Table 2 Factors influencing use of ORS and zinc in the management of childhood diarrhoea by theoretical construct

Executive

Deliberate planning, knowledge

Awareness of ORS and its purpose to replace fluids is well-understood - caregivers know that it does not stop diarrhoea

Limited knowledge of the importance of preparing correctly-concentrated solution as ORS is considered to work like rice water or an energy drink

Zinc is unknown and thus not part of current suite of medicines considered to treat diarrhoea.

Some knowledge that ORS should be given from onset of diarrhoea but lack of knowledge that it should be given throughout the episode

High level of knowledge regarding the use of clean water for ORS preparation but limited knowledge that 1 packet of ORS needs to be prepared with 1 l of water

Belief that injections/antibiotics are the best way of stopping diarrhoea

Planning: ORS may not be stocked at home ready to use

Planning: Zinc is not kept at home so is unavailable as a choice of treatment at start of diarrhoea episode

Motivated

Emotional drivers, interests, reward

It is rewarding when children respond to ORS (energy, play, eat). When a child is visibly sick (listless, dehydrated) mothers respond with ORS

Hoard: small volumes of ORS deliberately prepared using part sachets to avoid wasting limited supplies or preparing ORS that is not consumed by the child

Nurture: eager to stop diarrhoea in their child (and other family members with diarrhoea)

Nurture: Mothers primarily seek treatment to stop diarrhoea so ORS is not highly valued

Affiliation: eager to learn how to prepare ORS correctly for social approval

Curiosity: keen to see whether zinc is as 'strong' as other diarrhoea medicines

ORS is given away or is sold cheaply so is not highly valued

Hunger/Thirst, ORS given more easily when child complains of thirst

Hunger: Zinc tastes unpleasant but children could be persuaded to take it.

Reactive

Cues, habits & skills

ORS initiation is cued in response to dehydration rather than at onset of each diarrhoeal episode and discontinued when child visibly recovers

Cue to stop adding ORS sachet contents to water is when it ‘tastes right’

Reminders were often needed to cue daily zinc administration and to give zinc for 10 days

Physical

Objects/tools, infrastructure

Few ORS sachets are given at clinic, limiting ability to give ORS throughout diarrhoeal episode without purchasing more or returning to the clinic

Many households lack a container to measure 1 l of water. ‘Banana cups’ no longer found frequently

Zinc in blister packs or unmarked plastic bags look like common painkillers

It takes appreciable time and charcoal to boil water on a brazier that is needed for multiple purposes

Sachets to make up smaller quantities of ORS are not available

Caregivers move around during the day and carrying ORS solution can be awkward

Water is hauled from standpipes and stored in containers in the house

Social

Role models, relationships, networks, norms, institutions

Waiting time to get prescription and then get ORS dispensed at clinic is high

Neighbours may lend ORS and give previously used or left over medications

Lack of accountability for giving zinc when shared with multiple family members

Lack of private pharmacies in rural areas

Clinics give only one or two sachets of ORS, often after queuing for a long period

People talk. They share experiences of remedies that work and trial them.

Older (female) relatives and neighbours advise on appropriate treatment

Clinic pharmacies are the main source of medicine, but zinc is often unavailable and may not be given/prescribed. Lack of availability in private sector in rural areas even if affordable.

Illness may be concealed because people can gossip about why a child is ill

Clinic staff are trusted to determine the correct treatment

Biological

Parasites/foods/

animals

Diarrhoea is a common phenomenon

Home environment is hard to keep free of contamination (lack of running water/hard surfaces, cleaning equipment, toilets, etc.)