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Examination of perceptions of appropriate treatment for common illnesses and seizure symptoms among Cuban, Black, and Haitian informants indicated that illness was also treated in culturally appropriate modes. Black informants tended to seek biomedical modes of treatment more frequently than Cuban and Haitian informants. Among both Cubans and Haitians, utilization of biomedical modes of treatment was often associated with the degree of acculturation.
Black informants utilized biomedical approaches in the treatment of common illnesses more exclusively than did Cuban and Haitian informants. The illnesses of children were most often treated with over-the-counter medication, consultation with physicians, and prescribed medications. Adult illnesses were generally treated by physicians with prescribed medications. Cubans and Haitians, on the other hand, used a combination of biomedical modes of treatment and culturally specific home remedies to treat the illnesses of adults and children. This has important implications for the manner in which epilepsy is perceived and treated in these communities.
The degree to which informants in epilepsy target households relied on biomedical approaches to the treatment of epilepsy was related to three main factors: (1) seizure recognition; (2) whether or not the aetiology of the condition was known; and (3) the degree of seizure control achieved under medication.
As previously discussed, when seizures were not recognized as epilepsy, they were treated in culturally relevant manners, based on perceptions of the symptoms. In some cases, informants with epilepsy, while seeking treatment in the biomedical system for tonic clonic seizures, also sought care from mental health practitioners, spiritualists, and herbalists for symptoms of non-convulsive seizure disorders.
In cases where a specific cause for seizures could not be identified, epilepsy target informants more often utilized alternative sources of care. Among Haitian informants this was a frequent observation, with some families citing spiritual causation as the probable aetiology of the condition. Reliance on culturally appropriate explanations for symptoms in the absence of a medically identified aetiology was also common among Black and Cuban informants. Among Cubans, seizures were sometimes attributed to nervous and emotional problems, and occasionally to periodic spirit possession. Among Black informants, idiopathic non-convulsive seizures were attributed to stress and mental disorders. These patterns of beliefs were important in the choices of alternative care.
When non-medical sources and other support systems of treatment were sought, these included Blacks utilizing mental health professionals and occasionally, ministers and priests. Cubans and Haitians, on the other hand, used spiritual practitioners (santeros, voodouns) and a variety of traditional practitioners, such as homeopaths and herbalists in the treatment of idiopathic, poorly controlled seizure disorders. In addition, some Cuban informants had consulted mental health professionals for the treatment of nervous conditions and complex partial seizures.
When epilepsy had been diagnosed and treated in the medical system, poor seizure control, in spite of maintaining medication therapy was frequently associated with the use of alternative sources of care. Utilization of spiritual practitioners and herbal remedies among Cubans and Haitians, and mental health practitioners among Cubans and Blacks, were common in cases of poorly controlled seizures. The logical deduction was that, if the medication did not work, then perhaps the condition was not entirely medical in nature.
All individuals with epilepsy in target families knew that medication worked on the brain, but did not know how. Most of the individuals took medication but showed consistent irregularity in complying with treatment. For example, they took medication only at the first sign of a seizure, whereas others took twice as much medication after forgetting a dosage.
Among Black and Cuban informants, non-convulsive seizures, poor seizure control, and levels of disruptiveness of the symptoms were associated with cessation of using epilepsy-specific health services. Among Haitian informants, documentation status was an additional factor in service utilization. While the group of informants studied did not include Cubans of undocumented immigration status, it is likely that a similar problem exists in the Cuban community.
The factors associated with use of services in the three communities examined have important implications for early intervention in the primary stages of treatment. First, health professionals need to be aware of alternate explanations for seizure symptoms in these communities. In providing services to individuals with idiopathic seizures (seizures of unknown origin), it is possible that beliefs regarding emotional, mental and spiritual causation will be strong. Understanding these beliefs, and the culturally appropriate modes of treatment often sought, may facilitate more open communication between the individual with epilepsy and those providing medical care.
physicians, especially, should be aware of the potential for
dropout when seizure control is not easily achieved with
medication. The need to change medications or adjust dosages
should be discussed thoroughly with the individual and his or her
family shortly following diagnosis. Medication, while not
generally perceived as a cure for epilepsy among those
interviewed, was often viewed as an immediate control measure for
seizures. It is important that individuals with epilepsy
understand that the first medication prescribed may not
completely control their seizures, but that other medications are
available. By discussing the individual's perceptions of
medication and his or her frustration with continued seizures
while on medication, health professionals maintain open lines of
communication, thereby reducing the probability of dropout.
The manner in which epilepsy is perceived is an important factor in the psychosocial adjustment of individuals with seizure disorders. When family, friends, and acquaintances relate with acceptance and understanding to the individual with epilepsy, good adjustment to the medical aspects of epilepsy is facilitated. On the other hand, when the individual is ostracized and feared, epilepsy can easily become a major psychosocial complication in the person's life.
In the Haitian community the stigma associated with epilepsy often resulted in' severe isolation and ridicule. Epilepsy was indeed a "hidden condition" in the Haitian community and was not openly discussed among community members. Individuals with epilepsy were maligned and feared. Consequently, they did not disclose their condition to others and avoided contact with all but their closest friends and relatives. Much of the stigma associated with epilepsy in this community was related to beliefs regarding spiritual causation. Beliefs that epilepsy was contagious also contributed to the isolation individuals experienced. However, even when informants believed that their condition was medical in nature, epilepsy was not generally discussed outside of the household. The hidden nature of the condition contributed to the perpetuation of the stigma within the community.
While the stigma of epilepsy was not as severe among Cuban and Black informants, there were distinct perceptions of epilepsy that impacted the manner in which individuals with the condition were treated within these communities. The majority of Black and Cuban informants with epilepsy stated that they were treated differently by the general community and often by family and friends. Among family members, overprotection and restriction of activities were the major problems cited. Among the general community, informants cited job discrimination and isolation as the major problems associated with their condition.
In all three ethnic groups, stigma was based on fear. Among Haitians, fear was associated with contracting the illness or being exposed to the seizure itself. (It is important to recall that only tonic clonic seizures were recognized as epilepsy among the Haitian general population informants.) Among Cubans and Blacks, fear was associated with witnessing a seizure. Informants with epilepsy stated that people were afraid primarily because they would not know what to do in the event of a seizure. Individuals with epilepsy were often viewed as less capable intellectually and socially.
associated with epilepsy in these communities can be combatted on
several levels. First, public education is greatly needed in
these communities, not only to facilitate seizure recognition,
but also to provide information on first aid practices to reduce
the fear associated with witnessing a seizure. Second, education
and outreach for individuals with epilepsy and their families is
needed to facilitate recognition of non-convulsive seizures,
assist families in coping with frustration regarding poor seizure
control, and reduce the likelihood of persons leaving the medical
Once the critical information needs of the target populations were identified through the use of the ERAP, the Epilepsy Foundation of America designed a public education campaign that included the development of culturally relevant educational materials and a media campaign with public service announcements on radio and television. Primary goals of the campaign included outreach and epilepsy education of individuals, families, and the general public from these ethnic groups, and increased awareness by affiliates and other health care professionals of the unique strengths, resources, and needs of the communities.
The materials developed as a result of the transcultural study Epilepsy Demonstration Project have been produced in both English and in Spanish and include television and radio public service announcements, radio announcements, posters on recognition, medical advances and first aid, press kits with newspaper ads and special articles for the press. It also includes a set of five of the most frequently requested brochures on epilepsy and on living with epilepsy.
Principles followed in the development and production of the campaign materials were those elicited from the ethnographic study through the use of the ERAP. These included using terms and idioms familiar to the communities as occasional synonyms for seizures; approaching folk or religious beliefs with respect, but emphasizing the need for a medical approach; addressing practices and beliefs that might limit options for the individual; using photos and graphics representative of the ethnic communities; using recognized figures of authority for conveying messages; and developing bright, colourful, and attractive educational materials that could be easily read.
Further, the Epilepsy Foundation of America has followed these principles in the design of other programmes and materials to maintain the cultural relevance for these groups. Additionally, EFA recently received national recognition for its transcultural education materials to consumers by the U.S. Food and Drug Administration.
strengthen the transcultural initiative nationwide, in 1989 EFA
awarded nine Outreach to Underserved grants
to local affiliates. One of the grantees chose to work with the
Hispanic community through the Catholic Church. Other grants were
directed to American Indians, migrant families, prisoners,
Hawaiians, the elderly, and rural populations.
1. Address all inquiries to: Nyrma Hernandez, Deputy Executive Vice President of the Epilepsy Foundation of America, 4351 Garden City Drive, #400, Landover, MD 20785.
1. Haerer AF, Anderson DW, Schoenberg BS. Prevalence and clinical features of epilepsy in a biracial United States population. Epilepsia; 1986; 27: 66-75.
2. Hauser WA, Annegers JF, Anderson VE. Epidemiology and the genetics of epilepsy. ARNMD; 1983; 61: 267-294.
3. Hauser WA, Hesdorffer DC. Epilepsy: frequency, causes and consequences. Landover, Maryland: The Epilepsy Foundation of America, 1990.
4. Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care. Anthropological approaches to improving programme effectiveness. Los Angeles, CA: UCLA, Latin American Center, 1987.
5. Long A,
Scrimshaw SCM, Hurtado E. Epilepsy rapid assessment procedures.
Rapid assessment procedures for the evaluation of epilepsy
specific beliefs, attitudes, and behaviors. Landover, Maryland:
Epilepsy Foundation of America, 1988.
Background: The WHO ARI programme
Requirements for effective FES research on ARI
Some commonalties in the results of the ARI FES studies
Summary and conclusions
By Gretel H. Pelto and Sandy Gove
Gretel Pelto is affiliated with the Department of Nutritional Sciences, University of Connecticut, Storrs, CT, and Sandy Gove is affiliated with the Programme for Control of Acute Respiratory Infections, World Health Organization, Geneva, Switzerland.
This paper describes the process of a thorough and systematic adaptation and testing of the original RAP guidelines and other field procedures to a specific primary health care area - Acute Respirator Infections. A number of specific methodological issues are emphasized, based on sequential field testing.
Tools used here but not emphasized in the original RAP guidelines include labelled cards for sorting and ranking activities and video tape. Both helped elicit reactions about signs of respiratory disease from the mothers. Subsequent studies identified the value of recording forms for the effective management of data collection. Adapting the structure of a study report to address answers to a set of questions predetermined as important to programme managers helped make the reports more understandable and useful to public health professionals.
This paper provides useful experience based suggestions for training in RAP, including the value of a workbook providing examples of data compilation and analysis. When fully developed, these guidelines for ARI will be a valuable addition to the specialized uses of RAP methods and will provide an example for those developing similar guides in other areas of primary health care. - Eds.
THIS PAPER DESCRIBES the developmental process we used to construct and test a protocol for conducting community-based, focused ethnographic studies of acute respiratory infections (ARI) in children. The development of the FES (Focused Ethnographic Study) protocol is a component of the behavioural research activities of the Acute Respiratory infections Programme of the World Health Organization. The goal of the project is to create research guidelines that will enable investigators to "generate" descriptive ethnographic data on beliefs and practices related to pneumonia and other respiratory conditions that can be used in the implementation of national programmes" .
Specifically, the research is intended to assist the following programmatic activities:
1. The development of advice on home care of children with ARI that will be understandable to mothers and other child caretakers. (A basic premise of this goal is that effective communication with mothers of young children requires information on the signs, symptoms, and associated terms by which mothers recognize illness and which correspond, in whole or in part, to clinically diagnosed pneumonia.)
2. The identification of factors that facilitate or constrain prompt seeking of care from health care providers who are trained in the standard case management of pneumonia.
3. The identification of maternal expectations concerning antibiotic and other drug therapy that can be used to anticipate common problems related to compliance and satisfaction with services.
4. The identification of other relevant cultural and economic characteristics and conditions that are likely to influence community responses to programme activities.
5. The improvement of household morbidity and treatment surveys that are used to monitor programme effectiveness, including suggestions for questions and terminology that reflect local cultural perceptions and practices.
The main objective of the Programme for the Control of Acute Respiratory Infections is to reduce mortality from ARI in young children in developing countries. Most of this mortality is due to bacterial pneumonia, and it is estimated that half of pneumonia deaths could be prevented if children with pneumonia are treated early with oral antibiotics. WHO has developed guidelines and training materials to assist health workers at first level facilities and community-based practitioners to efficiently identify children with pneumonia from the larger group of children with coughs and breathing problems, most of whom have only a simple cough or cold and need only home care.
deaths from pneumonia requires that caretakers recognize the
signs that indicate a child with an acute respiratory infection
may have pneumonia and then take the appropriate action of
immediately seeking care from a trained provider. Pneumonia can
kill within a few days; delays that occur when families try home
remedies or seek inappropriate care, can result in an infection
becoming so severe that the child cannot be saved by oral
antibiotics or by the care that can be delivered at a small
hospital. Given the crucial importance of caretaker recognition
and appropriate careseeking, the ARI Programme has given high
priority to behavioural research. Specifically, the first
behavioural research priority has been the development of
guidelines for research that provide insights for national
programmes on local cultural conditions.
The published literature in applied anthropology, as well as the informal lore among both social science and public health professionals, is replete with examples of the problems that are typically encountered in attempting to interface ethnographic studies with epidemiology and public health practice . For example, anthropological reports are often seen by public health practitioners as too diffuse, overly long, and full of irrelevant detail, to which the anthropological response is that the behaviours in question cannot be understood without "the context" the report provides. Another common complaint is that anthropologists take too long to complete the research and report writing. The anthropologists' counter that their reports molder away on a shelf, unused and gathering dust, so it is difficult to accept the demand for urgency. Yet another criticism, that the ethnographer's interpretation is medically naive, points to the need for better communication and collaboration between the social and biological scientists.
In the light of these and related problems, we generated a list of requirements for effective studies and attempted to address them in the developmental process of the FES:
1. The ethnographers have to understand the general goals of the WHO ARI Programme, and the specific goals of the country-level programme for whom the research is being conducted.
2. The ethnographers must understand how their results will be used to facilitate programme goals.
3. The ethnographers need to have some knowledge about the nature of the pathologies and symptomology that are classified under the rubric of "acute respiratory infections" and how these are manifest in sick children. Minimally, they need to understand the distinction between "lower" versus "upper" respiratory infections; the distinctions the WHO Programme makes between "severe pneumonia," "pneumonia," and "no pneumonia" (illness with cough or cold); and the observable clinical signs of pneumonia.
4. The research has to be completed in a relatively short period of time. The model of long-term participant observation research extending over many months in the field site, with many more months for analysis and write-up is not feasible. (It should be noted that this requirement is characteristic of much of applied anthropology and is not unique to applied research for the WHO ARI Programme.)
5. Ethnographers have to be able to communicate the results in a manner that is immediately intelligible and useful to ARI Programme Managers and other relevant administrative and training personnel.
6. Closely related to the preceding point, ethnographers must be willing to make concrete suggestions and put forth specific recommendations concerning the implications of their findings.
The best, most efficient mechanisms for achieving these outcomes were not immediately apparent at the beginning of the project. In fact, they are still evolving as we continue with the process of testing and refining the protocol and the training materials that accompany it. The protocol itself - the instructions on how to collect, analyze, and present the data - are the primary means for assisting ethnographers to meet project goals. Secondly, training materials (video and workbook exercises) and short training workshops are other means to support and facilitate projects.
The format of the protocol
The research guidelines are organized into six main parts, as follows:
1. Overview of the Project
2. Guidelines on Research Management
3. Specific Research Procedures
4. Preparing the Report
5. Next Steps: Using the Information From the Study
6. Adapting the ARI Household Morbidity and Mortality Treatment Survey.
In addition, a series of appendices provide materials and information on: (i) Training Ethnographers to Assess Signs of Pneumonia; (ii) A glossary of Terms; (iii) Logistics of Showing a Video in Field Conditions; (iv) Sample Drawings for Use in Card Sorting Tasks; and (v) Forms to help organize and monitor the research process.
The first part of the manual is aimed primarily at providing the ethnographer with the requisite background information described above. Thus, it includes sections on clinical and epidemiological features of pneumonia that are relevant for the ethnographic study, and a summary of the WHO/
ARI case management strategy. The expected uses for the study results are described, along with a description of the study design and an overview of the research procedures.
The most important piece in the first part of the manual is the section titled, "Programme Manager's Questions." These consist of 50 questions that have been derived from the ARI Programme Manager's Manual . The structural organization of the WHO ARI Programme places primary responsibility for implementation of national ARI plans in a national ARI Programme Manager, who is usually (although not always) an individual with clinical background. The handbook and associated training programme for ARI Programme Managers include specific and detailed discussion about the importance of obtaining data on local cultural and social characteristics that influence care-seeking and communication.
The Programme Manager's Questions are organized into six sections, concerned with: (I) caretaker and household recognition and interpretation of ARI signs and symptoms; (II) ARI household management practices; (III) patterns of care seeking; (IV) maternal (caretaker) expectations concerning ARI treatment and compliance with treatment recommendations; (V) perspectives of practitioners on maternal recognition and care-seeking, and (VI) recommendations concerning communication with mothers.
Some of these questions are very pointed and specific. For example, the first question in Section I is "Do mothers recognize fast breathing (rapid respiratory rate)? Do they recognize only very fast breathing or all fast breathing?" However, other questions are more general, such as, "What is the sequence and timing of careseeking [for a child with ARI] and how does this vary with the perceived severity of illness and other characteristics of the child?" or "What are the factors that influence the likelihood that mothers will return to the health centre if the child's condition worsens?"
The Programme Manager's Questions provide the underlying framework for the study. In Part D, Preparing the Report, the ethnographer is requested to report the study findings in the form of answers to these questions. Our intention, in placing the Programme Manager's Questions at the beginning of the manual as well as at the end in the section on report writing, is to orient the ethnographer to the critical sectors of information collection.
Specific data-gathering techniques in the protocol
The ethnographic methods detailed in the FES protocol are as follows:
1. Key informant interviewing as an exploratory phase
2. Free listing to elicit specific terms for illnesses, signs and symptoms
3. Eliciting narratives of past ARI events
4. Presentation of videotape showing children with ARI to assess the relationships of illness terminology to observable signs, and to assess ability to distinguish children with elevated respiration rates from children with normal rates
5. Presentation of hypothetical cases ("scenarios") to elicit careseeking and management practices
6. Card-sorting to link signs and symptoms to specific illnesses
7. Paired comparisons to examine choices among health providers and reasons for those choices
8. Rating of relative severity of ARI signs, symptoms, and illnesses
9. Inventory of medications in the homes
10. Interviews with mothers bringing children with ARI to health care providers
11. Interviews with providers concerning their perceptions of mothers' and other caretakers' management of ARI episodes
12. Eliciting of responses from pharmacists and other drug sellers
The steps in data-gathering in the protocol are intended to be completed in approximately five to six weeks, including the initial week of training and site selection. A longer period of research would be required if more than one cultural group were included in the study. Like the RAP protocol of Scrimshaw and Hurtado , the FES manual is intended for use by persons already trained in anthropological or related field methods.
The sequence of field studies
The first field study for the project was carried out in July-August, 1989 in Mindoro Oriente Province in the Philippines under the auspices of the Research Institute for Tropical Medicine (RITM). The research in the rural field site was conducted by a medical anthropologist, Mark Nichter, with the assistance of Mimi Nichter, a communications specialist . In the urban centre of Calapan, Maria Soccoro Sison-Castillo (anthropologist at RITM) undertook parallel data collection . The purposes of the study were:
1. The development of a "first approximation" of a community-based description of the cultural and behavioural aspects of ARI, which would include data concerning five sectors of information:
emic perceptions of acute respiratory infection, which was to be used to construct the explanatory model of ARI in the community
the relationship between the emic model and the biomedical model
identification of home-based therapies for ARI
health care seeking behavior for ARIs
relationship of ARI to other childhood diseases
2. The assessment of the utility of specific research procedures and community reactions to these procedures.
3. The identification of issues that required further investigation, modification and amplification in the next round of studies.
These initial studies provided critical insights into the nature of the issues and challenges that would confront researchers conducting focused ethnographic studies of ARI. Among the substantive findings of note that we expected would be likely to be of importance in the other parts of the world were: 1) the complexity of the explanatory models and extensiveness of terminology for ARI signs, symptoms and illness categories; 2) the importance of the sequencing in the appearance of signs and symptoms for parental interpretation of the illness; and 3) the importance of non-ARI signs (especially fever and rash) for the interpretation of ARI symptoms.
Methodologically, the summer research was also very instructive. For example, it confirmed the feasibility of using cards in sorting and ranking activities with literate informants and the tremendous value of the video for eliciting reactions about ARI signs from mothers. Of great importance to the next set of development activities was the recognition that data analysis was a major bottleneck for timely preparation of the report. As a result, we made the decision to include the guidelines for rapid methods of data analysis in the manual. The importance of establishing a system for coding and summarizing interview data in relation to a set of main questions was also reinforced.
Another issue that emerged from the summer research was the matter of consultants. Nichter suggested that regional workshops, or a short training programme in which a group of regional consultants was trained with the instrument, would probably need to be an integral part of the programme.
The next round of studies took place in Ankara and Ghana, the latter concerned mainly with techniques of eliciting terminology and interpreting terms in relation to observable physical signs. The Ankara study demonstrated the value of recording forms for the effective management of data collection and analysis; it also underscored the importance of providing training for the ethnographers in the recognition of signs of pneumonia.
The study in Honduras provided the evidence that - in the hands of a skilled ethnographer fluent in the language of the community - the study could be completed, including preparation of the report, in five to six weeks. The Honduras work also demonstrated that structuring the report as a set of answers to the Programme Manager's Questions provided a solution to the problem of making the report understandable and useful to public health professionals, without a further "translation" from the language of anthropology to public health discourse.
In the next set of field studies in Haiti and Egypt, a number of issues of field management emerged, which led to the addition of more concrete detail concerning administration of the research modules.
The first training workshop on the use of the FES Manual was held in Solis, Mexico in October, 1990. Researchers from Bolivia, Indonesia, Guatemala, and Mexico were given five days of intensive demonstration and practice with the specific data-gathering procedures, including techniques of interviewing during viewing of the videotape of children with pneumonia. The workshop also provided a forum for discussion of the underlying theoretical and methodological assumptions on which the FES is based.
workshop in Mexico demonstrated that the efficiency of training
could be enhanced by means of a workbook, in which participants
can work through concrete examples of data compilation and
analysis. The data examples used in the workbook are drawn from
the earlier FES studies. The workbook played a central role in
the next training workshop, which took place in Thailand in the
spring of 1991. This time the trainees were from Thailand,
Pakistan, and Iran.
As previously stated, the primary purpose of the ARI ethnographic studies is to assist national programme development. At the same time, comparisons across projects that use a common methodology can provide additional insights of potential usefulness for a variety of purposes. The field studies to date have been undertaken to develop and test methodologies; however, keeping in mind the purpose of these early studies and their preliminary nature, some elements of commonality and contrast have already begun to emerge. These generalizations will almost certainly be modified as further studies are carried out.
1. In all areas studied this far, we find that peoples' explanatory models of respiratory illnesses are complex, often with considerable differentiation of signs and symptoms.
2. In a number of widely divergent cultural groups, respiratory illnesses are thought of as linked developmental sequences, in which milder conditions are likely to progress into successively more severe forms, particularly if not effectively treated. The sequence that begins with symptoms of the "common cold" and progresses to more severe respiratory illnesses was identified in several of the studies.
3. Home remedies for ARI signs and symptoms are found in all the cultural groups studied thus far. When these are judged not to be working, people seek care outside the household, from either traditional or modern medical resources.
4. Studies in research sites in Africa, Asia, and Latin America all have found emic terms or phrases for common ARI signs and symptoms, such as kinds of "cough," "breathing difficulties," "fever," and "loss of appetite." However, specific signs of pneumonia - especially rapid breathing and chest indrawing - are not universally noted as such, and may be given widely different interpretations. For example, in some cultures chest indrawing is seen as a sign of an illness "in the stomach," or even as a sign of recovery because it indicates the muscles are strong.
5. In practically all cases, even in societies that use illness labels taken from modern medicine, the local terminology for illnesses does not correspond neatly with biomedical definitions of respiratory infections.
6. In all the areas studied, investigators have identified one or more illness terms that refer to severe respiratory illness. However, these illness terms (and the signs and symptoms associated with them) correspond only approximately to clinical pneumonia. Often more than one indigenous illness term can be found that refers to episodes that include the signs and symptoms of pneumonia.
7. The studies thus far suggest that cultures vary considerably in the extent to which attention is focused on specific illnesses (what Young,  refers to as "diagnoses") as contrasted with a focus on signs and symptoms. In some study areas, people appear to assess a child's condition and make decisions about treatment and care-seeking based on specific symptoms or combinations of symptoms, whereas in other cultures, parental judgments about the child's "illness" or "diagnosis" are more likely to influence household management.
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