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Homero Martínez and Jean-Pierre Habicht
A strategy to develop a programme for the fluid management of acute diarrhoea in childhood, based on culturally and medically sound home-based practices, is presented. The strategy outlined comprised a sequence of studies. The first was an ethnographic description of home practices in the study area, oriented to identify mothers' beliefs and practices regarding fluid management during acute diarrhoeal episodes, with the aim of selecting one beverage that could be used as a rehydration solution. Once the beverage was selected, the second study consisted of a clinical trial to test the efficacy of this beverage, compared with standard oral rehydration salts (ORS), in rehydrating children with acute diarrhoea. Having proved the clinical efficacy of the beverage, the third study consisted of a public health intervention, in which the use of the home-made beverage was promoted with the specific intention of rehydrating diarrhoea-affected children. Characteristics of the acceptability, preparation, and use of the promoted beverage at the community level were compared with those of ORS. A distinct feature of the strategy outlined was the attempt to follow a "from-the-village" approach to tailor the intervention, taking into account the mothers' beliefs and practices as well as medical criteria.
Acute diarrhoeal diseases are a major health problem in the developing world. They are responsible for an estimated 4.6 million infant deaths each year [1], usually related to the accompanying loss of water and electrolytes caused by the acute episode. In addition, repeated episodes among survivors are a major cause of growth stunting, accounting for approximately 25% of the growth differential between children from developing countries and those from more privileged areas [2-4].
Comprehensive therapy for diarrhoea should include sustained feeding if no dehydration is present, or early reintroduction of foods once rehydration has been achieved, preferably locally available foods [5]. Oral rehydration therapy using pre-packaged oral rehydration salts (ORS) is effective in preventing and curing dehydration secondary to acute diarrhoea [6]. However, several regional and national studies have shown low acceptability of ORS by both mothers and physicians [79]. The causes are various: poor availability of the prepackaged salts at the home level [8, 10], inadequate information about the need to rehydrate a child with diarrhoea [11], inadequate expectations regarding the therapeutic role of oral rehydration [12], resistance of physicians to prescribe the therapy [13-15], and rejection by the non-dehydrated child due to the flavour of the solution [16].
The following series of three articles describes a programme developed to find effective home-based methods of fluid management of children with diarrhoea. The strategy has two features: first, the attempt to find better ways to tailor medical intervention to actual practice based on a from-the-village approach, and second, the sequence of studies that made up the programme.
The first phase of the programme consisted of an ethnographic study carried out in a rural area representative of a population where diarrhoea was a common problem, where the research could identify actual practices to deal with the disease at the home level, and where the intervention-related findings would be relevant to other areas of the country. The purpose was to identify mothers' beliefs and practices regarding fluid management during acute diarrhoeal episodes in their children. This first study was aimed at reconciling two different approaches to diarrhoea management: villagers' and clinicians'.
Mothers and other caregivers in the family and the community employ various strategies to deal with daily health problems. Drawing on experiences from all these sources, each mother develops a system of beliefs related to disease [17] and a set of actions to resolve her child's health problems. Several factors influence her choice of treatment, including experience with the treatment, availability of the remedy or medicine, and cost and social value of that therapy [11, 18-20].
The medical training physicians receive in hospitals conforms to scientific theories of disease. These are based on understanding basic medical sciences and on awareness of the alterations in normal body function caused by disease. Treatment of a given illness is meant to restore normal function. In the case of infectious diseases, treatment also entails getting rid of the noxious microorganism.
Thus, medical practice emphasizes disease management and pays little attention to the patient's understanding of it. This approach is usually effective when dealing with life-threatening conditions in the hospital; however, outside the hospital boundaries, it is less useful. The treatment has to fit into the patient's explanatory model of the disease if the patient is going to comply with it. The from-the-village approach permits reconciling the mother's and the clinician's approaches by selecting a common village practice that at the same time conforms best to the scientific concept of an appropriate treatment.
It turned out that the best home-made beverage, a rice-based gruel, did not fully conform to clinicians' perception of adequate therapy. Therefore, the second study was a randomized clinical trial to assess the rice gruel's efficacy as an oral hydration solution under controlled clinical conditions in the Hospital Infantil de México, a tertiary-level paediatric hospital in Mexico City. This trial was carried out under extreme conditions, as the beverage was evaluated in children judged to be ill enough to warrant admission to the hospital for rehydration, although its eventual use was intended for children with less severe diarrhoea cared for at home.
This phase was important for meeting the ethical concerns of clinicians by ensuring the efficacy of the beverage before attempting to implement an intervention at the community level, and also for political reasons. The hospital was the main teaching and training facility for the National Program for Oral Hydration Therapy (NPOHT), and the head of this programme was invited to join as co-investigator. In that way, when the trial proved the efficacy of the rice-based beverage, the results not only were not disputed, but were eventually incorporated into current practices of the NPOHT.
A final phase consisted of a field trial to teach mothers to give the beverage to their children with acute diarrhoea. We assessed mothers' acceptance of these recommendations through a controlled, randomized, community-based study comparing the acceptability and adoption of the rice-based gruel with ORS.
A similar programme was also carried out by the same study team in relation to food management of acute diarrhoea. These results will be published elsewhere. We hope that the model can be replicated by other investigators, and that their results will prove as encouraging as the ones presented here.
The authors acknowledge Drs. Robert E. Black and Kenneth H. Brown for their ideas, input, and feedback, which helped to clarify the approach described in this paper, and their subsequent strong support and encouragement. The present programme received financial support from the United Nations University, the Applied Diarrheal Disease Research Project of Harvard University by means of a cooperative agreement with the US Agency for International Development, the National Institute of Nutrition in Mexico, and the Children's Hospital.