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The domain of women's illnesses

Unit 12. Ranking: Women's Health Problems by Severity

Purpose

The purpose of this procedure is to obtain data concerning people's perceptions of the relative seriousness (or severity) of women's illnesses. Research on illness categories in a number of different cultures has demonstrated that the perceived relative severity of an illness is a mayor criterion affecting choices of practitioners, types of treatment, and readiness to expend resources to seek remedies.

Data Collection

1. Prepare Materials. Choose 10 to 20 key illnesses/ symptoms of women. You may wish to use the illness terms generated in Unit 4. Prior to using the instrument, the key illnesses should be randomly written on the left column of Form 12.1. Note: Make the order of the illnesses different for each individual respondent.

2. Selection of Respondents: 10 to 20 respondents, selected to be as representative as possible of the local community.

3. Suggested Wording:

"In our talks with people here in (community), we have heard about the following common illnesses of women.

Read the whole list of 10 to 20 illnesses/symptoms.

"Now I would like to ask you about how serious, or how mild, each of these illnesses are. Please tell me which of these illnesses are usually serious. Which ones are usually not serious, and which of these illnesses would you say are 'in between' ...somewhat serious but not as serious as these others?"

"Is (first illness/symptom on list) severe? mild? or in between?"

Continue for all 10 to 20 illnesses. When you have completed this exercise for all the illness/ symptom terms, read the list of illnesses described as severe, and ask:

"Why are these illnesses severe?"

Record answer in the space provided on Form 12.1. Then read the illnesses described as neither mild nor severe, and ask:

"Why are these illnesses neither mild nor severe.

Record answer in the space provided on Form 12.1. Then read the illnesses described as mild, and ask:

"Why are these illnesses mild?"

Record answer in the space provided on Form 12.1.

Data Analysis

1. Tabulate the Severity Data. To tabulate the responses, list the illnesses along the left hand side of a tabulation sheet (Form 12.2) and the three severity ratings across the top. Record the results from the individual sheets, placing a check mark in the appropriate box. Most illnesses will have "votes" In more than one column, as some people consider an illness to be serious, while others consider it "intermediate," or "mild".

2. Calculate an Overall Severity Score for Each Illness. Score the relative severity of each illness by assigning a number value to each category of severity. For instance, '2' for each severe 'vote,' '1' for each intermediate 'vote,' and '0' for each mild 'vote.' Thus, in the following example, white discharge is considered the most severe with a score of I 5.

[(2x6 severe votes) + (1x3 intermediate votes) + (0x1 mild vote)= 15]

3. Create a Ranking for Each Illness Based on the Raw Severity Scores. Higher numbers indicate greater severity. Record ties as the same ranking number.

Interpretation

1. A high score indicates that people consider this illness more severe. Do local perceptions of illness severity agree with the institution's (health center or your NGO programme) priority illnesses?

2. Examine the distribution of votes. Note that backache and fever have the same score, but very different distributions. There is more agreement about severity for backache. Where there is less agreement (e.g., fever), it may mean there are two different perceptions of the illness. Some people may think of fever in terms of malaria or some other 'severe' illness, while others may look at it as a symptom. You may need to do some open-ended interviewing to explore these issues further.

3. What do people think of when they say a term is "severe?" Is it based on reduced ability to work, pain, threat of death? Some other feature?

DATA COLLECTION FORM 12.1
Illness Severity Recording Sheet (sample)

Why are (read Pile-1 illnesses) severe? can cause infertility
Why are (read Pile-2 illnesses) neither mild nor severe? should see a doctor, but can be cured easily
Why are (read Pile-3 illnesses) mild? a part of life, no need to see a doctor

DATA ANALYSIS FORM 12.2
Illness Severity Tabulation Sheet (sample)

On a second copy of this form, illness terms can be re-ordered in order of decreasing severity scores.

Unit 13. Semi-Structured Key Informant Interviewing: Determining the Causal Links between Women's Illnesses

Purpose

1. To differentiate between closely related/overlapping illness concepts in terms of perceived causality, progression, preferred treatments, etc..

2. To develop an overall explanatory model of women's illnesses in the research community.

Data Collection

1. Prepare Materials. Select a subset of 5 to 7 key women's illnesses for focused study.

2. Develop a semi-structured instrument for recording perceived causes of women's key illnesses (see Form 13.1).

3. Suggested Wording.

"In our discussions with women here in (community name), a number of common illnesses of women have been mentioned. These include (read different illness terms)."

"We want to learn more about these illnesses. We are interested in your opinion about their causes. What do you think is the cause of (give first illness term)? Are there other causes?"

Complete the list, filling out Form 13.1.

4. Develop a semi-structured instrument for determining links between key illnesses (Form 13.2). Choose three main illnesses that appear interlinked in the local conceptual model (more illnesses may be selected, but it becomes difficult to give every combination to each informant).

5. Suggested Wording.

"There are still some illnesses we are confused about. We are interested in your opinion about them. Q1: How are (illness 1) and (illness 2) different from each other? How are they related?" Q2: Same for illnesses 1 and 3; Q3: Same for illnesses 2 and 3; Q4: Relate these 3 illnesses to another illness.

Complete the list, filling out Form 13.2.

Data Analysis

1. Develop an Ethnomedical Model of Key Women's Illnesses using the data from this unit (if you want, you can draw in data from other units as well). There are many ways for presenting an Ethnomedical Model of an Illness (or in this case, several interrelated illnesses).

2. Construct a Flow Diagram of Perceived Illness Causes.

a. On a blank sheet of paper, write the names of the illnesses - each one above the other.

b. Take the first informant's description of the causes of these illnesses. Somewhat to the left of the illness terms, write the name of the perceived causes, connected with an arrow (indicating causality). Put a tick mark above the arrow to indicate that this pathway was mentioned by one person (so far). Keep making arrows to indicate different causal pathways for different illnesses perceived by the woman.

c. Continue to draw this picture adding in the other women's perceived illness causes. Each time a particular cause is utilized, place another tick mark over that arrow. The picture will get complicated, especially if you have many informants, with multiple overlapping lines. You will need to redraw the picture to get a clean copy.

3. Construct a Flow Diagram of Perceived Illness Progression.

a. Tabulate responses to Form 13.2 (Illness Interrelationships) on Form 13.3. It is likely that there are a limited number of relationships between illness terms, for instance: progression (one leads to the other). causal (they have similar perceived causes), unrelated, and so on. Identify the most frequently mentioned types of interrelationships.

b. Using the results of Form 13.3, select the most commonly mentioned relationships (i.e., those mentioned by 25% or more of respondents). Take the first informant's description of the interrelationships between the illnesses.

c. Modify Form 13.4 to utilize the types of interrelationships most frequently mentioned by informants. In the example given, the main types of relationships that will be depicted are causal, progressive, and associated signs and symptoms. There are many ways to create this model.

d. On Form 13.4, write the names of the two illnesses most frequently mentioned (Form 13.3) by the key informants. Where you place the names will depend on the relationship between them. If one of the illnesses is seen as leading to the other, you would place the first illness under the heading Illnesses (Early Stage), and the second under the heading

Illnesses (Later Stage). Draw an arrow from the first to the second illness and write the frequency of mention above the arrow. Alternatively, you can have different levels of frequency indicated by different types of arrows (i.e., very frequently mentioned (75-100% (r)), frequently mentioned (50-74% (r)), mentioned sometimes (25-49% (r)).

e. Take the next most frequently mentioned interrelationship and add it to the chart. Keep making arrows to indicate different pathways for different illnesses perceived by the woman. The picture may get complicated, especially if you have many informants, with multiple overlapping lines. You may need to redraw the picture to get a clean copy.

Interpretation Suggestions

1. How does this explanatory model relate to the analyses of treatment-seeking behavior you have already conducted? Does this model help you understand why allopathic health services (particularly those you provide) may be bypassed in some instances?

2. At some point, you may wish to show this explanatory model to some of the best key informants in the community and see if they agree or disagree with the relationships that you have diagramed.

DATA COLLECTION FORM 13.1
Perceived Causes of Common Illnesses (sample)

We want to learn more about these illnesses of women. We are interested in your opinion about the cause of these illnesses. What do you think is the cause of illness? [Probe to get complete answers ... in full sentences.]

DATA COLLECTION FORM 13.2
Differences and Similarities Between Common Women's Illnesses (sample)
_______________________________________________________________
1. How are safed paani and khamjoori different from each other, and how are they related?

How different: Safed paani does not affect my ability to work, while khamjoori makes it hard for me to work.

How related: Khamjoori can lead to safed paani in women.
_______________________________________________________________

2. How are masik takliff and khamjoori different from each other, and how are they related?

How different: Masik takliff should be treated by the dai, but you should see the doctor for khamjoori.

How related: Both are problems that women especially set here in the village; women with masik takliff often develop khamjoori.
_______________________________________________________________

3. How are masik takliff and safed paani different from each other, and how are they related?

How different: Safed paani ´e much more serious then masik takliff.

How related: Both of these problems happen to women, especially after they have had the family planning operation.
_______________________________________________________________

4. How are these three illnesses related to kamar dukhe? To taav? To TB ?

How different: Those other illnesses can happen to anyone, while the first three happen mostly to women.

How related: All of these happen to vulnerable people, like women and children

DATA ANALYSIS FORM 13.3
Comparing Interrelationships Between Illnesses (sample)

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