Step 5. Identify possible approaches

1.Make lists of beliefs and practices
3. Review findings and possible approaches with CDD advisors
4. Develop a list of additional questions

Persons: You, the field workers, and the program advisors

Time: 2-3 days

This step involves reviewing the information collected, identifying existing beliefs and practices related to AHM behaviors, developing a list of possible approaches to promote these recommended practices, and drafting a set of additional questions to pose to key informants. It requires a series of meetings and discussions, first between the researcher and the field workers, then with CDD advisors.

1.Make lists of beliefs and practices

With the assistance of your field workers, review the revised field notes from key informant interviews, case history narratives, results of card-sorting exercises, and the decision models. List all the beliefs, practices, and recurrent themes that may relate to communicating the practices of appropriate household management (AHM)1 of diarrhea.

Make separate lists for each household management practice that the program or project seeks to encourage. This will usually result in at least four lists, but the priorities of different programs will vary. For example, some programs may be particularly interested in discouraging the inappropriate use of antibiotics and antidiarrheals. In that case, make a separate list related to drug use.

After drafting the lists, identify beliefs or practices that are likely to be helpful in encouraging AHM, those that are likely to be harmful, and those that have an unknown effect. A format for doing this is suggested in the following sections.

Giving extra fluids during diarrhea

The following questions may help to identify beliefs and practices related to giving extra fluids, but do not limit yourself to them:

• What are the cultural guidelines about giving extra fluids during illness? During diarrhea! illnesses?

• What signs and symptoms of diarrhea are of most concern to caregivers and are most likely to trigger action?

• Can any of these signs and symptoms be relieved by giving fluids? Is there concern about water loss during diarrhea?

· Are any actions taken during diarrhea to strengthen the child?

• Where do people think the fluid goes after the child drinks it?

• Do they perceive any bad effects of drinking during diarrhea?

• Do they think it is possible to drink too much fluid? (See Example in Table 3.3)

Table 3.3

EXAMPLE: Researchers in Baluchistan identified the following beliefs and practices related to giving increased fluids and classified them according to their presumed helpfulness in promoting AHM.

Belief or Practice	Helpful	Harmful	Do not know
Children often are more thirsty when they have diarrhea	X
Thirst comes from excess "heat" in the body, not necessarily from fluid loss		X
Traditional medicines (e.g., teas made from local plants) are used to treat thirst			X
Giving fluids during diarrhea might make it worse and lead to vomiting		X
Prolonged diarrhea causes weakness	X
Loss of water from the body can be dangerous	X
It is not good to give extra fluids, including ORS, to young babies			X

Giving ORS or SSS

Now list beliefs and practices related to using ORS and SSS. Consider but do not limit yourself to the following questions:

• Are people aware of the ingredients of ORS or SSS? How do they perceive them?

• What are caregivers' experiences with, and perceptions of, ORS and SSS?

• Can ORS or SSS be promoted as acting in the same way as any traditional treatments?

• How do people prepare ORS or SSS? Are there any problems with container size or measuring utensils?

(See Example in Table 3.4)

Table 3.4

EXAMPLE: Researchers in Baluchistan identified the following beliefs and practices related to ORS and SSS and classified them according to their presumed helpfulness in promoting AHM.

Belief or Practice	Helpful	Harmful	Do not know
Give sugared drinks when children have diarrhea because sugar "gives strength," children like the taste, and sugar, which is humorally "cold," is considered helpful in "cooling" the stomach	X
Humorally hot substances, such as salt, should not be given during diarrhea, which is a hot disease		X
Salt hurts when it is rubbed into wounds and should not be given when the stomach is "sore" and "injured"		X
Children do not like the taste of ORS because it is "too salty"		X
Intravenous drips are the best way to treat diarrhea and are "strong medicine" because the fluid goes directly "into the veins"		X
Different actions are necessary for different types of diarrhea. For example, if ORS or SSS were to be promoted as a cold solution, it would not be used if the child also had a cold illness such as a cough		X
Measuring a certain amount of water and mixing an entire liter of ORS or SSS at one time seems difficult and wasteful		X

Encouraging feeding

List beliefs and practices related to continued breast-feeding and feeding during diarrhea, and to increased feeding during convalescence. Consider but do not limit yourself to the following questions:

• What are the cultural guidelines about breast-feeding and feeding during illness? During diarrhea! illness?

• What do people think happens to food after it is eaten? How does it affect the body? Is the relationship between food and growth or between food and strength recognized?

• Do people fear any bad effects of breast-feeding or feeding during diarrhea?

• What are local beliefs about how to produce a healthy child or to avoid having a child become "sick"?

• What are local beliefs about special foods to be offered or avoided during diarrhea?

(See Example in Table 3.5)

Table 3.5

EXAMPLE: Researchers in Baluchistan identified the following beliefs and practices related to feeding during diarrhea and classified them according to their presumed helpfulness in promoting AHM.

Belief or Practice	Helpful	Harmful	Do not know
Failure of the body to digest foods properly is a characteristic of many folk types of diarrhea			X
The stomach is the center of the body. Food digested in the stomach and nutrients go from there to other parts of the body. The stomach is connected to other parts of the body by "veins"	X
Children cannot digest foods as well as adults. Diarrhea results when children eat foods that they cannot digest			X
Like any other container, the stomach gets "dirty. " It is good to clean out the stomach from time to time		X
Caregivers try to feed children with diarrhea but report that children lose their appetite			X
Caregivers sometimes withhold food when diarrhea is prolonged (more than 1 week) or recurrent		X
Breast milk can go bad and cause diarrhea		X
Powdered milk can cause diarrhea	X
Many women believe they have insufficient breast milk and need to supplement it with powdered milk		X

Recognizing and responding to danger signs

List beliefs and practices related to recognizing and responding to the danger signs of diarrhea. Consider but do not limit yourself to the following questions:

• What signs and symptoms of diarrhea are of most concern to mothers and are most likely to trigger action?

• What signs or symptoms are most likely to lead to seeking care from a biomedical provider?

• What signs or symptoms are most likely to lead to seeking care from a nonbiomedical provider?

• What are the obstacles to seeking prompt care from biomedical providers?

• Are caregivers concerned about water loss during diarrhea, and what words do they use to describe it?

• Are there any signs and symptoms that encourage dangerous treatments (such as giving enemas or laxatives, extracting teeth, or cutting the body)?

(See Example, Table 3. 6)

Table 3.6

EXAMPLE: Researchers in Baluchistan identified the following beliefs and practices related to danger signs and classified them according to their presumed helpfulness in promoting AHM.

Belief or Practice	Helpful	Harmful	Do not know
The type of diarrhea and the action taken are determined by a number of factors, including signs and symptoms, the child's age, stool characteristics, and events in the child's life			X
During the first 1 or 2 days of diarrhea, children are usually just observed and not treated			X
Profuse or frequent diarrhea (more than 4 times a day), vomiting, weakness, and thirst lead to earlier intervention	X
Action is usually taken if the diarrhea lasts more than 2 days	X
Enemas and laxatives are given to children with watery diarrhea and a hard or swollen stomach ("constipation diarrhea") and to children with stool with undigested pieces of food in it ("indigestion diarrhea")		X
Diarrhea associated with a sunken fontanelle is treated by trying to raise the fontanelle (by applying a plaster to the head or by pushing up on the soft palate or uvula)		X
Although caregivers think that water loss is dangerous, they treat it by trying to stop the diarrhea and not by giving extra fluids		X

2. Explore possible approaches to promote AHM practices

Approach refers here to a word, image, or explanation that links new ideas about the management of diarrhea with familiar beliefs and concepts. Review your lists and identify some general ideas for explaining and promoting each AHM practice. How can you use existing beliefs? Can you draw on caregivers' concerns about signs and symptoms? Can you make use of the local folk physiology to explain recommended practices? Consider all ideas at this point, even those that may be problematic.

This section continues the example of Baluchistan. Your study results may suggest some of the same approaches, but you should also develop different ones that are specific to the context in which you are working. Although the example focuses on promoting ORS, the same methodology applies to the other AHM practices:

EXAMPLE: Possible approaches for promoting ORS:

• ORS prevents and treats thirst;
• ORS prevents and treats weakness due to diarrhea;
• ORS replaces the water lost during diarrhea;
• ORS is strong medicine like an intravenous drip; it goes directly into the veins;
• ORS cleans out the stomach;
• ORS cools the stomach.

List the advantages of each approach. Is it supported by existing beliefs? Does it give you a way of discouraging or getting around harmful beliefs? Does the approach apply to the majority of diarrhea types?

Next list the disadvantages of each approach. Are there potential points of misunderstanding if the ORS component of AHM is explained n this way? Review the lists of harmful beliefs and practices. If you cannot think of any way to get around them using the approach, list them under the disadvantages.

Now list the additional information you need to assess each approach. You may need to know more about what your participants think about digestion, how the body works, or the amounts of traditional medicines given.

An example of the process of listing advantages, disadvantages, and additional questions is continued for three of the possible approaches identified during the Baluchistan field test:

EXAMPLE: An Assessment of possible approaches to promoting ORS

• ORS prevents and treats thirst

Advantages

• There are traditional medicines that treat thirst

• Treating signs and symptoms may avoid the problem of different actions for different folk types of diarrhea

Disadvantages

• Thirst is caused by heat, not fluid loss
• Does not address the reluctance to give ORS to babies
• Does not address the issue of fluids causing more diarrhea and vomiting
• Does not address problems of salt, taste, and measuring

Questions

• Do caregivers perceive that all types of diarrhea make children thirsty?
• How much fluid is given with traditional medicines?
• How do caregivers recognize thirst, especially in infants?
• ORS replaces water lost during diarrhea

Advantages

• Caregivers recognize water loss as dangerous
• Replacing water may avoid the problem of different actions for different folk types of diarrhea

Disadvantages

• There are no home remedies or actions that act this way
• Does not address the reluctance to give ORS to babies
• Does not address the issue of fluids causing more diarrhea and vomiting
• Does not address problems of salt, taste, and measuring

Questions

• Where does the water in diarrhea come from?
• What happens when a child drinks fluid or eats something?
• What can be done about water loss?
• ORS is a strong medicine like IV drips, going directly into the veins

Advantages

• Used for all types of diarrhea regardless of the cause
• Because it goes into the veins, hot versus cold qualities are not considered important
• Salt may be less of a problem if it goes into the veins

Disadvantages

• Does not address problems of taste and measuring
• Does not address the issue of fluids causing more diarrhea and vomiting

Questions

• What do people mean by "veins"?

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