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2.Take detailed case histories

Up to this point, key informants have been talking in general terms about hypothetical or abstract situations. Case histories show how things actually happen. Do caregivers identify the type of diarrhea and its cause before taking action, or do they treat all episodes of loose or frequent stools in more or less the same way? What happens if the resources needed to take appropriate action are not available?

Households in which children are sick with diarrhea can be found by asking, for example, community health workers or neighborhood children, or by going from house to house asking if there are any young children and if any of them are sick. Try to record at least 20 case histories. Do not identify cases from clinic attendance lists. Cases taken to clinics or health centers may be very different from those that are managed entirely in the home.

Once you find a child with recent or current diarrhea, record such information as the child's age, gender, breast-feeding and weaning history, and previous medical problems; the household's socioeconomic status; and whether it is a nuclear or an extended family. Next determine when the episode started. This may be difficult because caregivers sometimes report that children have had diarrhea for "months," although there have been many diarrhea-free days in between. Try to determine the last time the child had two days of normal stools in a row, and begin from there.

Ask how the episode started. What was the first thing the caregiver noticed? What, if anything, did she do? What did she think was the cause of the signs and symptoms? Guide the caregiver step by step through the entire episode.

Here is an example of an interview focusing one specific case. Note the probes to find out which home remedies were used and what the caregiver means by "fever." Also note inconsistencies between what this caregiver did and what other informants describe as appropriate action for giving hot medicines.

EXAMPLE:

Researcher: "l understand that your two-year-old daughter has just recovered from diarrhea. Can you tell me how it started?"

Caregiver: "She woke up with muddy-colored diarrhea that was watery and very smelly. She was thirsty and drinking all that day. My husband took the baby to a doctor in Quetta city and he got these medicines." (The informant brings out five bottles of antibiotics and antidiarrheals.)

Researcher: "I will look at the medicines later, but first, tell me if you did anything at home before your husband took the baby to the doctor? Can you remember when you first decided that something needed to be done, and what you did?"

Caregiver: "In the evening of the day the diarrhea started, the child started vomiting and so I began to worry. My mother-in-law made up a mixture of buckum, kamazor, sugar and water."

Researcher: "Why did your mother-in-law choose that mixture?"

Caregiver: "We thought it was constipation diarrhea because only water was coming out, no solids. We gave the mixture to try to clean out the stomach."

Researcher: "I think that I must not understand something. I thought that buckum is a hot medicine. Why would you give it during constipation diarrhea, which is a hot disease?

Caregiver: "Well, buckum itself is hot, but when you mix it with kamazor and sugar, which are cold, the mixture becomes cold and it is okay to give."

Researcher: "What happened after you gave the buckum?"

Caregiver: "She vomited it up so we didn't give any more. The next day she continued to have watery diarrhea.

Researcher: "What did you do next?"

Caregiver: "I gave her water mixed with 'glucose' and some medicine I got from the local shop."

Researcher: "Did you still think it was constipation diarrhea?"

Caregiver: "No, I thought it was probably heat diarrhea."

Researcher: "Why did you think it was heat diarrhea?"

Caregiver: "She was getting very weak, and constipation diarrhea doesn't do that."

Researcher: "Why did you give the 'glucose' water?"

Caregiver: "I gave it because it is cold and because I wanted to stop the thirst."

Researcher: "What happened next?"

Caregiver: "The diarrhea continued, so in the evening my husband took her to the doctor. That's where we got these medicines."

Researcher: "Did you give the medicines?"

Caregiver: "Yes, and she stopped vomiting, but the next day she got fever."

Researcher: "People use the word 'fever' to mean many different things. Can you tell me what you mean when you say she had fever?"

Caregiver: "Well, her forehead got warm and she cried a lot, got very lazy, and just lay in one place."

In addition to your interview notes, you should record relevant observations. During the interview above, the interviewer noticed that the child in question was sitting and crying for food. The Caregiver did not give her anything to eat. She said that she was afraid feeding would make the diarrhea come back again, and it was better to let the child be hungry for a while.

3. Test decision models

Decision models are a short form of showing the points of choice or decision in a process (in this case, managing a child with diarrhea) and the reasons certain choices are made. For example, "if there is fever, follow plan A. If there is no fever, follow plan B."

After recording specific case details, go back over them and identify the sequence of decisions. Try to understand the reasons for each action. In the above example:

• The first decision was whether the child had diarrhea. It appears that the Caregiver decided the child had diarrhea when she noticed watery and smelly stools;

• The second decision was whether something needed to be done. The Caregiver did not think anything was necessary until the evening when the child started vomiting;

• The next decision was what to do. The choice to give the buckum mixture was influenced by the guess that the diarrhea was "constipation" diarrhea. Thus the action taken was influenced by the perceived cause;

• The next decision was what to do when the baby vomited the buckum mixture.

The series of decisions can be sketched out with boxes and arrows (see the example in Figure 3.6).

Once you have sketched the series of decisions, go back to the caregiver and ask "What would have happened if...?" For example, you may want to ask the caregiver what she would have done if the diarrhea had continued but the child did not vomit. Would the action have been different? After doing this with a number of cases, you will get an idea about what factors influence the decisions to recognize that the child is sick, to take some action, and to do one thing rather than another.

Sketch the steps and sequences of decisions for several families with recent episodes of diarrhea. Look for differences in actions taken. If there is a difference, then it should be traceable to some factor that was a significant characteristic (see Part II:4). These are the keys you are looking for.

EXAMPLE: In Pakistan it was found that one child in a family was given ORS during diarrhea while the other was not. The difference was that the second child also had a runny nose. Because the ORS was perceived as humorally cold, the caregiver did not want to give it to the child with a cold disease.

4. Summarize relationships

At this point, you should be able to give preliminary answers to a number of questions about the relationship among parts of the belief system:

• What factors determine the perceived cause and type of a diarrhea! episode? Do physical signs and symptoms influence caregivers' perceptions about the cause and type of diarrhea?

• What is the relationship between the type of diarrhea and the perceived cause? Does the perceived cause determine the type of diarrhea, or can a specific type have several possible causes?

· Do people generally group types of diarrhea into larger categories? If so, what are the distinguishing characteristics of the categories?

• What is the practical importance of the types and categories of diarrhea? Do caregivers only classify diarrhea when it becomes "complicated," or do they give importance to it from the onset? Does the type or category of the child's diarrhea affect what action is taken?

• Does the perceived cause of the diarrhea influence the action taken?

• What are the significant characteristics of a diarrhea! episode that motivate caregivers to take action and that influence the choice of action? What other factors (for example, financial considerations, caregivers' work schedules, or the closeness of different providers) influence the choice of action?

• Do people distinguish between different categories of actions? Do they take different actions to stop the diarrhea, to strengthen the child, and to treat associated signs and symptoms? Are actions taken to prevent the diarrhea from becoming complicated or dangerous? Are preventive measures taken during other childhood illnesses?

• What is the general pattern of treatment? Do people assign a type or cause to diarrhea at its onset and treat accordingly throughout the episode? Does the perceived cause change as signs and symptoms and treatment progress?

Read through the questions again carefully, then review your field notes from the card sorting, case history, and decision model procedures. Answer the questions based on the data collected, including one or two examples to back up your answers.

Key Points

• Conduct card sorting with key informants to learn how they group types of diarrhea and types of treatments;

• Take detailed histories of specific cases to understand how caregivers' perceptions and interpretations of physical signs and symptoms, beliefs about the causes and types of diarrhea, and situational constraints influence treatment behavior;

• Sketch the sequence of events in specific cases, then try to understand and explore the reasons for taking certain actions;

• Summarize what you have learned by answering questions about the relationships among pieces of the belief system.

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