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4. Revise your assessment of possible approaches to promote AHM

Summarize the new information you have collected in this step by revising your Step 5 assessment of possible approaches to promote AHM. Images and proverbs that might be helpful in presenting the approach should be included in the revised assessment.

The following examples from Baluchistan demonstrate how the assessment of two approaches to promote ORS was revised using data from additional key informant interviews. Further questioning about local concepts of physiology revealed that key informants had an understanding of "veins" that was very similar to the biomedical concept. They explained that veins are small tubes, like the ones you can see on the back of your hand, that connect different parts of the body. Normally, when a child eats or drinks something, it is digested in the stomach and goes through the veins to other parts of the body. The water of diarrhea comes from the veins and the stomach. Researchers considered all of these concepts potentially helpful in promoting AHM practices.

While clarifying local perceptions about intravenous fluids and water loss during diarrhea, researchers learned that intravenous drips were perceived to work by stopping diarrhea. When asked if anything could be done about water loss during diarrhea, key informants responded that the only thing to do was to stop diarrhea and vomiting. Note that in the revised assessments of possible approaches on the following pages, both of these concepts were listed as probably disadvantages. Note also that the suggested image of the roots of a tree is included in the revised assessment.

EXAMPLE: ORS Replaces Water Lost During Diarrhea

• Initial findings advantages


• Caregivers recognize that water loss is dangerous
• Replacing water may avoid the problem of different actions for different types
• Consistent with the biomedical rationale for using ORS


• There are no home remedies that act this way
• Does not address the problem of different actions for different types
• Does not address reluctance to give ORS to babies
• Does not address issue of fluids causing more diarrhea and vomiting Additional Questions

Additional Questions

• Where does the water in diarrhea come from?
• What happens when a child drinks or eats something?
• Is there anything that can be done about water loss?

• Additional findings


• The water in diarrhea comes from the "veins" or from the stomach
• Normally when a child eats or drinks something it is digested and then goes through the veins to the rest of the body


• Caregivers perceive that the only thing to do about water loss is to stop the diarrhea and vomiting

EXAMPLE: ORS Is Strong Medicine (Like IV Drips); It Goes Directly Into The Veins

• Initial findings


• Considered good for all types of diarrhea
• Because it goes into the veins, hot and cold qualities are not considered important
• Salt may be less of a problem because it goes directly into the veins
• Drips are considered good for babies


• Drips are given to treat dehydration, not to prevent it
• Does not address problems of taste and measuring
• Does not address issue of fluids causing more diarrhea and vomiting

Additional Questions

• How are drips perceived to work?
• What are veins?

• Additional findings


• The local concept of veins is similar to the biomedical concept
• It is possible to use the roots of a tree image to explain this metaphor


• Drips are perceived to stop the diarrhea

5. Choose the most useful approaches

Concentrate now on identifying two or three approaches that have the most advantages: No approach will be perfect. The information you have collected, however, will help you estimate the approaches that are likely to be most helpful in communicating messages about AHM. In discussing the options, consider the following:

• Does the approach imply that the recommended practice (giving fluids, using ORS or SSS, feeding, or watching for danger signs) is good far all types of diarrhea?

• Does the approach encourage the administration of large enough volumes of fluids to prevent dehydration?

• Does the approach apply to infants as well as to older children?

• Are there any commonly recognized images that can be used to demonstrate and reinforce the message?

• Can the approach be misunderstood to encourage inappropriate actions? For example, the idea of promoting ORS or SSS as "cleaning out the stomach" was not adopted in Baluchistan because the study team feared this might appear to justify the use of purgatives during diarrhea.

Look at the disadvantages of the approaches you think are best. Think if there are any ways to get around them. It may be useful to outline the messages--the specific bits of information you want to communicate. For each approach there may be a number of messages. Some of these can be designed to get around the disadvantages.

EXAMPLE: The study team in Baluchistan wanted to explain that if a child passes a large amount of stool, a large amount of ORS should be given. This was difficult to explain using the metaphor "ORS treats thirst," because participants believed that thirst was caused by "heat" and not necessarily by fluid loss. Therefore they believed that the appropriate treatment for thirst was a small amount of cooling medicines and not a large amount of ORS.

The team suggested a message that connects the amount of diarrhea with the amount of heat. The basic message is "ORS treats and prevents thirst. " An appropriate related message is "A large amount of diarrhea means there is a large amount of heat... If there is a large amount of heat, then a large amount of ORS is needed to stop the thirst."

Sometimes it is possible to overcome the disadvantages by slightly changing the approach or by combining two approaches:

EXAMPLE: Information from Baluchistan showed that although all mothers recognized water loss as dangerous, very few said they would give fluids to replace lost water. They thought that any water put into the body through the mouth would come out again as diarrhea and vomiting. Therefore they believed that water loss should be managed by stopping diarrhea and vomiting.

The clue to how this obstacle might be overcome came from answers to the question "Where does the water in diarrhea come from?" Twenty-one of 36 (58%) mothers responded that the water comes from the "veins."

The team recommended the message:

"ORS goes into the veins and puts back the water lost during diarrhea."

This message combines two metaphors: "ORS is a strong medicine like intravenous drips" and "ORS replaces water lost during diarrhea." Saying that ORS goes into the veins, not just into the stomach, addresses the major concern that ORS will cause more diarrhea and vomiting.

Write down the specific message(s) that you want to communicate using your approach. Note if there are any images that might be helpful.

EXAMPLE: The following messages were developed around the metaphor that "ORS or SSS goes into the veins and puts back the water lost during diarrhea":

• Water loss from diarrhea or vomiting is dangerous.
• When a child has diarrhea, it is important to put back the water lost from the veins.
• Using ORS packets or SSS helps the water go into the veins.

The team decided to explain the messages using the image of planting a tree in a hole to help water go into the roots. The importance of measuring the right amount of water, sugar, and salt might be compared to the importance of digging a hole that is neither too big nor too small. A preliminary drawing designed to communicate these ideas is shown on the following page in Figure 3.7. (Note that series of pictures are read from right to left in Baluchistan.)

Figure 3.7. Drawing

Key Points

• Using the list of information needs and questions developed in Step 5 and the same methods used for initial data collection, meet again with five or six key informants;

• Explore possible images and proverbs that can be used to demonstrate the approaches for promoting AHM;

• Use the new information to revise your assessment of possible approaches;

• Select the two or three approaches that have the most advantages.


1 AHM includes the administration of adequate amounts of fluids, the preparation and administration of SSS or ORS according to policy, continued feeding during the episode and increased feeding during convalescence, and medical referral when necessary.

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