Many children with diarrhoea in India are deprived of the standard oral rehydration solution (ORS) treatment because doctors mistakenly believe that parents do not prefer ORS, a study across 253 towns in two states has suggested.

The study, which used “actors” pretending to be parents to probe treatment practices, has found that some doctors and other healthcare providers do not prescribe ORS although they know it is the standard first-choice treatment.

Misperceptions that parents and caregivers do not want ORS to be prescribed explains 42 per cent of underprescribing, according to the study, described as the first to assess and quantify the barriers that contribute to children with diarrhoea being deprived of ORS.

ORS is a low-cost, life-saving treatment for childhood diarrhoea and defined as a standard treatment since the late 1970s. However, studies have indicated that many healthcare providers prescribe antibiotics instead of ORS even in cases of virus-induced diarrhoea, denying children standard treatment and exposing them to needless drugs.

A demographic and health survey in India covering the period 2019-20 had indicated that 45 per cent of a sample of children with diarrhoea brought to private healthcare providers did not receive ORS.

“We found that (healthcare) providers avoided prescribing ORS because they thought caregivers wanted something different for their child,” said Zachary Wagner, the study’s lead author and an economist at RAND, a non-profit research organisation in the US.

“But ORS was the most preferred treatment when we asked caregivers directly about their preferences,” he said in a media release from his institution.

Wagner and his collaborators at IIM Bangalore, and academic institutions in the US, set out to measure three possible barriers to ORS prescriptions — parents’ preferences, financial incentives for healthcare providers under the assumption that prescribing antibiotics is more lucrative than prescribing ORS, and local stockouts of ORS.

They designed an experiment in which 25 trained actors memorised a script to play the role of a parent seeking care for a two-year-old child with diarrhoea for two days. The actors visited over 2,000 doctors and other healthcare providers — modern doctors, traditional medicine practitioners, even staff in pharmacies who dispense medicines on request — in 253 towns in Bihar and Karnataka.

The study, published on Thursday in the US journal Science, found that pharmacies were least likely to dispense ORS (16 per cent), while MBBS doctors were most likely to prescribe ORS (46 per cent).

The researchers also surveyed 963 homes in Bihar and 237 homes in Karnataka and found that 48 per cent of parents and other caregivers described ORS as the best treatment for child diarrhoea. But only 16 per cent expressed this preference when seeking care.

Their analysis has suggested that a mistaken belief among healthcare providers that parents do not prefer ORS accounted for 42 per cent of underprescription, stockouts explained 6 per cent and financial incentives accounted for 5 per cent of the underprescription.

Paediatricians say that ORS is always prescribed for childhood diarrhoea when there is no evidence or suspicion of a bacterial infection.

“Every single paediatrician I know would write ORS,” said Shreya Dubey, a consultant paediatrician at the C.K. Birla Hospital, Gurugram, who was not associated with the study.

“Antibiotics have no role unless a superimposed (bacterial) infection is confirmed,” she said.

However, Dubey said, some parents themselves ask that their children not be given ORS saying it does not taste good. “This is not a decision that parents should influence, but some doctors under pressure prescribe antibiotics for diarrhoea.”