003-2922-3315</orcidid><oa>free_for_read</oa></addata></record> |
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| recordid | cdi_plos_journals_2252258382 |
| source | MEDLINE; DOAJ Directory of Open Access Journals; Public Library of Science (PLoS); EZB-FREE-00999 freely available EZB journals; PubMed Central |
| subjects | Access control Adult Biology and Life Sciences Care and treatment Child, Preschool Childhood diarrhea Children Children & youth Clinical trials Community Community Health Workers - statistics & numerical data Diarrhea Diarrhea - economics Diarrhea - therapy Diarrhea, Infantile - economics Diarrhea, Infantile - therapy Drug Costs Economics Female Fluid Therapy - economics Fluid Therapy - statistics & numerical data Funding Handbooks Health Health insurance Health Services Accessibility - economics Health Services Accessibility - organization & administration Households Humans Infant Insecticides Intervention Laws, regulations and rules Low income groups Male Market prices Medical personnel Medical research Medicine and Health Sciences Mortality Oral rehydration fluids People and Places Polls & surveys Private sector Profits Public health Rehydration Research and Analysis Methods Retirement benefits Salts Social Sciences Towns Uganda Workers Zinc Zinc (Nutrient) |
| title | The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-12T23%3A41%3A22IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=The%20role%20of%20price%20and%20convenience%20in%20use%20of%20oral%20rehydration%20salts%20to%20treat%20child%20diarrhea:%20A%20cluster%20randomized%20trial%20in%20Uganda&rft.jtitle=PLoS%20medicine&rft.au=Wagner,%20Zachary&rft.date=2019-01-24&rft.volume=16&rft.issue=1&rft.spage=e1002734&rft.epage=e1002734&rft.pages=e1002734-e1002734&rft.issn=1549-1676&rft.eissn=1549-1676&rft_id=info:doi/10.1371/journal.pmed.1002734&rft_dat=%3Cgale_plos_%3EA571883901%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2252258382&rft_id=info:pmid/30677019&rft_galeid=A571883901&rft_doaj_id=oai_doaj_org_article_bb48fdf7408146b281e937cd94b16a28&rfr_iscdi=true |