Oral rehydration solution (ORS) is one of the most effective ways to treat dehydration and has saved the lives of millions of children all over the world over the past few decades. Even so, diarrheal dehydration continues to kill hundreds of thousands of children each year. A recent research in Bangladesh, along with studies from other low- and middle-income countries, shows that high awareness of ORS does not guarantee correct or timely use. Closing this persistent and dangerous ‘knowledge-practice gap’ remains a significant development policy challenge, in Bangladesh and elsewhere.
Six decades ago, Bangladeshi scientists helped transform global healthcare for children. During a severe cholera outbreak in the late 1960s, researchers working in Dhaka developed an oral rehydration solution (ORS) – a simple mixture of sugar, salt and water that prevents dehydration from diarrhea. Since the late 1970s, ORS has saved an estimated 70 million lives worldwide. Today, the challenge is not about innovation but instead involves ensuring that caregivers can use ORS correctly and on time.
Once recognized by The Lancet as “the most important medical discovery of the 20th century”, Bangladesh not only helped invent ORS, but it also demonstrated how to scale it. By 1980, more than 12 million Bangladeshi women had been trained to prepare ORS at home. Community-based efforts – most notably the door-to-door ‘Lobon-Gur Solution’ campaign – turned a medical formula into a household practice. Between 1980 and 2015, diarrheal deaths among children under five fell from 15.1 to 6 per 1,000 live births. Bangladesh’s experience shaped global practice, and today WHO and UNICEF endorse ORS as the first-line treatment for diarrheal dehydration (further strengthened by zinc supplementation since 2004).
Despite this legacy, major gaps persist. The WHO estimates that diarrheal disease remains the third leading cause of death among children under five, killing approximately 443,000 children each year. In low- and middle-income countries (LMICs), fewer than half of children with diarrhea receive ORS when they need it. Even in Bangladesh, often cited as a global success story, our recent field study conducted in rural northern Bangladesh (Dinajpur) reveals a troubling gap between knowledge and correct practice.
- 91.7% of mothers knew that ORS is used to treat diarrhea.
- 53% prepared ORS with an inadequate amount of water.
- 48.3% relied on mugs, glasses, or other non-standard containers despite knowing the correct measurement.
- Only 37% knew the correct storage duration for prepared ORS.
- Most caregivers initiated ORS only after symptoms worsened, rather than at the onset of diarrhea.
Water measurement tools used during ORS preparation
The field study by the authors revealed a lack of proper measurement tools to prepare ORS. More than half of caregivers reported either using a drinking mug (48.3%) or a drinking glass (32.2%)—both without any measurements. Only 19.4% relied on a 500 ml water bottle.
Together, these findings show that high awareness of ORS does not translate into correct or timely use. In Rajshahi, most mothers knew how to prepare ORS, but fewer than half used it correctly. A study in Manikganj also found that while mothers had adequate knowledge of ORS and its preparation, many did not apply it properly in practice. Measurement errors, storage inaccuracies, misinformation and delayed initiation persist, driven largely by informal advice and social norms that often outweigh medical guidance. Only 42.8% of mothers understood that ORS prevents water loss and just 22.2% knew it corrects salt–water imbalance, highlighting persistent gaps in conceptual understanding of the treatment. This knowledge-practice gap disproportionately applies to women, who carry the primary responsibility for childcare but frequently receive incomplete or inconsistent support.
Knowing is not enough: A global pattern
This pattern is not unique to Bangladesh. Evidence from separate studies across other LMICs points to a similar contradiction between awareness and correct practice. In Pakistan, for example, one study finds that mothers’ knowledge of ORS stands at 53%, while understanding of diarrhea itself is 51%, with researchers warning that improper preparation contributes to otherwise preventable illness and mortality. In India, although 73.3% of mothers are aware of ORS, only 52.8% know how to prepare it correctly and 41.4% lack knowledge about the causes of diarrhea. Studies from Egypt similarly show that caregivers frequently delay ORS initiation or misjudge the timing of treatment, reducing its effectiveness.
Why the gap persists
Our study and others suggest that both behavioral and structural factors are at play. Health system interactions often prioritize distribution over demonstration. Mothers may receive ORS packets from hospitals or dispensaries without clear guidance on preparation, storage or timing. Literacy and numeracy limitations further complicate accurate use, while cultural beliefs and informal advice networks frequently override formal medical instructions.
Bangladesh’s own experience offers important lessons. Early monitoring of Lobon-Gur Solution campaigns showed that even with high awareness, correct use remained uneven. In this context, the Bangladesh Rural Advancement Committee (BRAC), the world’s largest non-governmental organization, played an instrumental role in identifying gaps between knowledge of ORS and its proper practice. The effectiveness of BRAC’s approach lay not merely in awareness-raising but hands-on, household-level demonstrations. Our recent field study reinforces this lesson: while trust in ORS remains high, preparation errors and delayed initiation persist. At the same time, 88% of mothers report wanting more information, signaling strong potential for improved behavior-change interventions. Ensuring the availability of ORS packets, practical demonstrations and sustained community engagement are essential to translate knowledge into action.
Implications for policy
Addressing this gap requires greater emphasis on how guidance is delivered and reinforced. Improving support during health facility visits, expanding community health worker-led demonstrations and prioritizing outreach in low-literacy and high-risk areas can significantly reduce preparation errors and delays. Simple tools like visual instructions, standard measuring containers and consistent messaging delivered through trusted local channels can further support caregivers.
Bangladesh once led a global health revolution by turning a simple formula into a mass movement. Today, the task is to lead again, not through new technology but by ensuring that caregivers everywhere can use ORS correctly and confidently. If knowledge is matched by practice, one of the world’s most powerful policy interventions can continue to save millions of lives.