REVIEW Open Access Systematic review of strategies to increase use of oral rehydration solution at the household level Lindsey M Lenters 1 , Jai K Das 2 , Zulfiqar A Bhutta 1,2* Abstract Background: Diarrhea is one of the major causes of death in children under five years of age, disproportionately affecting children in low- and middle-income countries. Treatment of diarrhea with oral rehydration solution addresses dehydration and reduces diarrhea related deaths. The World Health Organization Programme for the Control of Diarrhoeal Disease began in 1978 and while global ORS access rates have improved substantially over the past forty years, rates of ORS use have stagnated. Investigation is required to understand which interventions are effective in promoting the use of ORS, and where there are gaps in the literature. Methods: We conducted a systematic search of peer-reviewed and grey literature and included interventions to promote the use of ORS for the treatment of acute diarrhea in children under 6 years. We used a standardized grading format based on the Child Health Epidemiology Research Group guidelines and performed meta-analysis for all categories with more than one data point. Results: We identified 19 studies for abstraction. For co-promotion of zinc and ORS, mothers in the intervention group were 1.82 (95% CI 1.17, 2.85) times more likely to use ORS to treat their child’s diarrhea episode than mothers in the comparison group. Meta-analysis of ORS social marketing and mass media strategies indicates that mothers exposed to messages were 2.05 (95% CI, 0.78, 5.42) times more likely to use ORS to treat their child’s diarrhea episode than unexposed mothers. However, this is not statistically significant. Both meta-analysis had significant heterogeneity and were graded as moderate/low and low quality, respectively. Conclusions: We found few studies of interventions to promote the use of ORS; many categories of interventions had only one study. While there are some promising results, this analysis reinforces the need for further investigation into approaches to increasing ORS use. Background Diarrhea is one of the major causes of death in children under five years of age, leading to an estimated 1.071 million annual deaths and disproportionately affecting children in low- and middle-income countries [1]. In patients with diarrhea, the cause of death is almost always due to fluid loss and dehydration [2]. This can be addressed through fluid therapy in the form of oral rehydration solution - a simple, cost-effective treatment that was proven to be effective during a cholera epi- demic in Bangladesh in the 1970s [3]. Treatment of diarrhea with oral rehydration solution (ORS) can remedy 90% of dehydration from diarrhea. ORS is the cornerstone of diarrhea treatment, according to the World Health Organization (WHO), whereas antibiotic treatment in addition to ORS is only indicated in cases of cholera or bloody diarrhea [2]. The WHO Programme for the Control of Diarrhoeal Disease began in 1978. Activities in diarrheal disease control programs vary widely from country to country and have included social marketing and mass media campaigns, the involvement of political figures and reli- gious leaders, educational campaigns in schools, training of partly skilled health care workers, changes to medical school curricula, distribution schemes, as well as the establishment of outpatient oral rehydration centers [2]. A 2010 systematic review by Munos et al. indicated that universal coverage with ORS would reduce diarrhea related deaths by 93% [4]. While ORS access rates have improved substantially over the past forty years, use * Correspondence: zulfiqar.bhutta@aku.edu 1 Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada Full list of author information is available at the end of the article Lenters et al. BMC Public Health 2013, 13(Suppl 3):S28 http://www.biomedcentral.com/1471-2458/13/S3/S28 © 2013 Lenters et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.