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The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda

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  • Zachary Wagner
  • John Bosco Asiimwe
  • William H Dow
  • David I Levine

Abstract

Background: 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. Methods and findings: 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

Suggested Citation

  • Zachary Wagner & John Bosco Asiimwe & William H Dow & David I Levine, 2019. "The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda," PLOS Medicine, Public Library of Science, vol. 16(1), pages 1-18, January.
    • Handle: RePEc:plo:pmed00:1002734
    DOI: 10.1371/journal.pmed.1002734
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    Citations

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    Cited by:

    1. Wagner, Zachary & Asiimwe, John Bosco & Levine, David I., 2020. "When financial incentives backfire: Evidence from a community health worker experiment in Uganda," Journal of Development Economics, Elsevier, vol. 144(C).
    2. Pascaline Dupas & Basimenye Nhlema & Zachary Wagner & Aaron Wolf & Emily Wroe, 2023. "Expanding Access to Clean Water for the Rural Poor: Experimental Evidence from Malawi," American Economic Journal: Economic Policy, American Economic Association, vol. 15(1), pages 272-305, February.
    3. Zachary Wagner & Somalee Banerjee & Manoj Mohanan & Neeraj Sood, 2023. "Does the market reward quality? Evidence from India," International Journal of Health Economics and Management, Springer, vol. 23(3), pages 467-505, September.

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