Predictors of Under-Five Caregivers’ Utilization of Co-Packaged Zinc and Oral Rehydration Salts for Childhood Diarrhea in East Wollega Zone, Western Ethiopia

**Background:** Diarrheal disease remains a major cause of morbidity and mortality among children under five in low-resource settings, including Ethiopia. The World Health Organization recommends co-packaged zinc and oral rehydration salts (ORS) as a cost-effective treatment for childhood diarrhea, yet utilization remains low. This study aimed to identify predictors of under-five caregivers' utilization of co-packaged zinc and ORS in East Wollega Zone, Western Ethiopia.

**Methods:** A community-based cross-sectional study was conducted from April 1 to 30, 2022, among 540 randomly selected participants (96.4% response rate). A multi-stage sampling procedure was used to select four districts from nine Nutrition International project-supported districts, then 12 kebeles (3 per district). Data were collected using interviewer-administered semi-structured questionnaires, entered into Epi-data version 3.1, and analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were performed; adjusted odds ratios (AOR) with 95% confidence intervals were estimated, and a p-value <0.05 was considered statistically significant.

**Key Results:** The study found that 39.6% (214/540) of under-five caregivers had utilized co-packaged zinc and ORS at least once in the last 12 months. In multivariable analysis, five factors were significantly associated with utilization: having a family size less than 5 (AOR = 5.72; 95% CI: 2.93–11.15); having heard about the co-pack (AOR = 9.52; 95% CI: 4.95–23.68); perceiving the child's health status for the recent episode as poor (AOR = 5.90; 95% CI: 2.58–15.96) or medium (AOR = 2.20; 95% CI: 1.02–4.83); perceiving the severity of the recent episode as moderate (AOR = 4.48; 95% CI: 1.36–14.76); and being a community-based health insurance (CBHI) non-member (AOR = 2.28; 95% CI: 1.34–6.90). Notably, only 20.7% of respondents had heard about the zinc and ORS co-pack, and 82.9% considered antibiotic syrup as the first choice of treatment.

**Clinical Implications:** The utilization of co-packaged zinc and ORS in this study (39.6%) is substantially lower than the WHO-recommended target and lower than rates reported in some other Ethiopian studies (67–75%), though higher than the 17% reported in the 2016 Ethiopian Demographic and Health Survey. The strong association between awareness of the co-pack and its utilization (9.5 times higher odds) highlights the critical role of health education and information dissemination. The finding that CBHI non-members were more likely to utilize the co-pack than members was unexpected and warrants further investigation. The study's limitations include its cross-sectional design (precluding causal inference) and potential recall bias. The authors recommend that health offices and institutions strengthen health education and information dissemination to maximize uptake of co-packaged zinc and ORS, and that further studies using stronger designs assess cost-effectiveness.