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Part III. Field Guide

Step 1. Meet CDD program or project personnel
Step 2. Prepare the study
Step 3. Collect basic information
Step 4. Understand the belief system
Step 5. Identify possible approaches
Step. 6 Assess and improve the approaches

Step 1. Meet CDD program or project personnel

1. Identify CDD advisors
2. Ask questions about the program or project
3. Identify information needs
4. Explain ethnographic research
5. Discuss the scope and plan of the research
6. Develop a medical referral plan
7. Arrange further working sessions

Persons: You and the CDD staff

Time: 1/2 - 1 day (about 1 month before field work)

1. Identify CDD advisors

Whether you will be working with the CDD program or project of the ministry of health, a nongovernmental organization (NGO), or another health care project, identify senior technical staff who will be available to meet with you several times during the course of the study. If possible, include your field workers in the meetings and working sessions.

CDD intervention programs and projects vary greatly in scope, specific household management policies, level of resources, and experience with social science research. You must understand the program or project you will be assisting. You must know what kinds of recommendations are needed, and CDD staff must know what kind of information ethnographic research can produce. It is best to start these discussions about 1 month before the field work to allow enough time to obtain approvals and arrange logistics.

2. Ask questions about the program or project

To help identify and meet the needs of the program or project, get background information about its history and policies:

• Household management strategy. What specific behaviors are encouraged in the household when a child develops diarrhea? At what point should the caregiver take action: for example, after the first loose stool, after three loose stools, etc.? Are specific foods and fluids recommended? What is the role of ORS and SSS in the household? How are caregivers encouraged to give extra fluids and to continue feeding? When are caregivers advised to bring children to health facilities?

• History of CDD policy. In addition to asking about the current household management strategy, ask if the policy has been changed. For example, was SSS promoted at one time but later phased out? Try to identify other major changes in policy and the reasons for them. Obtain written reports and verbal information about research done to help design the intervention, test materials, or evaluate activities.

• Caregiver practices. Is there any information about caregivers' current practices? What percentage of caregivers use ORS, SSS, or home fluids during diarrhea? Do they give fluids frequently, in large enough quantities, and at the onset of diarrhea? What percentage of caregivers continue to breast-feed and to feed the usual diet during diarrhea?

• Communication strategy. What population(s) has the CDD program or project targeted: national or regional, particular ethnic groups, urban or rural? What communication channels and materials have been used to reach the target population(s)? How have messages and materials been adapted to local belief systems and cultural differences?

3. Identify information needs

Through discussions with CDD personnel, try to define the decisions and actions that will be influenced by the results of your study. Is the program or project in the process of developing a household management policy or evaluating the current policy? Will the results of the study be used to revise training or communication materials, or to design and interpret questions for a survey?

CDD advisors may expect that the study will help solve implementation problems. For example, they may want to know how to encourage caregivers to give extra food following a diarrhea! episode, or how to address the problem of their giving only small volumes of ORS. Ask what options the staff see for solving the problems they present. One of your tasks will be to assess the cultural feasibility of their options and others that you uncover.

4. Explain ethnographic research

Many CDD staff may not distinguish one social science research method from another and may assume that you will be conducting a KAP survey. Be prepared to present a brief explanation of ethnographic methods and to contrast them with the KAP survey methodology. You may find it helpful to refer to Part 1:2 in preparation for the meeting. Ensure that the staff understand the types of data they will get, the uses of these data, and their limitations.

You may be asked whether the information collected in the study can be generalized to the entire country. Be realistic. Detailed ethnographic studies can usually be conducted in only a few places. A reasonable compromise between the need for detailed information and the need for representative information is to do ethnographic studies in a few locations to identify "key beliefs" related to diarrhea! diseases. Key beliefs are those that are particularly problematic and are likely to interfer with the behavioral objectives, or that are potentially useful in promoting the objectives. The prevalence of such beliefs throughout the country can be determined by using less intensive methods such as surveys or health facility interviews. If great variation in key beliefs is found, it may be necessary to conduct additional ethnographic studies.

5. Discuss the scope and plan of the research

The scope of the research and current information needs will influence the choice and number of study sites. For example, the study may be the first phase of a pilot project that involves designing educational messages for a few communities. In this case, the choice of study sites is easy. In other cases, the study may be part of a long-term plan to develop a communication campaign for a district or country. The program's plans and priorities would dictate choosing study sites from communities that are the first targets of the CDD intervention. Some countries may choose to start their training and communication efforts in densely populated urban areas. Others may focus on rural areas with particularly high diarrhea mortality rates.

The following criteria should be considered in selecting a community for study:

• Linguistically and ethnically, the community should belong to the larger target population;
• There should be high morbidity and mortality from diarrhea! diseases in the community;
• There should be no serious logistic problems in transportation and communication.

6. Develop a medical referral plan

During the field work, you and the field assistants may be asked questions about medical problems or may encounter people who are seriously ill. It is important that you and the CDD staff agree on a plan for managing these situations.

If there is a community health worker, you may ask the family's consent to notify this person. If local health facilities charge fees, it may be possible to arrange free services for patients with a referral note from the organization sponsoring the research. If you have a government or project vehicle for the research, you may be able to obtain authorization to use it to transport emergency patients to a health facility.

7. Arrange further working sessions

You will probably need more than one meeting to address all the issues outlined in this session. Before ending your meeting, make sure that CDD staff understand the purpose and know the approximate time of the next meeting and that they agree to further participation in the study.

Key Points

• Meet CDD technical staff as often as necessary to learn the current household management policy, the history of household management policy and interventions, present and past communication and research strategies, and current caregivers' behavior related to diarrhea;

• Determine how the ethnographic information will be used: what decisions will be made, who will make them, what kinds of recommendations are expected, and what programming alternatives are under consideration;

• Explain the strengths and weaknesses of ethnographic research. Prepare a brief, straightforward explanation of ethnographic research;

• Agree on the scope and plan for the research and on a strategy for handling any medical problems encountered;

• Ensure that CDD staff know when and why you will meet again during the course of the study.

Step 2. Prepare the study

1. Brief the field workers
2. Prepare a list of priority questions
3. Review existing information
4. Prepare interview guide(s)
5. Train the field workers

Persons: You and the field workers

Time: 3-10 days, depending on your experience and that of the field workers

1. Brief the field workers

Field workers who are adequately trained (or briefed) on the background and objectives of the research are more likely to produce useful information. Use Part 11 as a guide to brief them on the technical aspects of diarrhea case management and the cultural information that is relevant to CDD efforts. Allow plenty of time for questions and discussion. Check their understanding, focusing on the key points listed in Part II. If they have not participated in the discussion(s) with CDD personnel, summarize the content of those meeting(s).

2. Prepare a list of priority questions

Based on your discussion with CDD personnel and your understanding of their information needs, list the priority questions that the research should answer. The following list includes most of the questions you will need to address. You will add or subtract questions according to the program's or project's needs.

Local words for diarrhea and types of diarrhea

• What is the best word or phrase to use in designing messages about the management of diarrhea in children?

• Are there different locally recognized types of diarrhea? Are the distinctions based on observable characteristics of the child or episode? What is the significance of those types?

• Are there types of diarrhea that are perceived as not needing treatment? How can caregivers be encouraged to seek care for children with these types?

• Are there any "nondiarrheal diarrheas" - illnesses associated with loose stools but not considered to be diarrhea? How can communication materials encourage caregivers to seek care for these illnesses?

• How much variation is there in the terminology and local types among the different study sites? What are the implications for messages?

Household management

• How do perceived causes, severity of signs and symptoms, associated signs and symptoms, financial or logistic considerations, and characteristics of the child influence responses to a diarrhea! episode? Which of these are helpful and which present barriers to AHM and to appropriate referral? How can the obstacles be overcome?

• Who takes care of children with diarrhea? Who makes and contributes to decisions about how episodes are managed?

• Where and to whom do caregivers go for help and advice when children have diarrhea? What are the treatments given by different health care providers?

• What are the practices related to giving fluids during diarrhea ' What fluids are given? Are there any obstacles to giving increased volumes 1/2 to 2 liters per day) of these fluids? Are there any beliefs that support giving extra fluids?

• What are the practices related to feeding during diarrhea? What foods are given? Do caregivers change the amount or type of food offered during diarrhea? During the convalescent period? If yes, what are the reasons for these changes?

• What characteristics of a diarrhea! episode cause caregivers to become concerned and take special action? Do they recognize and are they concerned about the biomedical signs and symptoms associated with severe disease?

• How can caregivers be encouraged to give increased volumes of fluids, make special efforts to encourage children with diarrhea to eat, feed more during convalescence, and seek care from trained providers?

Related beliefs

• How can local beliefs about how the body works and what goes wrong or happens differently during diarrhea be used to explain or promote AHM?

• What results do caregivers expect from different interventions? Are interventions done only to stop the diarrhea, or are some interventions intended to prevent more serious illness or to strengthen the child?

• Do caregivers recognize the loss of body water and nutrients that occurs with diarrhea? If yes, is it of concern to them?

Biomedical treatment

• Are caregivers aware of, and have they used, ORS or SSS?

• What was their experience in using ORS or SSS?

• What are their perceptions of the effects of ORS and SSS?

• What are the barriers to home use of ORS or SSS (if this is the current policy)? How can those obstacles be overcome?

• What are caregivers' experiences with, and perceptions of, antibiotics and antidiarrheals? Intravenous fluids?

3. Review existing information

Review any existing information about health beliefs and practices among the people under study. Possible sources are the CDD program office and other departments in the Ministry of Health, libraries, United Nations and bilateral agencies, NGOs such as CARE, OXFAM, and Save the Children, and local health departments, medical schools, and universities. There are often unpublished reports on diarrhea! diseases and related topics that are not widely distributed. Reports about child rearing practices, weaning and feeding practices, health beliefs and behavior, and health care use may contain sections on children's diarrhea.

4. Prepare interview guide(s)

The purpose of a guide for unstructured interviews is to remind you and the field workers of the topics to be covered during conversations with key informants. All topics may not be discussed during one interview, and several visits may be required. The purpose is not merely to fill in the blanks of the interview guide. Rather, you are trying to understand local beliefs about diarrhea! illnesses. You do not have to follow the order of topics in the guide, but you should explore topics in detail as they come up in conversation. See example, Figure 3.1.

5. Train the field workers

The field workers will need review or training in the following skills:

• Introducing themselves, explaining the study, and establishing rap port;
• Conducting unstructured interviews;
• Taking and rewriting field notes;
• Card sorting;
• Checking lists;
• Taking detailed case histories;
• Conducting structured interviews.

This manual does not address training in general skills such as establishing rapport and taking field notes. The references in Part I provide more detail on both general and specific methods. The following sections provide some instruction on tasks specific to RAP studies.

Start by discussing and practicing the skills that will be used first: making introductions and establishing rapport, conducting unstructured interviews, and taking and rewriting field notes. The other skills can be taught just before they are used in the study. First, have the field workers observe you perform these tasks, then have them practice with you or with each other. Next, observe them practicing with caregivers who are not in the study area. Provide reinforcement and feedback until you are satisfied with their performance.

Key Points

• Brief the field workers on the background and objectives of the study;

• Define the questions of most significance to the program or project;

• Review existing sources of information on childhood illnesses, child feeding, child rearing practices, and sources of medical care in the study population(s);

• Prepare an interview guide for discussion topics;

• Train the field workers by having them observe and practice the skills needed for the research.

Step 3. Collect basic information

1. Approach the community
2. "Map" the community
3. Identify key informants
4. Conduct unstructured interviews
5. Check Lists
6. Organize the information
7. Summarize belief system "pieces"

Persons: You and the field workers

Time: 1-2 weeks

1. Approach the community

Many rural communities or urban neighborhoods in developing countries are small, intact social settings where the presence of strangers is at least a curiosity, if not a cause for concern. How you approach the community should be based on local factors and behavioral norms. You need to take care when entering the community, with or without official "sponsorship."

In some places, introduction to the community by medical doctors, district health officials, or other representatives of government or international agencies has negative implications for local residents. In other settings, these may be ideal facilitators. Ask other researchers who have conducted household studies what is the best approach.

Even when entry has proceeded smoothly, it may be necessary to have preliminary meetings with a number of other individuals and groups. Depending on the culture, these may include local elders, council members, religious leaders, healers, members of women's groups, or other influential community members.

Use the entry time to your best advantage by gathering background data on the community's population - for example, ethnic groups, languages, religions, common causes of morbidity and mortality, socioeconomic levels, occupations, social amenities (schools, clinics, shops), access roads, water sources, and other features that may affect communication among subgroups in the community.

2. "Map" the community

An effective technique to learn about a community quickly is to conduct a "community mapping" to identify the layout of the community and to ask questions about health and health care treatment. This technique has been adapted from participatory rural appraisal (PRA) research (see references in Part 1) and is particularly appropriate for RAP.

Begin by telling the residents that you want them to make a picture of their community on the ground or on a large piece of paper. Provide them with simple materials such as sticks, stones, seeds, markers, pencils, or chalk. The group should choose a few people to create the map. All the roads, houses, buildings, water pumps, and other landmarks should be depicted. Distinctions between ethnic groups, castes, or neighborhoods should be shown. If there is disagreement, encourage the participants to reach consensus. During the process, it is appropriate to ask a few questions for clarification, but on the whole you should just observe. The whole process usually takes no more than two or three hours, depending on the size of the community.

After the basic map has been completed, someone from your team should record it on paper (if it has been done on the ground). At this point you can ask the community members a number of direct questions. Which households currently have children with diarrhea? (Later you could visit those households to do unstructured interviews.) Which parts of the community or which households experience the most sickness and diarrhea, and why is this so? What are the different health care options and health-seeking behaviors for diarrhea? (Having a visual picture of treatment options and spatial relationships should facilitate this line of questioning.) Where do the individuals live who are particularly knowledgeable about childhood illnesses and who are sought out by other people for advice? What households have the most vulnerable or malnourished children?

This technique has been used in many different settings and is an effective way to learn about the study site. The technique provides a substantial amount of information that can be expanded upon or checked against later. An example of a map of a small community is included in Figure 3.2.

3. Identify key informants

Those most knowledgeable about diarrhea in children will probably be experienced mothers, older women, and traditional birth attendants. Of course you cannot concentrate only on older women, because young mothers may be developing a new value system and set of behaviors. Although you may want to talk to one or two traditional or religious healers, be wary, as they may overemphasize their own special healing activity.

Try to identify seven to 10 key informants. Begin by asking community leaders or leaders of women's groups:

• "Who in this community knows about diarrhea and other childhood illnesses? To whom do caregivers go for advice when their children are ill?"

Ask if they know of any young children who currently have or recently have had diarrhea. The caregivers of these children are especially useful informants because their experience is recent. You may also ask the local health workers, school teachers, pharmacists, or shopkeepers for recommendations.

Another way to identify key informants is to use the map from the community mapping exercise. Choose individuals from households that represent the various ethnic and socioeconomic groups in the community.

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