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1. Diarrhea case management
2. Oral rehydration and feeding
3. Appropriate referral
4. The cultural context of diarrhea
References
Diarrhea ranks with acute
respiratory infection as one of the top two causes of childhood
death in developing countries. Most episodes of childhood
diarrhea last one to seven days and are characterized by
frequent, loose, or watery stools. Deaths associated with this
type of diarrhea result from dehydration - the excessive loss of
fluid from the body.
Dysentery, defined as diarrhea with blood, is particularly dangerous. The blood results from damage to the lining of the gut. The germs that cause bloody diarrhea can also spread from the gut and infect the blood and other organs of the body.
Children with diarrhea often lose their appetites and may lose weight. Persistent diarrhea (lasting 14 days or more) or recurrent diarrhea can lead to death through negative effects on nutrition status. Several studies have shown that children with persistent diarrhea are more likely to die than children with diarrhea of shorter duration. A strong relationship exists among persistent diarrhea, malnutrition, and mortality. There is a need, therefore, to understand how caregivers manage these episodes (Bentley, 1992).
Most deaths are caused not by the diarrhea itself but by the fluid losses and nutritional effects that accompany diarrhea. The most important interventions during diarrhea are, therefore, the replacement of fluid losses and continued feeding during the episode, and increased catch-up feeding following the episode. Feeding during diarrhea not only supports nutrition but also shortens the diarrheal episode. Many studies have shown, however, that caregivers have trouble feeding a child with decreased appetite during diarrhea. In this case the best strategy may be to encourage larger and more frequent feedings when the appetite returns and the child starts to get better.
The chief concern of many caregivers when children have diarrhea is to stop the loose stools. Although this would prevent dehydration and nutritional loss, it is not necessarily desirable. "Antidiarrheal" drugs do not act against the infection, but they slow or stop the natural movement: of the bowel that pushes food and fluid along the digestive tract. This action may stop or reduce stool output, but it may also spread the infection around the body and lead to prolonged illness or death, particularly in young children.
Antibiotics
(drugs that act by killing germs) do not work against most of the
organisms that cause diarrhea in children in developing
countries. The germs that cause dysentery and cholera are
exceptions, and early treatment of these diseases with an
appropriate antibiotic is recommended. The use of ineffective
antibiotics and antidiarrheals also places a financial burden on
families and distracts attention from the lifesaving
interventions of fluid replacement and feeding.
Diarrheal stools contain
electrolytes (chemicals such as sodium that are in balance in the
body) as well as water. One of the most revolutionary discoveries
of this century was that the sodium and water lost in diarrhea
can be replaced orally (by mouth). The mechanisms by which water
and sodium are absorbed across the intestinal wall remain intact
during diarrhea. Absorption can be increased if sugar, starch, or
certain other carrier molecules are present. Therefore sodium and
a sugar (such as glucose) or starch (such as rice powder) are the
basic ingredients of fluids used for oral rehydration. In severe
diarrhea it is also important to replace other electrolytes,
including potassium, and to supply a base such as sodium
bicarbonate. Solutions made from oral rehydration salts (ORS)
packets are ideal because they contain all the necessary
ingredients to replace stool losses: water, sodium, glucose,
potassium, and a base.
Most childhood diarrhea is mild and self-limited and does not require treatment with special balanced electrolyte solutions, such as ORS. They can be helped by increased intake of fluids, such as breast milk, water, fresh juices, or sugar-salt solution (SSS), together with their usual diet. However, a few children with diarrhea lose large amounts of fluids and electrolytes and require all the ingredients of ORS. The goal of improved diarrhea case management is to ensure that children in need of ORS get it, and that all children with diarrhea receive increased fluids together with food.
Some CDD programs recommend giving every child ORS during every episode of diarrhea. Other programs recognize that they cannot ensure the availability of ORS for every episode. In this case, one option is to teach caregivers to prepare SSS from sugar, table salt, and water. Another option is to promote the use of fluids that are commonly available in the home, together with food, at the onset of all diarrhea! episodes to prevent dehydration before it starts, reserving ORS for the treatment of existing dehydration. Children with signs of dehydration and those with complications such as fever or blood in the stool should be referred to trained health care providers.
Although CDD programs have been fairly successful in convincing caregivers to try ORS and SSS, they have been less successful in convincing them to continue giving sufficient amounts of-these fluids throughout the diarrhea! episode. One reason for this reluctance is a mistaken perception that extra fluids will make the diarrhea worse.
Although caregivers want and encourage their children to continue eating, they often shift the diet to more dilute or softer foods that are perceived to be easier to digest but that may be of lower nutrient density. This practice can occur in response to the decrease in appetite that frequently occurs with diarrhea, or in response to the child's preference for softer or more liquid foods.
The
challenge in promoting AHM of diarrhea, therefore, is to convince
caregivers to focus on the fluid and food needs of the children,
and not exclusively on stopping the diarrhea. Local beliefs that
are inconsistent with recommended case management are among the
many factors (together with multiple demands on caregivers' time,
poverty, and limited access to transportation) that make it
difficult to achieve desired behavioral changes in households. The
researcher's role is to understand these factors and their
interrelationships so that some of the barriers to effective case
management can be overcome. Furthermore, the researcher
should help to identify and reinforce existing behaviors that are
consistent with AHM practices.
Recognizing and responding to cases of diarrhea that should be evaluated and/or treated by a trained health care provider is an important part of AHM. Caregivers should recognize when children are becoming dehydrated or displaying other signs of severe disease.
Dehydration occurs when children lose more fluid through diarrhea than they are able to take in. It is more likely to occur when stools are very watery, frequent, or large, and when diarrhea is accompanied by vomiting. Dehydrated children may become less active and more irritable; they may have increased thirst or, in severe cases, be unable to drink. They also display physical signs of body fluid loss, including dry mouth, sunken eyes, lack of tears when crying, sunken fontanelle,1 and decreased skin turgor.2
Signs associated with severe or dangerous diarrhea! episodes include fever, bloody diarrhea, loss of appetite, diarrhea lasting longer than 14 days, and severe undernutrition.
It would be an overwhelming task to teach caregivers all the signs and symptoms of dehydration as well as other danger signs that are associated with diarrhea. It is important to consider the results of ethnographic research when selecting signs and symptoms for emphasis, because caregivers in different cultures may see, interpret, and respond to the same signs and symptoms in different ways. Different programs and projects will choose to emphasize different signs and symptoms in educational messages to caregivers.
Ethnographic data can identify signs and symptoms that 1) are of particular concern to caregivers or 2) lead to inappropriate household management. For example, a study might show that vomiting is of particular concern to caregivers, prompting them to seek medical care. In this case educational messages may not need to stress the importance of vomiting, since caregivers already consider it important. On the other hand, a study might show that caregivers think bloody diarrhea should be treated by traditional healers or with traditional medicines. In this case educational messages must explain why dysentery should be treated by biomedical health care workers.
This manual
does not describe how to validate signs and symptoms; that is, it
does not compare caregivers' definitions of physical signs, such
as dry mouth or sunken eyes, with those of biomedical personnel.
Researchers who would like to do so are referred to a manual
under development by the World Health Organization.
• Diarrhea can cause death in children through loss of water and electrolytes from the body and through the nutritional consequences of multiple and persistent episodes;
• Most diarrhea! episodes can be effectively treated by giving extra fluids as soon as the diarrhea starts, together with continued feeding;
• In addition, antibiotic treatment is recommended for cholera and dysentery (bloody diarrhea);
• When large stool losses or vomiting lead to dehydration, a balanced solution of electrolytes in water (ORS) is needed;
• The role of the researcher is to understand the local belief system so that positive aspects can be encouraged and barriers to AHM of diarrhea can be addressed.
Words
Locally recognized types
Perceived causes
Actions taken
Relationship with other childhood diseases
Significant characteristics
Relationships among beliefs
Key Points
All cultural groups have belief systems that explain illness, its causes, and its consequences. Beliefs about illness are related to ideas about how the body works and about what forces make things happen in the world. Although some are very old, local beliefs are constantly changing, and today they usually include some concepts from the biomedical model of disease.
This manual is based on the assumption that the design of effective educational messages requires an understanding of these local beliefs. An individual's decisions about household management of illness, and about when and where to seek care, are influenced by his/her beliefs and perceptions of the type and severity of signs and symptoms, as well as by financial considerations, logistics, and other factors. An educational message is more likely to achieve behavioral change if it is consistent with existing beliefs and uses familiar words and examples to explain new ideas.
Studies suggest that the following are important aspects of beliefs about diarrhea:
• The words used to talk about diarrhea;
• The different locally recognized types of diarrhea;
• The perceived causes of the different locally recognized types of diarrhea;
• The actions taken in response to diarrhea;
• The relationship of diarrhea to other childhood illnesses;
• The significant characteristics of diarrhea (i.e., those that affect caregivers' decisions);
• The relationships among local types of diarrhea, perceived causes, actions taken, and assumptions about what happens in the body during diarrhea.
These seven
aspects of cultural beliefs about diarrhea are discussed below.
All cultures studied to
date identify a condition characterized by stools that are looser
or more frequent than usual. The condition may not always be seen
as an illness, but rather may be considered as a normal part of
growing up (for example, associated with teething) or as a
symptom of another illness.
Many cultures have a single word (such as the English diarrhea) that refers to the general symptom of loose or frequent stools. Some cultures have different words for childhood and adult diarrhea, or for diarrhea that is perceived as an illness and that which is perceived as a normal process. Sometimes the same word refers both to loose or watery stools and to "stomach pains" with normal stools.
Good translation is very important. The following example shows how confusion can result when the meaning of local words is not clarified:
EXAMPLE: In Sri Lanka educational messages to promote ORS used the term pachanya roga to mean "diarrhea in general." However, to many people in the community, pachanya roga means only "severe diarrhea in adults." People were therefore confused about why they were being told to give ORS to their children. The materials should have used terms that refer to diarrhea in children, such as ajeerna, bada amaruwa, or badaelayanawa (Nichter, 1988).
Most cultures recognize
different local types of diarrhea distinguished by the appearance
of the stool, the presence or absence of certain other signs and
symptoms, the presumed causes of the episode, or the
characteristics of individuals with the condition.
EXAMPLE: People in Baluchistan identify 13 types of diarrhea, each with a different name. Most types are distinguished by perceived cause: constipation, indigestion, excess "heat" in the body, spirit possession, lifting the child suddenly, worms. Some are related to other diseases or body processes, such as cough and cold, teething, earache, measles, or sunken fontanelle. The only type that is distinguished by the appearance of the stool is bloody diarrhea (Herman et al., 1988).
EXAMPLE: In a region in northern India, the diarrhea classification system is based predominantly on the appearance of the stool: yellow (pila dust), green (hare dust), bloody (knooni dust), watery (pant dust), and "bits and pieces" (phate-phate)(Bentley, 1988).
Knowledge of local types of diarrhea is needed for the development of educational messages. In some cases it may be necessary to name the different local types of diarrhea to emphasize that fluids and food are the initial treatment of choice for all episodes of loose or watery stools.
The local type of diarrhea associated with a particular episode often determines the action taken. The following demonstrates what can happen when the local classification is ignored in developing communication messages:
EXAMPLE: In Honduras people identified four illnesses associated with diarrhea: empacho (painful intestinal gas), ojo (evil eye), caida de mollera (fallen fontanelle), and lombrices (worms).
The researchers predicted that parents would not use ORS for empacho if ORS was promoted only for dehydration. This is because empacho is believed to be caused by improper eating, and the appropriate treatment is cleaning the bowel with a purgative. Despite this prediction, the researchers did not explain in their promotional messages why ORS should also be used for empacho. Follow-up results confirmed that most diarrhea! episodes in which ORS was not used were attributed to empacho (Kendall et al., 1984).
There are many perceived
causes of diarrhea, and certain themes are common across
cultures. The concept that teething causes diarrhea is among the
most widespread. In many parts of the world, diarrhea is
attributed to supernatural influences such as evil eye or spirit
possession.
The idea that an imbalance of "hot" and "cold" causes illness is common in Latin America, Asia, and Africa. The idea comes from ancient Greek medicine, which described the human body as containing "humors" with opposing qualities that balance each other. Illness results from an excess of one humor. Illnesses, foods, and medicines have hot or cold qualities. Hot illnesses are associated with excess heat in the body, and cold illnesses are associated with excess cold in the body. Eating too much of a hot or a cold food (or exposure to excess heat or cold in some other way) can cause illness.
Other perceived causes of diarrhea include the environment (such as hot weather or "dirty" surroundings), physical actions of the child (such as falling down or sitting in one place too long), behavior or actions of the parents (such as inappropriate sexual activity or exposure to a place where lightning has struck), coexisting diseases, and eating contaminated or inappropriate food.
In many cultures the perceived cause of diarrhea determines how the episode is managed. The following illustrates the importance of understanding local beliefs about the causes of illness:
EXAMPLE: Numerous possible causes of diarrhea were identified in rural Zimbabwe. Researchers divided these into 1) "physical" causes such as a polluted environment, diet, and teething and 2) "social and spiritual" causes. For 402 recalled episodes of diarrhea, the perceived cause, severity of the illness, personal characteristics of the respondent, and accessibility of health services were examined. The only factor that was related to whether or not formal health services were used was the perceived cause of the episode. People with illnesses that were thought to have a physical cause were more likely to be brought to a health facility than those whose illnesses were thought to have a social or spiritual cause (De Zoysa et al., 1984)
Research has shown a wide
range of culturally defined actions in response to diarrhea.
Several actions may occur at the same time or they may be
sequential. The following are possible actions:
• Delayed or no action. Caregivers will often "wait and see" if the diarrhea continues and if the child "gets worse";
• Changing feeding patterns. The total amount of food may be increased or decreased, foods believed to be harmful during diarrhea may be withheld, or foods believed to be helpful may be added to the diet;
• Changing the type or amount of fluids given;
• Giving traditional home remedies, such as herbal teas and other locally available plant products as well as measures such as massage, charms, or "plasters";
• Changing the behavior of the child (for example, preventing the child from going out in the sun or running) or the parents (for example, restricting sexual activity);
•·Administering drugs from stores, pharmacies, or other sources;
• Administrating SSS or ORS;
• Consulting traditional or religious healers;
• Consulting doctors in public clinics or private practice; there is often a range of healers who combine traditional and modern therapy.
The goal of ethnographic research is not only to describe actions taken in response to diarrhea, but also to explore perceptions of whether treatments work or not, and if and when they are worth the effort.
It is necessary to integrate messages promoting AHM (as defined by the CDD program) with traditional diarrhea management. If caregivers believe it is harmful to give traditional and biomedical medicines at the same time, then promoting ORS as a "strong modern medicine" may limit its use. It may be more effective to say that ORS is a "drink" that can be given with traditional medicines.
Knowledge of traditional treatments may also help in finding ways to explain the function of ORS or extra fluids:
EXAMPLE: In Haiti diarrhea is categorized as a "hot" illness. The most common home treatments are "cooling" fluids (raflechi) made from leaves, roots, or tree bark that are given at the onset of diarrhea. A possible way of promoting ORS in this setting is to explain that it acts as a raflechi and should be given in the same manner as these traditional fluids (Coreil and Genece, 1988).
Understanding local beliefs
about diarrhea in the context of other childhood diseases helps
to identify "nondiarrheal diarrheas." These are
illnesses that are associated with loose or watery stools but
that are not considered diarrhea. For example, many cultures
recognize a childhood illness characterized by a sunken
fontanelle, dry skin, and weakness. Although these are signs of
dehydration, the relationship between them and fluid loss is not
recognized. The sunken fontanelle is seen as the primary problem
and the diarrhea is believed to be caused by it. Interventions
may be physical actions to raise the fontanelle (such as pushing
up on the roof of the mouth). Since this illness is not
considered a type of diarrhea, it may not be identified unless
the researchers inquire about childhood illnesses in general.
Sometimes comparing diarrhea with other childhood illnesses can lead to a better understanding of diarrhea! illnesses and their management:
EXAMPLE: In Baluchistan a participant said that children with measles become very thirsty because measles is a "very hot" disease. This comment led to more questions about what causes thirst and how it can be treated. The researcher learned that in the local beliefs thirst is related not to fluid loss but to the amount of "heat" entering the body. Therefore thirst is treated by "cooling" drinks and not necessarily by large volumes of liquids. The researcher concluded that ORS should not be promoted as a treatment for thirst, because this approach would not encourage the administration of adequate volumes of ORS.
When children have loose or
watery stools, caregivers must decide whether the condition is an
illness, whether any action is required, and if so, what to do.
Each
culture has locally defined significant characteristics of
diarrhea that affect caregivers' decisions. The frequency and
duration of stooling are usually considered important. Fever,
vomiting, or bloody stool may also be seen as worrisome. It is
important to understand the local words that people use for
characteristics of diarrhea. For example, perceived
"weakness" from diarrhea often causes concern and
triggers an action. However, definitions vary. In some settings
weakness is indicated by a reduction in activity, in others by a
loss of appetite.
Understanding a culture's
beliefs about diarrhea is like trying to put together a jigsaw
puzzle. The beliefs are the "pieces" that must be put
together to see the picture. This requires understanding the
dynamics of the belief system:
• What are the relationships among locally recognized types of diarrhea and the perceived causes of diarrhea?
• What influences decisions about whether to take action and what action to take?
• How does the child's response to treatment influence the caregiver's initial impressions about the cause or the type of an episode?
• How are the type and perceived cause of the diarrhea related to the characteristics of the child (for example, gender, age, previous illnesses, severity of signs and symptoms)?
EXAMPLE: Caregivers in South Sumatra identify three main types of diarrhea: regular diarrhea, diarrhea with vomiting, and diarrhea with blood. The perceived causes include dirty or unbolted water, dirty food, certain types of food (cucumbers and peanuts), excess heat or fever, hot weather, spoiled breast milk, trauma, worms, and a "fight" between hot and cool air inside the body. Rice water, guava leaf water, ORS, and SSS are the most common treatments for all three types of diarrhea, but a variety of fluids prepared from various plant products are also recommended.
The underlying relationships among these beliefs were explored by taking case histories of diarrhea! episodes and by other methods. These revealed that the action taken during a diarrhea! episode is influenced more by the type of diarrhea than by its perceived cause or by characteristics of the child. Caregivers are likely to treat bloody diarrhea with specific kinds of traditional herbal preparations. They consider diarrhea with vomiting to be most serious and an indication for seeking help outside the home. Weakness during diarrhea is of particular concern and frequently leads to an intervention or action. Other demands on the caregiver's time, the availability of money and transport, and the convenience of health facility hours are also important determinants of action.
Caregivers
describe illness as a dynamic process with certain signs and
symptoms or illnesses frequently leading to other signs and
symptoms or illnesses. Heat (panas) and "air inside
the body" (masuk angin) are used to explain many
illnesses including diarrhea. A commonly perceived sequence is
that muscle ache caused by an injury (such as a fall) leads to
fever, which in turn leads to an illness such as diarrhea or
cough. The most dreaded consequence of this process is the
development of seizures (Herman et al., 1989).
• The meaning of
different words used locally to refer to "stools that are
looser or more watery than usual" is important for designing
communication messages;
• People tend to distinguish several locally recognized types of diarrhea that may or may not correspond to biomedically defined types of diarrhea. The types may be distinguished from each other by the appearance of the stool, presence or absence of associated signs and symptoms, characteristics of the person with the illness, or other criteria;
• Some illnesses characterized by loose stools may not be considered diarrhea (nondiarrheal diarrheas);
• The perceived cause or type of a diarrhea! episode often determines the action taken in response to it;
• Within each culture, there are locally defined signs and symptoms and significant characteristics of diarrhea! episodes that motivate caregivers to take action;
• It is important to determine what actions are usually taken. during diarrheal episodes in order to integrate messages promoting fluid administration and feeding with existing patterns of diarrhea management;
• A
description of the different local beliefs about types of
diarrhea, perceived causes, and usual actions taken does not
provide a complete picture of the cultural context of diarrhea.
It is important to understand how the different beliefs fit
together with the realities of everyday life to influence
behavior.
Bentley, M.E. The household
management of childhood diarrhea in rural North India.
Social Science and
Medicine 1988:27;75-85
Bentley, M.E. Household behaviors in the management of diarrhea and their relevance for persistent diarrhea. Acta Paediatrica 1992:81(Suppl 381);49-54
Coreil, J., and Genece, E. Adoption of oral rehydration therapy among Haitian mothers. Social Science and Medicine 1988:27;87-96
De Zoysa, I., Carson, D., Feachem, R., Kirkwood, B., Lindsay-Smith, E., and Loewenso R. Perceptions of childhood diarrhoea and its treatment in rural Zimbabwe. Social Science and Medicine 1984:19;727-734
Kendall, C., Foote, D., and Martorell, R. Ethnomedicine and oral rehydration therapy: A case study of ethnomedical investigation and program planning. Social Science and Medicine 1984:19;253-260
Herman, E., Hamzah, M., Huzaifah, S., and Masreah, S. 1989. Local beliefs and practices related to diarrhoeal diseases: A summary of qualitative research conducted in South Sumatra, Indonesia (unpublished manuscript)
Herman, E., Sultana, F., and Baluch, H. 1988. Report of ethnographic research on diarrhoeal diseases in Baluchistan, Pakistan (unpublished manuscript)
Nichter, M. From Arulu to ORS. Sinhalese perceptions of digestion, diarrhea and dehydration. Social Science and Medicine 1988;27;39-52
Notes
1 Sunken fontanelle refers to a depression of the soft spot at the front of a child's head.
This sign is usually helpful only for children less than 1 year of age.2 Skin turgor refers to the response of skin when it is gently pinched. Normally skin goes back to its original position quickly. When skin turgor is decreased, the skin goes back slowly or very slowly (taking longer than 2 seconds). When assessing skin turgor in a child, the skin of the abdomen or thigh is pinched.