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1. Conduct card sorting with key informants
2.Take detailed case histories
3. Test decision models
4. Summarize relationships
Persons: You and the field workers
Time: 7-10 days
This step explores how the beliefs about diarrhea types, causes, and actions relate to each other. How do the pieces fit together to form a system? How are beliefs related to behavior?
The tools
used to obtain this information are card sorting, taking detailed
histories of specific cases, and testing decision models based on
the detailed case histories.
Card sorting is a good
technique for determining how key informants group things on the
basis of their cultural classification system. The informants are
shown a series of cards with words or pictures representing
different items in a category (for example, different types of
diarrhea or different treatments for diarrhea) and asked to sort
them into groups of similar items.
Sometimes this information will provide clues about what people believe or do in relation to diarrhea management. For example, key informants in Baluchistan sorted diarrhea treatments according to "how they work. " Some traditional remedies were said to "treat thirst," others to "treat weakness," and still others to "stop the diarrhea." Allopathic medicines were generally placed in the pile of treatments that "stop the diarrhea" or in a pile by themselves. Different informants classified ORS packets in different ways. Some thought that ORS might "treat thirst" or "give strength." Others placed ORS with allopathic medicines because they thought ORS was supposed to "stop the diarrhea." A few put ORS in a separate pile because it "replaces lost water" and no other product was perceived as working in this way. Many said they did not use ORS very much and did not know where to put it.
It is tempting for a researcher to define categories that seem to make sense to him or her. For example, after having determined how the caregivers identify different types of diarrhea, a researcher might classify the types as due to "natural" causes (such as food or environmental conditions) or "supernatural" causes (such as spirit possession or evil eye). But card sorting may show that caregivers do not categorize things in this way at all. Card sorting lets the people interviewed define the relationships among the pieces of their belief system.
If key informants identify many (more than five or six) types of diarrhea (see Step 3), it may be cumbersome for the CDD program or project to address so many types in their communication and educational materials. It would be useful to know if some of the types are grouped together into larger categories. Therefore, you should consider card sorting the types of diarrhea. If there are few local types of diarrhea, if may be more useful to card sort different childhood illnesses (including the types of diarrhea) to get an idea of how diarrhea is perceived in relation to the other illnesses.
It is usually helpful to card sort the different actions that are taken or treatments that are given in response to diarrhea (including ORS and/or SSS). This can clarify what expectations people have for different treatments and may suggest an analogy that can explain how ORS or SSS works.
It is recommended that you go through the card-sorting exercise with five or six key informants. The first step is to write or draw the items that you want to sort on cards or paper. Simple drawings may be used to represent children with different types of diarrhea. Some examples of drawings used in Baluchistan are shown at the end of this step. Besides pictures, you can use other visuals. For example, if informants distinguish diarrhea by its color, different colored papers may serve as illustrations.
To categorize actions taken during diarrhea! episodes, samples of different treatments may be attached to the cards, such as traditional medicines, ORS packets, illustrations of how to prepare SSS, and labels from antibiotics and other medicines. Some actions cannot be represented with samples, so drawings have to suffice: a child getting intravenous fluids, a child being massaged or being kept out of the sun, and so on.
Go through all cards to be sure the key informant can identify what each represents. A few repetitions may be needed. Then, ask him/her to put the cards into similar piles.
EXAMPLE: "Here are things people say they do when a child has diarrhea. Can you tell me what this is?" (At this point, you hand the informant a card with a sample of the herb shakumpara taped on it. It is helpful to start with common and traditional treatments to put the participant at ease.)
"And this next one, what is it?" (Continue until all cards have been reviewed. Put aside any cards with treatments the participant is not familiar with. Do not include them in the card sorting.)
" Now I would like you to sort these into piles of treatments that are similar. You can make as many piles as you like. Some things may go in more than one pile. This is okay too.,
Allow people plenty of time to think about the items. Explain again if necessary. Do not lead or suggest how to sort the items, but let the participant think about the sorting.
When sorting is finished, ask about the piles:
"Why did you put these together in the same pile?"
"Can you tell me the ways in which these are like each other?"
Record how the key informant sorts the items and his/her reasons for sorting them that way. Now that you know how the items are categorized, you may want to ask some additional questions. For example, if you are talking about types of actions:
"Which of these would you use to treat (insert type) diarrhea?"
"Could any of them harm the child if given under the wrong circumstances? "
"What does this treatment do for the child? Are there any others that work in the same way?"
Note how people sort ORS and SSS. Have they heard of them? Do they put them in a pile with modern medicines? Do they see ORS as "acting like" some traditional medicine? Are they confused about where to put it?
Sorting different types of diarrhea may reveal relationships among them. For example, one type may be considered a more severe form of another type, or some types may be grouped together to form larger folk categories of diarrhea.
Depending
on the program's information needs and priorities, you may also
want to card sort types of foods or liquids given to children
during diarrhea.