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Annex A. Summary of research findings and recommendations: South Sumatra, Indonesia

1. Information obtained from unstructured key informant interviews
2. Key Informant interviews on focused topics
3. Possible approaches to promote AHM
4. Development and administration of the structured interview
5. Choice of a recommended approach
6. Choice of an educational image

1. Information obtained from unstructured key informant interviews

A total of 49 in-depth unstructured key informant interviews were conducted with traditional healers (dukun) and with mothers of young children. These interviews focused on obtaining descriptions of general childhood illnesses, particularly illnesses associated with loose or frequent stools.

The field workers recorded details about the associated signs and symptoms, perceived etiologies, and recommended treatments for the different illnesses. They also tried to understand local concepts about how the body works and what goes wrong or happens differently during illness. Handwritten field notes were reorganized daily into a standard format. Information from different informants was compiled according to type of illness.

Most informants categorized illnesses associated with loose stools into one of three types:

a) "regular" diarrhea
b) diarrhea with vomiting
c) diarrhea with blood

Some only distinguished between regular diarrhea (with or without vomiting) and diarrhea with blood. A few informants made a distinction between diarrhea caused by masuk angin (air inside) and diarrhea from other causes. A few distinguished between types of diarrhea according to their painfulness.

There was greater individual variation in the perceived causes and the recommended treatment for diarrhea than in the reported types of diarrhea. Dirty or unboiled water, dirty food, and certain types of food (especially cucumbers and peanuts) were the most commonly identified causes of loose stools. Excess heat or fever, hot weather, spoiled breast milk, trauma, worms, and a "fight:" between hot and cold air were other causes named. Several informants referred to kuman (tiny invisible animals that cause disease) as causing diarrhea.

Informants recommended different treatments for different types of diarrhea, but the research team could not identify any consistent pattern. Rice water, guava leaf water, ORS, and SSS were most commonly listed for all three types of diarrhea. A large variety of decoctions prepared from various leaves and plant products were also recommended. Papaya and selasih (a local herb) were more frequently recommended for bloody diarrhea than for other types.

Existing concepts of what happens in the body during illness are dynamic, with certain signs and symptoms or illnesses frequently "leading to", other signs and symptoms or illnesses. Panas (heat or fever) and masuk angin play a role in the folk pathophysiology of many illnesses, including diarrhea. Key informants frequently described sequences of keseleo (muscle ache) caused by an injury leading to fever, which in turn led to an illness such as diarrhea, cough, or seizures.

The key informants noted that thirst and weakness frequently occur with diarrhea. Thirst is perceived to be a result of heat and/or water loss. Weakness is attributed to the loss of food and water in the stools and to decreased food intake during illness. Perceived weakness is of particular concern to mothers and frequently leads to the initiation of therapeutic action. All types of diarrhea (including diarrhea associated with developmental changes) can cause weakness.

When questioned about where the water in diarrhea comes from, informants consistently said that it comes from the water and food that are taken in. The interviewers were unable to elicit any concepts about the body's drying out or about the loss of body water.

2. Key Informant interviews on focused topics

A preliminary analysis of unstructured key informant interviews revealed that none of the informants had mentioned teething diarrhea, diarrhea due to magic or supernatural causes, or diarrhea associated with a sunken fontanelle. These types of diarrhea are commonly recognized in other cultures. Other questions relating to the hot-cold quality of diarrhea, the concept of kuman and their relationship to illness, and the relationship between a child's signs and symptoms and changes in food and fluid intake were also raised. Interview guides were developed to gather information about these topics, and additional focused key informant interviews were conducted.

When questioned directly, the key informants said they did not believe that supernatural forces or sunken fontanelle were associated with diarrhea in children. However, most of them did say they believed that developmental landmarks (teething, learning to crawl, learning to walk, etc.) were associated with loose stools. These beliefs were not revealed during the initial interviews because loose or frequent stools associated with development are not considered "real diarrhea" unless the signs and symptoms are prolonged or severe.

There was remarkable consistency in the two explanations given for developmental diarrhea. One explanation is that children who are learning something new must "make the body lighter" so that it is easier to start to crawl, walk, etc. The second explanation is that children often fall when they are learning a new skill. The fall causes keseleo (muscle ache) which leads to either masuk angin (air inside) or panas (heat or fever). The masuk angin or panes then causes loose stools. When children had loose stools associated with development, key informants advised that it was not good to try to stop the diarrhea unless it lasts more than 2 or 3 days. This is the only type of diarrhea in which attempts to stop the loose stools were considered harmful.

The concept of kuman was familiar to all informants. Kuman were described as small living creatures that cannot be seen but can cause disease. Kuman live in soil, garbage, dirty water, and air. The concept was known to informants with no education as well as to teachers and others with years of schooling. Older and more traditional informants described kuman as anything (living or nonliving) that can cause disease, including cold air, the wrong food, or regular dirtiness. Some duke (traditional healers) claimed they could "see" kuman because of their special powers and said they learned about kuman from their ancestors.

Few key informants recommended withholding or decreasing food during diarrhea, but they often recommended a shift in the diet (for example from rice to porridge) and noted that children typically refuse to eat much. Very few recommended withholding fluids during diarrhea, although they did not advise encouraging fluids (especially in the case of vomiting or very watery diarrhea).

3. Possible approaches to promote AHM

Information obtained from the initial and focused key informant interviews was used to identify some general themes that characterized the health beliefs related to diarrhea. Some of the themes may be helpful and some harmful to the CDD program or project. They include the following observations:

a) All types of diarrhea and most of the other childhood illness are attributed to "natural" causes;

b) Most episodes of diarrhea are attributed to something "entering" the body: heat, dirty food, the wrong food, worms, or masuk (air);

c) The folk perception of pathophysiology is dynamic, with signs and symptoms and illnesses often leading to other signs and symptoms and illnesses;

d) Most diarrheal episodes are considered "hot" and are treated with "cooling" remedies;

e) It is not always in the child's best interest to stop diarrhea (specifically in the case of developmental diarrhea);

f) Diarrhea often leads to thirst and weakness;

g) The water in diarrhea comes from food and drink;

h) Giving fluids during diarrhea can cause vomiting and an increase in diarrhea;

i) In general, if one treatment does not stop the diarrhea, a different treatment should be tried;

j) Usually food is not withheld during diarrhea, but the relative amounts of different foods in the diet may be shifted, and the quantity of food may be decreased in response to a decrease in appetite;

k) Fluids are given during diarrhea, but increased amounts of fluids are not necessarily encouraged;

l) All traditional and allopathic diarrheal medicines are perceived as stopping diarrhea. No treatments are given to strengthen the child or to replace fluids;

m) The belief about kuman is very similar to the Western lay concept of germs. Kuman are associated with dirt and are perceived to cause many types of illness, including diarrhea.

This list was used to "brainstorm" about possible approaches to promote the administration of adequate amounts of fluid and foods during diarrhea. Possible approaches for addressing harmful beliefs were also identified. Some of the approaches initially considered are:

a) Using the idea that diarrhea is caused by something foreign entering the body and the perception that food and fluid are lost during diarrhea, explain that diarrhea is the body's way of getting rid of something bad. Treatment should focus on replacing lost food and fluid, and not on stopping the diarrhea;

b) Referring to the dynamic concepts of pathophysiology (one illness leading to another), explain that oral rehydration therapy (ORT) and feeding prevents the illness from leading to something more dangerous. This addresses the expectation that all diarrhea treatments should stop the diarrhea;

c) Given that most diarrhea! episodes are considered "hot," explain the need for additional fluids to "cool" the stomach;

d) Use existing beliefs about developmental diarrhea to explain why it is not good to try to stop the diarrhea with antidiarrheal medications;

e) Present ORT as treatment for thirst;

f) Present ORT as treatment for weakness.

4. Development and administration of the structured interview

Structured interview questions were designed to explore the possible approaches to promoting AHM. The interview was then administered in districts other than the initial study districts to determine whether key themes and concepts were specific to the villages studied, or whether they seemed to be common throughout the two regions in which the villages are located.

5. Choice of a recommended approach

The different possible approaches were assessed in the context of information obtained from additional key informant interviews and from results of structured interviews conducted with 60 respondents.

a) The results of a structured interview question about the causes of mencret (diarrhea) confirmed that diarrhea in children is attributed to natural causes, most of which involve something (dirt, air, food, heat, etc.) entering the body. Therefore this approach was considered potentially useful.

b) A review of case histories revealed that diarrhea was usually an end point of a series of signs and symptoms or illnesses. Diarrhea was not perceived as leading to the most dreaded signs and symptoms (fever and seizures) but was thought more likely to be a result of heat or air in the body. Therefore this approach was not pursued further.

c) Although initial key informant interviews suggested that diarrhea is usually considered a "hot" illness, an exercise involving sorting different childhood illnesses into "hot" and "cold" categories indicated that there is a great deal of person-to-person variation in this belief. Therefore this approach was not pursued further.

d) The belief that it is not good to stop loose stools during developmental diarrhea was based on the belief that a child needs to lose some weight in order to perform the next developmental task. Stopping the diarrhea might therefore delay development. This approach was not pursued for fear that it might be interpreted as suggesting that weight loss during diarrhea is desirable.

e) Although thirst was perceived as a consequence of diarrhea, focused questioning of key informants about the reason for this belief revealed that most people consider thirst to result from too much heat rather than from water loss. Therefore the hot or cold quality of the fluid given might be considered more important than the amount of fluid. In comparison, when asked why diarrhea makes children weak, 78 of 87 informants mentioned losing too much stool or water, or not wanting to eat. It was therefore considered better to emphasize weakness rather than thirst as a reason to match the amount of fluid given with stool consistency and with the amount of stool passed. Furthermore, AHM practices address the perceived causes of weakness (water loss, stool loss and anorexia), whereas they do not directly address the perceived cause of thirst (heat).

6. Choice of an educational image

The educational image chosen to explain the importance of fluid replacement and continued feeding during diarrhea was that of a small kerosene lamp that farmers use when they stay in the fields overnight (see the description in Part III.6).

The possibility remains that even if caregivers understand the importance of feeding and fluid replacement, they may be so preoccupied with trying to stop the diarrhea that they will not give top priority to appropriate case management. Therefore educational messages to promote fluid replacement may be more effective if preceded by messages that directly address this concern. Existing beliefs about kuman bad food, or bad air entering the body and causing diarrhea can be utilized to explain that diarrhea is the body's way of getting rid of these agents of disease. Treatment should therefore focus on replacing fluid losses and on feeding rather than on stopping the diarrhea.

Rapid Assessment Procedure (RAP): To Improve the Household Management of Diarrhea

This manual guides the reader to rapidly collect, analyze and use the information about the cultural context of diarrhea. Its purpose is to is to identify household and behavioral factors that are characteristic of the local culture and facilitate the development, implementation and monitoring of programs for the control and prevention of diarrhea. Rapid assessment procedures (RAP) are used to determine people's beliefs about how the body works, the causes and consequences of illness and other factors that influence the household response to diarrhea. Separate section present the RAP guide for conducting a study; and options for applying the study result.

These books may be ordered from the International Nutrition Foundation for Developing Countries (INFDC),by writing to:

INFDC
P.O. Box 500
Charles Street Station
Boston, MA 02114-0500 USA

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