Date Published: January 24, 2019
Publisher: Public Library of Science
Author(s): Zachary Wagner, John Bosco Asiimwe, William H. Dow, David I. Levine, James K. Tumwine
Abstract: BackgroundOver 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.Methods and findingsIn 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.ConclusionsMost 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 registrationTrial registry number AEARCTR-0001288.
Partial Text: Diarrhea continues to kill over half a million children each year, almost all in poor nations . Fortunately, use of oral rehydration salts (ORS) could avert nearly all of these deaths [2–6]. Thus, in 1978, The Lancet lauded ORS as “potentially the most important medical advance of this century” .
We recruited 4,150 caretakers to participate in the baseline survey in July 2016. We randomized and trained CHWs to carry out the interventions in March of 2017 and followed up with a household survey of 7,949 caretakers in April and May of 2017 (4 weeks after the interventions started). Random assignment resulted in 30 CHWs in the free and convenient arm, 29 CHWs in the convenient only arm, 29 CHWs in the free only arm, and 30 CHWs in the control arm (see Fig 1). Of the 88 CHWs invited to a training session, 86 attended. In two villages assigned to free and convenient distribution, the CHW quit after random assignment and BRAC did not hire a replacement. Therefore, the intervention was not carried out in these villages. However, we still included these villages in the ITT analysis.
Instructing CHWs to distribute ORS + zinc for free (either with free delivery ahead of illness or with a voucher) substantially increased household usage of these products relative to a sales model. Relative to the status quo, the free and convenient distribution model increased ORS coverage by 37% (21 percentage points) and more than doubled ORS + zinc coverage (33 percentage point increase). Moreover, only 60% of households actually received the free home deliveries, suggesting that usage could be improved further with better CHW adherence. These results suggest that CHW programs that sell ORS + zinc should consider switching to free distribution.