Oral rehydration therapy is the cornerstone of fluid replacement and national programs to promote ORS have been strongly supported by WHO, UNICEF and USAID in the treatment of diarrhea [1
]. Our study found that the overall therapy rate of ORS in all care of diarrhea among children under 36
months old is 34.62%. In the 4 care groups, the utilization proportion of ORS in HBC was only 15.03%, significantly lower than that in VLC, TLC or CLC. It was clear that these caretakers did not use ORS against childhood diarrhea in HBC more often. In our study, overwhelming majority of the mothers of these children completed only a primary education. It is possible that this may contribute to less education about when to appropriately use ORS. The previous study also showed that the devalued status of ORS in the eyes of caretakers had become a major problem [17
]. It should be acknowledged that these children with diarrhea in HBC usually had symptoms not as severe as those who were taken to a formal healthcare facility. These may lead to the low utilization of ORS in HBC. So programs of promoting ORS use should give a significant priority to the households. Meanwhile, communication strategies are needed to ensure that families understand and accept ORS as a key treatment component in HBC [1
]. Also, there should be an urgent need for caregivers to be educated to use ORS packets at home as early as possible when a diarrheal symptom appeared in their children. GEE model analysis of ORS use in HBC found that the caretakers who cared for more than one child seemed less likely to use ORS in recent diarrheal episode. In the multi-child families in rural China, it is common for the caretakers to delegate some care burdens to their older children. However, other children in the household may not have the appropriate knowledge or skills to care for a younger sibling with diarrhea. The demands of caring for multiple children negatively impacted caretakers’ ability to provide appropriate and timely diarrheal treatment for the ill child. This may contribute to low use of ORS packets for sick child in families with multiple children. Our study also found that the younger children were less likely to use ORS in HBC. Due to the fact that younger children were more likely to be breastfed or fed with more liquid food, caretakers would not like to think it necessary to use ORS frequently in their children with diarrhea in such a feeding period [18
]. In addition, a similar study of ORS therapy in rural Bangladesh demonstrated that the mothers generally had the perception that infants should not drink any fluids other than breast milk before this age, and the infants were introduced to water and other clear fluids after this age [19
]. In rural China, such a perception among the caretakers in home care may also be a factor, explaining why children less than 12
months old were offered ORS less frequently in HBC than those aged 25–36
months. So health communications should specifically inform caregivers that ORS can be used in sick children who are currently being breastfed.
The utilization rate of ORS in VLC (41.89%) was only lower than that in TLC (45.77%). Recent study of prescriptions of village doctors in these areas has shown that in the village clinics more than one-third of the doctors had no full-time medical education and village doctors were inclined to adopt inappropriate drug utilizations in the treatment of diarrhea [12
]. More educational or training projects about appropriate and early ORS use by the government should be carried out in village-level medical sectors urgently. GEE model analysis of ORS use in VLC showed that ORS use was positively associated with the habit of drinking boiled water often in the families. Families that drank boiled water often at home may have more faith in ORS as a treatment or consider it standard treatment of childhood diarrhea. When they took their children to village clinics, they also agreed that village doctors could use ORS for their children with diarrhea. Our study also showed that receiving educational materials about childhood diseases was more likely to increase the likelihood of ORS use in VLC. The prescription of ORS in village clinics seemed to meet with the profile of educational materials about the treatment of childhood diarrhea and thus made the caretakers more likely to believe in the decision of village doctors to use ORS. Our study also found that ORS available in village clinics was more likely to increase the use of ORS, as found by a study of ORS use at home [20
]. Thus, when ORS packets were not available in village clinics, self-made ORS based on the WHO formulation could be used to treat children with diarrhea.
Some limitations of our study should be acknowledged. As it had not been designed to collect all the information about ORS use, some important information such as the dose, type and frequency of ORS therapy and so on was not available, which could affect our results. Moreover, all data were collected by self-report, which might involve some recall biases. Besides, some other confounding factors which might potentially affect the incidence of childhood diarrhea such as the severity of childhood diarrhea, might also affect ORS use. In addition, use of ORS in HBC or care of clinic or hospital will likely depend on the perceived severity of the diarrhea. But this survey did not collect the information about severity of childhood diarrhea. This also may affect our study results potentially.