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This manual has been developed to help experienced health professionals collect, analyze, and use information about the cultural context of diarrhea. Its purpose is to identify household and behavioral factors that are characteristic of the local culture and to facilitate the development, implementation, and monitoring of programs for the control and prevention of diarrhea. The approach is an adaptation of that presented in Scrimshaw and Hurtado, Rapid Assessment Procedures for Nutrition and Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness (see references to Section A).
Cultural context refers to people's beliefs about how the body works, the causes and consequences of illness, what "goes wrong" or "happens differently" during illness, and other factors that influence the household response to diarrhea.
Rapid assessment procedures (RAP) is a generic term for anthropologically based methods that are used for the relatively rapid qualitative evaluation of health-related problems and of programs for their prevention. Their purpose is to facilitate the design and improvement of health services and educational practices. Although based on qualitative research methods providing descriptive information, they are usually enriched by quantitative research methods providing numerical information.
Appropriate household management (AHM) of diarrhea refers to specific household behaviors and practices recommended by the national or regional control of diarrhea! diseases (CDD) program or by projects to improve the health of young children. These include:
Giving adequate amounts of recommended fluids to replace stool losses;
Continued feeding (including breast-feeding) during the diarrhea! episode and increased feeding following the episode;
Recognition and appropriate referral of cases in need of additional treatment.
The greatest improvement in household management of diarrhea has resulted from an increased awareness on the part of caregivers of the need for special fluids during diarrhea. It has been much more difficult, however, to ensure that this awareness results in their giving fluids in sufficient volume, maintaining food intake during the diarrhea! episode despite anorexia, and continuing to give fluids for as long as the diarrhea persists. Failure to take into account local beliefs, practices, and motivating factors in promoting these behaviors may partially account for this situation.
New strategies are needed to communicate these recommendations in ways that are meaningful within a given cultural context. Beliefs about the causes of illness, its consequences, and how it should be managed vary from culture to culture. Therefore, cultural metaphors that make sense in one setting may have no meaning in another.
Equally important is behavioral modification to reduce the prevalence of diarrhea through improved personal hygiene. The RAP methodology facilitates the identification of improved strategies for communicating recommendations effectively within a specific cultural context. It identifies beliefs about the causes of illness and its consequences that vary from culture to culture.
Many CDD programs and primary health care projects have attempted to collect information on local beliefs and practices related to diarrhea. Few, however, have been successful in obtaining this information in a systematic way that has made it useful for program and communication decisions.
The purpose of this manual is to help bridge two gaps:
Awareness-Adoption: the gap between awareness and adoption of recommended practices. The strategy is to present a methodology for developing cultural metaphors that promote appropriate case management in terms of the local belief system.
Collection-Use: the gap between the collection of information on cultural beliefs related to diarrhea and the effective use of that information. This gap is bridged by directing the researcher's attention to the topics that are most relevant to interventions and by guiding the analysis and presentation of results so that they address specific program decisions.
The manual does not give specific guidelines for selecting fluids or foods for the home management of diarrhea. Information obtained from the RAP study should, however, contribute to those decisions. Several documents are available to guide these selection processes. They are described in the references to Part I.
The manual has four sections. Part I describes RAP methods. Part II gives background information on diarrhea case management and examples of important findings from previous studies of local beliefs about diarrhea. Part III is a field guide for conducting a study. It tells how to: 1) quickly identify a culture's belief system about illness, 2) define aspects that are most relevant to the program or project, 3) present the implications of the results to CDD staff, and 4) use the information to make appropriate recommendations. Part IV presents options for applying the study results.
The manual includes many examples from field experience in two sites: Baluchistan (Pakistan) and South Sumatra (Indonesia). Annex A summarizes the Indonesia results and the recommendations derived from them. These examples are intended to give a context to RAP methods and should not be followed as prescriptions or rules. The authors would greatly appreciate feedback on the application of RAP methods in other settings.
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