A picture is worth a 1000 words: visualizing the challenges of effective diarrhoea treatment

Towards the beginning of our journey in Zambia (May-12), we undertook a human-centred design process to better understand the challenges mothers face when treating their children suffering from diarrhoea. This revealed that the standard 1-litre ORS sachets available in the country (and most of the world) were not ideal for home treatment. Amongst other challenges, our findings demonstrated that caregivers typically had no standard way of measuring the litre of water required to prepare these standard ORS sachets in the correct concentration. We found that the types of containers used to measure the water varied from household to household (for detailed analysis and scientific papers see our open access area). You can also read more about the other challenges here and here.

While my dissertation highlighted that: “Different household containers were typically used, ranging from beer bottles to teacups to local beverage containers,” data collected during the ColaLife Operational Trial Zambia (COTZ) only allowed us to describe this through a narrative… Until now.

As part of our national scale-up efforts under the Kit Yamoyo Transition to Scale (KYTS) programme, we have been able to expand and leverage new data collection methods and tools available to us. During the KYTS-LUSAKA baseline, for example, our research team was able to capture photographs of the large variety of measurement vessels used by caregivers to measure out water when preparing ORS. This was made possible through the use of electronic surveys carried out on Android  tablets.

This type of visual evidence relating to the inconsistency of ORS preparation hasn’t been presented before, so we are excited to share it here first. With a sample size of over 1,000 households conducted during baseline, we are only able to present a selection of images here, but this selection is representative of the entire image dataset:

View the ORS measurement vessels on Flickr


Variations in water quantity used to dilute 1-litre sachets of oral rehydration salts create the risk of preparing a solution that is either too concentrated or too diluted.

“Such inaccuracies in home-mixing of solutions can lead to electrolyte imbalances like hypernatremia (Fayad et al., 1992). According to Nalin et al., failure to “ensure correct solution preparation, concentration, and appropriate drinking volumes can lead to electrolyte imbalance, whatever the formulation(Nalin et al., 2004). This incorrect dilution can result in either high or low concentrations of sodium and glucose, which in turn, decrease the effectiveness of oral rehydration therapy for the treatment of dehydration of acute diarrhea (Pulungsih, 1992; Snyder, 1992)… In cases where the solution is too concentrated, it can actually make the diarrhoea worse

While there is evidence that inaccuracies in home-preparation of ORS can be reversed with proper education and health promotion (Fayad et al., 1992), a more fail-safe strategy would be to also ensure inclusion of the tools necessary for proper health behaviour (i.e. correct dilution).”

Ramchandani R. (2016). Emulating Commercial, Private-Sector Value-Chains To Improve Access To ORS And Zinc In Rural Zambia: Evaluation Of The ColaLife Trial (Doctoral Dissertation). Retrieved from open access area.

Finally, as a reminder, one of the key findings from our trial was that only 60% (95% CI: 0.54-0.66) of 1-liter sachet users prepared ORS in the correct concentration when preparing the ORS at home. From the images above, it quickly becomes clear why this is the case. Of those who used the Kit Yamoyo, with the packaging acting as a measurement vessel, 93% (95% CI: 0.89-0.96) prepared the ORS solution in the correct concentration. This finding contributes to one of our overall recommendations for diarrhoea control globally – that we must go beyond simply measuring coverage of ORS and Zinc (ie use by children under 5 with diarrhoea) as our global indicator of success, to measuring effective use.

Till next time.