Table 4 Description of the themes from the interview

Theme 1: Facilitators to the use of nutraceuticals for acute diarrhoea

1.1 Effectiveness of nutraceuticals—expect doctor to prescribe ‘something’ to help with symptoms

“People come to see you and they would always expect you will provide “something” for them. Even if it is placebo, psychologically, they will feel better. It is hard in the Chinese context not to provide any medicines. The patient would feel you are not paying attention to them.” (52-year-old male doctor)

“I come to hospital because there is nothing I can do by myself so I would expect the doctors to give me something to help with my symptoms” (45-year-old female patient)

“It was very fast as I only took the medicines twice…then my diarrhoea stopped right away”. (37-year-old male patient)

“could you please tell me what these medicines names are so I can buy (from pharmaceutical stores) by myself next time…..”. (31-year-old male patient)

“These medicines are effective and most patients are happy with the treatment results”. (36-year-old male doctor)

There were only two patients who expressed some concerns with side effects (39-year-old female): “I am bit worried as I do not know if there are any long term side effects although I asked the doctors and they said it is safe to take…. but I do not know which medicines I am taking….”.

Two patients mentioned the one of the medicines was too big to swallow. (29-year-old female) “I found the yellow medicine was a bit too big to swallow.”

1.2 Flexible schedule, friendly environment and easy to participate

“The schedule was very convenient for me as I have to work during the daytime so I can only come to follow up during evening…” (30-year-old female).

“The students (research assistants) are very patient and always answer all the questions in detail, the process was simple and the diary was easy to fill..” (28-year-old male).

1.3 Carefully designed, fully consented and novel trial

“To be honest, I never saw a trial like this with a really careful design following all standardised operating procedures….. especially, you have insurance for the trial…”. (50-year-old male doctor)

Theme 2: Barriers to use nutraceuticals for acute diarrhoea

2.1. Injections and antibiotics were commonly used for acute diarrhoea

“I used to use injections (injectable antibiotics) and it worked very well…” (49-year-old female patient)

“if you do not prescribe it (antibiotics) to them, if they get angry, they might chase you with a knife….I do not want to face that….this is very common at the moment, it is hard to be a doctor in China….you might face a life threatening situation as you heard some doctors were killed by patients”(50-year-old male doctor).

“usually we will give injectable antibiotics if patients insist on ‘injection’”. (36-year-old male doctor)

“I do not know what medicines are inside the injection but I do feel the effect is fast with injections.” (36-year-old male patient)

“In my past experiences, antibiotics are effective, especially for patients who used to use antibiotics, they won’t get better until you give them antibiotics as you do not know if they are viral or bacterial infections. Most of the tests are not accurate, so what you can do is to cover bacterial infections in case patients get worse…”. (52-year-old female doctor)

2.2 Intensive doctor-patient relationship

“One argument was related to trial’s recruitment, another was during usual care patients to follow up. Although no one was injured, this indicates the extent of the distrust between doctors and patients. The argument related to trial’s recruitment, which resulted in police intervention occurred because a participant’s father was suspicious the trial’s therapy and came to the hospital to scold the recruiting doctor. They finally went to police office and checked all the documents. Of course they declined the trial after the argument. This is common in China. Although not so many patients are like this, you may occasionally face some patients who seem just to argue with doctors without any reasons.” (24-year-old male research assistant)

“Currently, the health literacy among the Chinese public is low from what I heard and recently observed from this clinic. They do not have basic knowledge of health….. In China, some of doctors also do not have good knowledge of antibiotics, infection…..and they are used to using them (antibiotics)”. (24-year-old male research assistant)

“it seems to me patients and doctors have had this habit (using injectable antibiotics for acute diarrhoea) for a long time. It is not easy to change a behaviour….. in a short time.” (24-year-old female research assistant)

2.3 Nutraceutical therapy is not new to Chinese doctors

One doctor (50-year-old male) mentioned that he started to recruit patients with more prominent symptoms, which he was reluctant to do at the beginning: “I started to recruit patients with higher while blood cell, higher fever, severe belly cramping…”.

Theme 3 Suggestions for future study

3.1 Diary and stool samples

There were conflicting reports from patients regarding the use of the diary for symptom report. Nine interviewed patients found that the diary was easy to use. However, four mentioned they could not carefully read and fully understand the diary and one patient suggested some wording changes. “We observed that patients usually do not have stool when they came to hospital as they had diarrhoea symptom at home. In total, we only received a small number of (stool) samples and none were positive for bacterial pathogens. This might need to change in the future study…” (25-year-old male research assistant).

3.2 Advocating this therapy for the public

“I found this is a very meaningful trial and I really hope we will know what those medications are so we can use them in the future or recommend them to families and friends”. (28-year-old male patient)

3.3 Communication skills training

"don’t say the word ‘trial’ in Chinese as patients would feel you are treating them like laboratory animals. In reality, not all trials are like that and at least this trial is safe and it is phase 4. Instead saying something like ‘research’ would be better”. (42-year-old male doctor)

“we received training from experienced peers who had been trained but we feel it is necessary to have more….”. (23-year-old male research assistant)

3.4 Education and campaign for public

“If patients stop demanding antibiotics or requesting that antibiotics not be used, this will reverse the situation and consequentially influence doctors’ behaviour. It seems easier starting from patients/public rather than with doctors.” (42-year-old male doctor)

“I usually follow a doctor’s advice as I do not know what will be good for me. If someone tells me that acute diarrhoea does not need antibiotics and there are additional side effects from an antibiotic, I won’t take it (antibiotic)…”. (30-year-old female patient)