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Field guide for the study of health-seeking behaviour at the household LEVEL
Susan C. M. Scrimshaw, Department of Anthropology, School of Public Health, University of California, Los Angeles, California, USA
Elena Hurtado, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
Since the WHO-sponsored Alma-Ata Conference on Primary Health Care of 1978, there has been general agreement that efforts to improve the nutritional status of developing country populations should be an integral part of programmes of primary health care (PHC). Moreover, most PHC activities, including immunization, environmental hygiene and personal sanitation, maternal and child health, and health education are essential contributors to improved nutrition. However, the effectiveness of programmes of primary health care are known to vary widely, and little is known of the extent to which nutritional considerations are really introduced and if so what effect they are having.
In 1983 the United Nations University and the United Nations Children's Fund (UNICEF) developed a programme to involve anthropologists and others using anthropological methodologies in examining the extent to which the nutritional and health practices of families are affected by programmes of primary health care that include nutrition activities. The idea was to select communities that are served by PHC programmes with a strong government commitment that includes nutrition.
This kind of assessment is complementary to large-scale epidemiological studies of programme impact on nutritional and health status and to process evaluations of the functioning of health programmes, projects, and their personnel. Knowledge of the effect of programmes on actual health behaviour within households fills a gap not covered by either impact or process evaluation.
Projects were initiated in 11 countries, and it was felt important to convene the investigators and develop some guidelines to ensure reasonable comparability of data. This field guide should be of value not only to researchers in the project but to others interested in undertaking similar studies of the impact of programmes on household behaviour.
It should be noted that this guide is concerned specifically with the perceived accessibility and value of nutrition and primary health care services to a community in the context of local conceptions of health and illness and how the latter should be treated. Because of the reality that many programmes are in place without adequate baseline information or resources for impact evaluation, the guide does not demand the ideal of comprehensive before-and-after observations and measurements. For guidelines on the evaluation of the actual impact of such programmes on the nutritional and health status of the community, the book Methods for the Evaluation of the Impact of Food and Nutrition Programmes (Food and Nutrition Bulletin Supplement 8) is available.
The guide does not provide detailed descriptions of basic anthropological techniques because it is intended for use by persons already trained in the methodology of anthropological field studies. It does, however, suggest the appropriate areas of data collection for the specific purpose. The individual guides and forms offered at the end of section IV below must always be adapted to local circumstances. They are designed primarily for relatively short periods of data collection, in the range of four to eight weeks, but they can readily be expanded for use in longer-term studies if resources permit.
II. RESEARCH GOALS
It is the expressed objective of WHO to extend basic health services to all by the year 2000. In the effort to achieve this goal it is important to understand how primary health care programmes interact with people's perceptions, beliefs, and behaviours related to health and illness, and how such programmes are influencing peoples' health-seeking behaviour. The major goal of the research guided by this manual will be to analyse the impact of existing government PHC programmes on the perceptions, beliefs, knowledge, and health-seeking behaviour of representative households in populations served by these programmes.
To achieve this goal, it will be necessary to
- describe the exiting health and nutrition knowledge, beliefs, and practices of the selected households;
- analyse what factors affect people's perception of the primary health care programme;
- examine how and to what extent the various health resources available to people, particularly the primary health care system, have affected their understanding of health and illness and their health-seeking behaviour.
The Definition of Primary Health Care
The Alma-Ata Conference defined primary health as:
Essential health care made accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford.
Appraisal of the impact of the PHC system on household health knowledge, attitudes, and practices makes little sense unless the essential elements of PHC are considered to be available to them. The Alma-Ata Conference recommended that PHC include at least "education concerning prevailing health problems and the methods of identifying, preventing, and controlling them; promotion of food supply and proper nutrition, an adequate supply of safe water, and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; promotion of mental health; and provision of essential drugs." Most of these are clearly relevant to nutritional improvement. These activities emphasize health promotion and disease prevention rather than the curative services that tend to be the primary concern of national health delivery systems.
The Alma-Ata report also stated that promotion of primary health care activities "requires a close relationship between the primary health care workers and the community." There is, however, great variation among countries in the extent to which this suggestion is implemented. Since there is some evidence that community involvement is a prerequisite for the success of most PHC activities, the extent of such involvement should be part of the description of the PHC system that is available to a population.
Recently UNICEF has emphasized certain elements of the PHC strategy that it considers most important and likely to be successful in reducing child malnutrition. These are
- child growth monitoring within the community to detect the need for additional food and/or medical attention, and to serve as a basis for nutrition education;
- the use of oral rehydration for the treatment of diarrhoea;
- the promotion of breast-feeding and the timely and appropriate complementary feeding of breast-fed infants;
- a comprehensive programme of immunization for children.
The general principles of the Alma-Ata declaration have been interpreted or emphasized differently by the health services of various countries so that it cannot be assumed that the PHC services of a given country will include all of the above activities. Hence, interpretation of information on household responses will depend on the characteristics of the specific PHC system to which they are exposed.
Basic Concepts Related to Health-Seeking Behavior
A few concepts basic to the study of health-seeking behaviour are defined here.
1. Health-seeking behaviour: What people do in order to maintain health and/or return to health, ranging from individual behaviour to collective behaviour. It concerns specific steps taken (sometimes called hierarchy of resort) and what is done and why.
2. Hierarchy of resort: The process of health-seeking behaviour. It implies specific steps, such as self-care, then asking a relative, then going to a pharmacy, then going to a health centre. In reality people may go back and forth between resources and use several simultaneously, so "hierarchy" is a misleading term.
3. Health care decision-making: A process of deciding on a course of action in relation to maintaining or restoring health, including factors and/or people who influence the decision and reasons (explicit and implicit) for the decision.
4. Outsider/insider: in anthropological terminology, the outsider perspective is referred to as etic, the insider perspective as emic. This is an important distinction both for data collection and for discussion of results. For example, the concept of "health" may be an outsider (Western biomedical) concept in some cultures, where a person is seen as "balanced" ("healthy") or "out of balance" ("ill") in terms "hot" and "cold." It is useful to work from both perspectives, and to be aware of the distinction.
5. Community: Each research project director will need to specify the definition used, because what constitutes a "community" may vary from country to country. Some examples are groups of individuals with a "sense of belonging" or individuals in one of the country's administrative units or in the "catchment area" for a primary health programme.
6. Household: A group of people who "share a fire," that is, who share food on a regular basis. Food is really a proxy of several economic activities shared by the people who comprise a household.
7. Health: From the outsider perspective, there is the WHO definition which states that health is "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." From an insider point of view, what constitutes health can vary a great deal from culture to culture.
8. Disease: Defined from a Western (outsider) biomedical perspective, disease is an undesirable deviation from a measurable norm. The emphasis here is on signs and symptoms that can be measured with current Western biomedical techniques.
9. Illness: Illenss is defined in insider cultural terms as the inability to function well in a society; the individual does not feel well and cannot function as usual.
10. Sick role: A role an individual adopts (or is made to adopt) when ill, involving altered behaviour in which normal activities are stopped or curtailed and special "sick behaviours" (such as staying in bed) are carried out instead. Usually, people treat someone in the sick role differently (e.g., isolation or more attention).
11. Medical system: The medical system can be conceived of as (a) the set of cultural beliefs about health and illness that forms the basis for health-seeking behaviour and (b) the institutional arrangements within which the behaviour occurs. A distinction is made between the endogenous (indigenous, traditional) health system and the Western biomedical (modern, cosmopolitan) health system. In a community the former is represented by local healers or curers, traditional birth attendants, and the like. The latter is represented by, for example, the official health care programmes with nurses and physicians trained in Western medicine. There is also a lay health care system representing the family-based prevention and treatment of illnesses.
12. Beliefs, perceptions, attitudes: These are very similar terms but with subtle variations in meaning. For example, in relation to breast-feeding:
- Belief: Mother's milk is the best for a baby younger than one year, but work and anxiety "spoil" the milk.
- Perceptions: She does not have enough milk, nor is the quality good.
- Attitude: She does not want to give breast-milk exclusively.
IV. DATA COLLECTION GUIDELINES
1. Community (ies)
Communities selected for this study must have access to a government primary health programme which is defined as being "in place" by the national and/or regional government. The primary health programme should be one considered good by the government (in comparison to existing government programmes). It should be within "comfortable" reach from the community perspective, and within the programme's catchment area from the government perspective. It should be a community of relatively low socio-economic status. It can be rural or a portion of an urban area.
In the first week of study in each community the anthropologist should make a map of the community (unless one is already available), locating all of the households. An existing map could also be modified. On the map the anthropologist should mark those dwellings where there are children under five years of age and should number those dwellings. The marked dwellings should then be used for a random selection, using a table of random numbers, of 15 households that represent more or less equal numbers of families with children under five years in order to study them in depth.
If the family in a household selected for study does not wish to participate, then that house must be replaced with the house to the left if it has a child under five. If there are no children under five in the next house to the left, then you should go to the house to the right, and so on. The families who refuse to participate should be noted.
If random selection is not possible, then the researcher must make every effort to pick "representative" families in terms of location, socio-economic status, etc. Ideally, the sample will yield households with both well nourished and malnourished children. If this does not occur, then a few appropriate households should be added.
Information from observations and interviews will provide a general description of the study community. This description includes geographical location, demographic distribution of the population, and socio-economic characteristics of the community. Four guides have been prepared for gathering these community-level data (Guides A-D).
1. Geographical conditions: Includes topography, climate, vegetation, transportation, and roads and pathways to and from the health services and communication with urban centres.
2. Demographic distribution: Includes ethnic groups, if any, age and sex distribution of the population, economically active population (EAP), language(s) spoken, religious affiliations, and male and female literacy rates.
3. Economic characteristics: Sources of production, distribution, and consumption. Economic activities (occupation). Employment.
4. Social conditions: Government and private institutions (water supply, electricity, sewerage, etc.), community organizations (clubs, churches, communal centre, youth groups, etc.), schools for boys and girls.
5. Health resources: A general description of all health resources available to the community will be made. This includes a description of those health resources that belong to the government, to the community, and to other resources outside the community.
- Government health services: Focal system of
health services/institutions. Infrastructure. Staff programming
and primary health services (as defined earlier).
- Endogenous health system: This includes an inventory of all individuals who treat illness in the community (private physicians, nurses, folk curers, midwives, religious leaders, shamans, injectionists, etc.).
Secondary information sources may be used in order to complete this section (e.g. maps, surveys, censuses, published literature).
Early in the project, information on the characteristics of the households selected for study will be collected. Most of this information can be obtained by means of more or less structured instruments that may already be available from surveys or growth monitoring. Three semi-structured forms for the household-level data and ten specific interview guides are provided (Forms I-III and Guides 1-10 on the following pages).
1. Household composition (Form I): Characteristics on household composition include identifying the head of the household, family relations, number of household members, their age, sex, literacy, years of schooling, language fluency, ethnicity, religion, occupation, length of residence in the community, place of origin. The information on the individual household members can be recorded in the form of a grid keyed by numbers to an anthropological diagram showing the relationships between the members (see example 1, accompanying Form I).
2 Household conditions (Form II): Characteristics on household conditions relevant to health will be recorded. These characteristics include the materials from which the house is made (walls, floor, and roof}, the number of rooms, existence of a separate kitchen, the sources and quality of the water supply, storage of food and water, and the presence and use of sanitary facilities, including the disposition of human wastes and garbage. This information can be obtained through a combination of observations and interviews. A map of the house can be used as an aid to record the information.
3. Socio-economic status (Form III): The information on occupation and household conditions above can be used as indicators of the socio-economic status of the family. In addition, other socio-economic information, culturally appropriate to each community, can be obtained. Some examples are the amount of cultivated land, access to land, wages, the possession of various material goods, etc.
4. Perceptions of the effect of nutrition and health activities in programmes of primary health care: The core of the study methodology consists of a series of in-depth interviews with members of selected families to find out their perceptions of the effect of primary health care programmes. Ten specific interview guides have been developed to aid in conducting the interviews. The guides cover the following areas:
(1) definitions of health and illness,
(2) common illnesses in children and possible solutions,
(3) diet of mothers and children,
(4) diet of sick children,
(5) morbidity history - all household members,
(a) morbidity history - children,
(7) inventory of remedies in the house,
(8) history of last/present pregnancy and delivery,
(9) use of health resources,
(10) use and experience with official health resources.
GUIDE A. GEOGRAPHIC CHARACTERISTICS
Distance to urban centres
Distance to official health services
Highways, roads, railways, and waterways
Transportation: availability and cost
GUIDE B. DEMOGRAPHIC CHARACTERISTICS
Economically active population
Migration (in and out)
GUIDE C. SOCIO-ECONOMIC CHARACTERISTICS
Economic activities of the population
Stability of employment
Land ownership/access to land
Nuclear vs. extended
Strength and nature of community organization
Attitudes toward government services and costs
Groups (clubs, religious, occupational, etc.)
GUIDE D. HEALTH RESOURCES
Health resources of the community and outside the community
2. Modern or Western
Health practitioners (Include description of PHC workers. Who are they? Where from? How selected, trained, supervised?)
EXAMPLE 1. Diagram of Family Relationships and Sample Grid for Household Composition
* Keyed to diagram of family relationships above.
FORM I. HOUSEHOLD COMPOSITION
Obtain the following data for each household member (using a grid as shown in example 1).
Age (number of months/years, last birthday)
Marital status (for heads of household)
Length of residence in the community
Place of origin, if applicable
Literacy (for those over 7 years old)
Years of schooling (for those over 7 years old)
Occupation (for those over 10 years old)
Status of mother (pregnant or nursing)
For each woman:
Number of pregnancies (mother)
Number of living children
Number of dead children
Number of stillbirths
Number of abortions
Currently using family planning? What method?
Ever used family planning? What method?
Number of persons in the household
Who is (are) the head(s) of the household?
FORM II. HOUSING CONDITIONS
Compound: area, type of surrounding wall
Type of household structure (tent, brush hut, mud house, etc. )
Number of rooms
Kitchen and type of cooking facilities
Availability of water: Source? Distance? How is it transported? Is it boiled before use?
Human waste disposal: availability and use
Inventory of key possessions (e.g., radio, television, bicycle, car)
Type of house ownership
FORM III OTHER SOCIO-ECONOMIC INDICATORS.
Amount of land cultivated: owned/rented
Amount of food stored in the house and how stored
Amount of food sold
Number of economically active household members
Wages/payment in kind
Number of economically dependent household members
*Indicators listed here are examples. Indicators appropriate to the local community should be selected,
GUIDE 1. DEFINITIONS OF HEALTH AND ILLNESS
Date (s ):___________
How does one know a healthy child? a sick
What are the most common illnesses of children here?
Knowledge and beliefs about each illness (symptoms, cause, treatment)
Time of year at which each illness occurs
GUIDE 2. COMMON ILLNESSES IN CHILDREN AND POSSIBLE SOLUTIONS
Knowledge and experience concerning each illness. The gravity or seriousness of each illness. Appropriate remedies or treatments. Expenses associated with treatment (hypothetical question: What would you do? What would you do if you had more money?).
Other (locally recognized illnesses)
GUIDE 3. DIET OF MOTHERS AND CHILDREN*
What foods do the mother and each child (five years old or under) usually consume each day? (Include all meals and snacks.)
|Group I (animal protein)|
|Group II (staples)|
|Group II (vegetables and fruits)|
(Or list according to local terminology and later group as above.)
What foods are appropriate for breast-fed
When and how are children weaned?
When are solid foods introduced? What are they?
What food qualities are considered appropriate for each of the following?
Children (boys vs. girls)
*Quantitative data on food consumption and nutrient intake may be added if collaboration with a trained nutritionist can be arranged.
GUIDE 4. DIET OF SICK CHILDREN
What foods are restricted during illness with
each of the following? Why?
Other (locally recognized illnesses)
Is there a recognized relation between health and diet? Illness and diet? Diet and growth?
GUIDE 5. MORBIDITY HISTORY - ALL HOUSEHOLD MEMBERS
Illnesses of all members of the family during
the past two weeks
Perceived cause of illness
GUIDE 6. MORBIDITY HISTORY - CHILDREN
History of illnesses in children five years of age and under, retrospectively, during the past two weeks and, concurrently, during the study period.
Why was the child sick?
Retrospectively: Who got sick? Symptoms? Duration? Treatments? Who decided? Expenses? Results?
Concurrently: Daily course of the illness, including symptoms. Who takes care of the child? Who gives advice? Recommended treatments. Who decides on treatments, and on what basis? Actual treatments. Expenses. Results.
GUIDE 7. INVENTORY OF REMEDIES IN THE HOUSE
Record all remedies (both folk and "medical") in the house to prevent or cure illness. What is it good for? Where did it come from? Cost? Last time it was used?
GUIDE 8. HISTORY OF LAST/PRESENT PREGNANCY AND DELIVERY
History of last pregnancy and delivery, and concurrently for sample women who are pregnant during the study period.
Date of last delivery. When did you first know you were pregnant? How did you find out? Who provided care? When did prenatal care begin? What is considered ideal care? Observe actual care. What foods can/cannot a pregnant woman eat (ideal/real)? Where was the baby born? Delivery conditions? Who attended the birth? Reason for choice of birth attendant. How was the cord cut? What was cord care? Who provided postnatal care? Postnatal diet?
GUIDE 9. USE OF HEALTH RESOURCES
|Neighbour or friend|
|Shaman or witch doctor|
|Mobile health unit|
* Resources will vary for each culture.
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