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FORM 8.4 Summary Ranking of Food by Age Subgroup with Attribute Comparison (M5)

* Ranked from most to least using a 5-point scale (4 = highest, 1 =lowest, 0 = none)

During the study, the team can identify factors important in health decisions. Note that one of the scenarios focuses on a pregnant women suffering from nigh/blindness. The same information should be elicited for this scenario and the questions should be directed to the mother in the household. The case scenarios were developed to represent situations which commonly occur in regions where vitamin A deficiency is prevalent and to depict illnesses that typically accompany vitamin A deficiency. The intention is to gather information about the best or most suitable course of behavior and action that the respondent sees appropriate in each situation. Hypothetical case studies are used to diminish inhibitions that the respondent might experience if she were asked to respond to questions about her own family situation.

During the pretesting of this module with key informants, you will be able to assess whether or not the respondents are likely to be comfortable with the situations. If you find that hypothetical situations do not work, experiment with other possible ways to conduct the module. Since each scenario was developed for a different purpose, it is preferable that you follow the same general story line.

The case scenarios are varied to represent the signs and symptoms at different stages of vitamin A deficiency. The responses will provide an idea as to when mothers recognize the danger signs and how their advice differs according to the specific sign that is presented. The information will also show whether respondents identify some of the accompanying diseases as eye problems, and how they perceive these diseases. The age and sex of the children mentioned in the scenarios is also varied to get information on how these factors influence perception and action.

Each mother should respond to three of the five scenarios. The time allotted should be approximately one hour.

How to Prepare the Scenarios

The set of enclosed visual aids illustrating xerophthalmia should be used to go over the local terminology with the key-informants. The goal is to identify terms associated with the various stages of xerophthalmia depicted in the case scenarios. You will additionally need to identify local terms used for the other illnesses described in the scenarios, such as measles and diarrhea. You should also assess with key-informants the extent to which people recognize these stages, and according to their suggestions, you may change the story line. You may find that certain case scenarios are not appropriate for particular geographic locations.

Modify the scenarios to the local context:

Follow the basic format of the case scenarios below for the age and details about signs and symptoms of vitamin A deficiency. Include specifics to give local context so that the cases become more believable to the respondents. You will need to modify the text as follows:

i. Give the persons mentioned in the scenarios names which correspond with common male and female names in the region.
ii. Use appropriate local terms for the signs and symptoms and other features in the scenarios.

For example, dundumi is the local term for nigh/blindness in Hausa-speaking regions in West Africa. You would therefore substitute dundumi for nightblindness in Hausa-speaking regions.

Troubleshooting for problems that may come up:

i. Confusion about hypothetical cases. In some cultures, people feel uncomfortable responding to hypothetical situations. For example, mothers in one village were confused when the researcher said, "...when Elana, the mother, returned late at night from work." Their response was, "Women don't work and they certainly don't stay out at night."

Possible alternate solutions to the problem:

• As stated above, make slight alterations so that the situation described in the scenario corresponds with local conditions and practices.
• If the respondents indicate that the situation described is at variance with their lifestyle, present the situation as though it occurred in another region or as though it took place in the past.
• It is Important to use pictures or diagrams to depict the situation. Identify a local artist to draw pictures (photographs are another possibility) and create the case study around the characters illustrated. This will depersonalize the situation, making it more objective.
• When making use of case scenarios which include the various stages of xerophthalmia, it is critical that you use the pictures provided with this manual illustrating the progression of the disease. While describing the scenario and getting responses to the series of questions, you will want to make continual reference to these pictures.

«««Valoare a indentului diferita de cele prezente in lista actuala»»»ii. Fear of giving bad advice or giving the wrong answer. You «««Nivel inferior lui 2 pe indent <> de 0»»»may find that the respondent is concerned that the answers she gives may be considered wrong and as a result she answers the same way for each case scenario. In this case, the module may get better information if the format is changed. Possible ways to deal with this situation:

• You may find it easier to gather information if you personalize the situation. You may say, "If your child was suffering from nigh/blindness, what would you do?" Another possible approach is to ask the respondent how she would advise a friend or neighbor with a child suffering from the illness or problem given in the scenario. For example, you may say, "If a good friend's child had these signs or symptoms how would you advise her?"
• Use additional probing techniques to get the action that the respondent would take.

When testing this procedure one of the researchers found that mothers responded more readily when the module began by saying, "I saw a child in (town name) the other day. I'd like to ask you about this child."

Scenarios

Words and phrases marked with brackets [ ] should not be changed, as these are the basic features, signs, and symptoms to be explored. You can change names, gender of child, etc. to make it culturally appropriate.

i. Miguel is [three years old.] He is a [very active little boy] who has many friends in the neighborhood to play with. But [for the past week, as the day ends and the sun sets], Miguel [chooses to stop playing] with his friends. [He just sits alone.] Miguel [seems frustrated and sad and is afraid to move around.] [His mother], Fey, [has noticed his recent inactivity at nightfall and wonders what should be done. What do you advise?]

(When describing this situation, make sure that it is understood that there is something wrong with the child, not that the child just did not like to walk at night.)

ii. Maria's [mother] Elena returned to work [two months after] Maria [was born.] Maria's grandmother [takes care of her when] Elena is at work, [feeding eight-month old] Maria [formula from a baby bottle.] [Recently,] the grandmother [has introduced] Maria to white corn tortillas [a dietary staple low in vitamin A]. Since her mother returned to work Maria [has had frequent bouts of diarrhea.] [Four days ago,] Maria [got a fever, runny nose, and cough, followed by a sore mouth and diarrhea. Her appetite has decreased, and due to her sore mouth it is painful] for Maria [to eat. Today, a rash has appeared around] Maria's [eyes and on her neck.] Her grandmother [is concerned. What should she do?]
iii. Moussa [is small for a five year old. He has had a very difficult childhood suffering from continual bouts of diarrhea and malnourishment.] Moussa [was sick with a fever and rash but he is now better. Yesterday,] Moussa's mother Fati [noticed a white foamy patch on the white part of his eye. This afternoon the white part of Moussa's [eye appears to be dry and the white foamy area has gotten bigger.] Fati [recognizes that this is unusual but doesn't know what to do. What do you recommend that she does?] Use the pictures in the manual to show Bitot's spots or corneal xerosis.
iv. Maimouna [is seven months pregnant. She is more tired than she was during her first pregnancy, and is finding it difficult to keep up with her fifteen month old son] Ali. [Furthermore, as her pregnancy progresses she has noticed that it has become impossible to see at night. As the sun sets,] Maimouna [is swept into darkness and is unable to continue the household chores, particularly the preparation of the evening meal.] (Normally the lamp is not lit at that time, in order to save fuel and money.) Maimouna's husband Ahmed expects the evening meal to be ready for him when he returns home from a long day of work. [ What is wrong] with Maimouna? [Do you have any advice for her?]
v. Caesar [is two and a half years old. He was a happy baby full of vigor and good health until his second birthday when he was abruptly weaned. Since that time he has experienced a series of health problems including chronic diarrhea, and most recently a severe respiratory infection.] Caesar's mother Edna [perceived a white spot in his eye a week ago. Within a day the spot enlarged and his eye became noticeably dry.] Edna [noticed the dry texture of the eye but felt that it was a temporary affliction that would resolve itself with time. Quickly] Caesar's [eye began to deteriorate and today, only several days later,] Caesar [is blind in one eye. What happened to] Caesar? [What should] Edna [have done? Do you have any advice for her now?] Use the pictures in the manual to show Bitot's sports, corneal xerosis, and keratomalacia.

Procedures for Administering the Task

Before beginning this module it is important to ensure that the field assistants feel comfortable conveying the messages in each case scenario and have developed methods to deal with potential obstacles or problems when telling the story lines to the respondents. Additionally, in order to facilitate the recording of responses, it is important that the interviewers are familiar with local home remedies and ways in which traditional practitioners respond to the stages of xerophthalmia before conducting the interviews. It is therefore recommended that the research team go through many practice sessions before conducting the interviews among the respondents. When going through these sessions, keep in mind that a primary objective of this module is to identify local perceptions and practices related to vitamin A deficiency. In other words, the research team will strive to capture emic language and information which reflects the local population's vocabulary, conceptual categories, and belief system (see Glossary). It is suggested that the scenarios be translated into the local language before training the assistants.

As was already mentioned, in some cultures people are less comfortable with hypothetical situations. When conducting the pretest, you will have to determine the most appropriate way to present the scenarios. You will have to remain flexible and modify the scenarios to fit with conditions and terminology in the local population, but do not change the basic elements that are inside the brackets.

i. Prepare the recording forms by circling the three scenarios that have been chosen on each form. Attach three forms for each mother. If you plan on visiting several households, you will need to prepare accordingly.
ii. Introduce the scenarios by letting the respondent know that you are going to read (tell) several stories to her. Explain that after reading each story, you would like to ask her some questions. You might add that you have already gathered some information on problems associated with eye problems, including nightblindness (use the local term), and would now like to learn more about how these problems are handled.
iii. Read the scenarios, one by one, to the respondent. Record the mother's responses on Form 9.1 immediately after she has answered the questions for each scenario. Be as detailed as possible and be sure to record emic information.
iv. When the mother has finished responding to the first question, continue by asking additional questions which are included on the form in the order which you think is most appropriate and which will get accurate information. v. You may find it necessary to probe for more information. The following suggestions may help to encourage the respondent to give more content:

• What do you think is wrong with the child or woman (if you are referring to the scenario involving the pregnant woman)?
• Is there any other information you would like to know about the child and mother before you give advice?
• When should the mother (or caretaker) have sought care for the child?
• What are some other signs that the mother should watch for?
• Who (in your household, in your neighborhood) knows a lot about these kinds of eye problems?

If a home remedy is suggested:

• How long will it take for the home treatment to take effect?
• If there is no change in the child's condition, what are the next steps the caretaker should take? When should these steps be taken?
• What are the signs that would inspire the mother to take these steps?
• At what point should the caretaker seek outside treatment? Who in the household makes this decision?

Care administered by a health provider (traditional or modern):

• What type of healthcare provider would you seek advice from?
• Why would you choose this provider?
• What is the usual treatment for this problem?
• Does this treatment produce a cure for the condition?
• If so, how long does it take?
• What are some indications that the child/ woman is getting better?
• If there is no improvement after a treatment what should the mother do?
• Is there anybody else she should seek treatment from?
• How does this health provider compare to others? Who are some of the other healthcare providers she might go to? (Probe for differences among the healthcare providers).

vii. If you find that respondents give more than one response to «««Valoare a indentului diferita de cele prezente in lista actuala»»»«««Nivel inferior lui 2 pe indent <> de 0»»»the questions, be sure to record all of the answers and comments that the respondent makes on Form 9.1. Through this module you may uncover valuable information related to the perceived seriousness of the problem, factors involved such as access to health facilities, costs, reception of the client by the health practitioner, time involved, etc., in deciding whether care outside of the household is necessary; who the decision- maker is in the household regarding healthcare, and other factors which influence health-seeking behavior. Remember that it is important to conduct this module in an informal, conversational fashion.
viii. Once the modules have been completed and the team returns to the team meeting site, go through the individual forms to ensure that the responses are complete and legible.

FORM 9.1 Scenario Form for Individuals (M6)

Use one form for each scenario presented to the respondent

Procedures for Analyzing the Data

i. For each case scenario, create a list of all of the responses to the initial group of questions. Group similar responses together and tabulate the answers on Form 9.2, putting a check in the appropriate box. To make a clearer illustration of health-seeking behavior you may find it useful to present similar responses on separate tabulation forms.

For example, answers to the question, "What illness does the child have in case scenario A?" could include:

a. "The child is tired and the body is weak."
b. "The child is suffering from nigh/blindness."
c. "A spirit has done this to the child."
d. "A part of the child's body hurts, is not well." ]
e. "This is the illness which affects children when the sun sets."
f. "The child has been affected by bad spirits."
g. "The child has a fever within his body."

The responses could be grouped as follows:

1. Child is weak or ill. (a, d, g)
2. Child is suffering from nightblindness. (b, e)
3. Child has been affected by a spirit. (c, fl

Separate all of the responses to the initial questions according to similarities and tabulate the responses for each case scenario on Form 9.2.

ii. For each scenario, make a list of all of the responses to the questions about homecare practices. Group together responses that are similar and assign a label to each such category. Using your categories, tabulate the responses on Form 9.3. If you find it easier to use a separate tabulation form for each home remedy mentioned, by scenario, you will need many forms to analyze the data.

For example, responses to the question, "Who in the household makes the decision to seek outside assistance?" could include:

a. "The father of the household."
b. "The menfolk."
c. The uncle.
d. "The husband."
e. "Husband and his father."
f. "Mother of the child."
g. "Grandmother."
h. "Mother-in-law. "
i. "Husband's mother."
j. "Wife's mother."
k. "The older women who know..."

In this case, your categories will be:

1. Male household heads (a, b, c, d, e)
2. Senior women ( g, h, i, j, k)
3. Mother/caretaker of the child (f)

Responses about treatments could include the following:

a. "The child should be fed hot foods."
b. "The child should stay in bed until he or she feels better."
c. "The child should be fed some grilled liver."
d. "The child should be given medicine in the form of a capsule."
e. "The nurse would tell me to feed (child's name) foods that are vitamin-rich and will allow him or her to regain his or her health."
f. "The child should be administered an injection."
g. "Give the child palm oil."
h. "Should give some__________ (medicinal) tea."
i. "The _____________ceremony."
j. "Strong medicine from the pharmacy."
k. "Those red and yellow pills we see at the marker."
l. "Give the child eggs."
m. "Rub lightly with____________ leaves (a local plant).
n. "Feed the child rich foods (a local emic category)."

These responses can be grouped (categorized) as:

1. Foods (a, c, e, g, 1, n)
2. Rest/bed (b)
3. Medicine (capsules, tablets) (d, j, k,)
4. Medicine (injections) (f)
5. Teas (h)
6. Other (i, m)

iii. Continue by coding and tabulating the remaining responses to th«««Valoare a indentului diferita de cele prezente in lista actuala»»»«««Nivel inferior lui 2 pe indent <> de 0»»»e open-ended questions. Make a list of all of the individual answers to each question and combine (group) any responses that are similar in their general meaning. If you are doubtful whether responses are similar enough to be combined, list all of the answers separately. Use a code to tabulate responses about time needed-for example, one to three days, four to six days, one week, etc.
iv. Tabulate all the answers and record them appropriately in Form 9.2. Be sure to mark the scenario to which the response corresponds.
v. Make a list of all of the practitioners/healthcare providers or health services that are mentioned in each scenario. Combine any health providers that could be categorized under the same term. For example, if nurse is mentioned frequently, as well as health clinic, and you know that the nurse is the only person who administers healthcare in the health clinic, combine these two responses in a single category. Use codes to record time needed for improvement.

Tabulate all of the answers to healthcare providers and record them on Form 9.4. Once again, since the space is limited in the table, you may need to create your own form following the same format or use a separate form for each of the grouped responses. Be sure to mark the scenario to which the response corresponds.

vi. The following example illustrates how you would analyze why people choose to see a particular healthcare provider.

FORM 9.2 Summary Scenario Form (M6)

FORM 9.3 Summary Case Scenario Tabulation Sheet: Homecare (M6)

Content Analysis of the Explanation for the Choices

a. The question, "Why do people choose to see a particular healthcare provider?" generally results in brief statements.

Examples are: "Cheaper." "She always provides a cure." "He speaks my language." "He is easy to get to." "She has the strongest medicines." "He is better able to assess the problem."

b. Make a list of all of the responses and group them into categories. The following categories should cover most of the responses, but you may need to create additional categories:

• Economic reason ("Cheaper." "She will accept gifts." "You get your money's worth.")
• Belief in modern drugs ("She has the strongest medicines." "His medicines always cure.")
• Belief in traditional medicines and practices ("Traditional medicines are more powerful.")
• Convenience, social access ("She lives very close to my home." "She understands my needs.")
• Special qualities of the practitioner ("She knows some very important people." "She is better able to evaluate the problem.")
• Negative qualities of the practitioner ("She yells at me every time my child gets ill." "I saw her ridiculing another mother.")

c. Record the descriptive paragraphs.

Of course it is quite likely that the significant categories in any particular local area will be different from this hypothetical example. You should modify these groups or categories to take into account the special features of your area.

vii. Code and tabulate the remaining responses to the open-ended questions as you did on Form 9.3.
viii. Tabulate all the answers and record them on Form 9.4. Be sure to mark the scenario to which the response corresponds.

FOR M 9.4 Summary Scenario Form-Healthcare System (M6)

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