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Findings

Characteristics of the respondents

The cooperation of the clinic staff, Ministry of Health, and village health workers made it possible for us to conduct more interviews than anticipated. The team conducted interviews of 30 individuals and 9 groups in 14 villages in the Bethany and Matukeng areas. The group size ranged from three to 20 persons. Although the majority of the respondents were married mothers of children under the age of five, also included were grandmothers, fathers, and village health workers who resided in the two sites. Most of the respondents recognized different types of ARI illness terms, had children who had a past case of ARI, and knew about or had used different types of traditional medicines to treat ARI in their children.

Sesotho illness teens for acute respiratory injections

The data suggest that the Basotho have a specific comprehension of ARI. To discuss ARI in Lesotho, one must refer to the domain of sefuba. We found three basic uses of this term: a literal meaning (the chest), a more general meaning reserved for describing any illness or ailment, and its use as a descriptor of childhood illnesses. In Lesotho, people think and talk about children suffering from sefuba and adults being ill (ho kula). When we asked respondents to name the types of sefuba they know about, the list included feberu (fever), hloana (sunken fontanelle), ho melisa (teething), ho khohlela (coughing), kokoana (a tiny insect)⁹, lehlatso (vomiting), letsoejana (little breast)¹⁰, letsollo (diarrhoea), mocheso (body heat, fever)¹¹, mokhokhothoane (whooping cough), sefubanyana (a small, minor cold), and ho thimola (sneezing) (Table 1). A child may have one of these illnesses, or suffer from a combination of two or more.

Categories of severity for ARI illness teens

In contrast to the etic (biomedical) definition of acute respiratory infections, is the emic (respondent's) conceptualization of sefuba in Lesotho.¹² Within the category sefuba, some illnesses are considered a normal part of the children's growing up process. These illnesses include sefubanyana, ho khohlela, mocheso, ho thimola, and ho melisa. Respondents indicated that these illnesses come and go without the need for any serious treatment. We have labeled them ordinary ARI-illnesses or lifuba¹³. More serious lifuba include feberu, letsoejana, lehlatso, letsollo, lefuba, 'mesalese (measles), kokoana, liso (sores), metso-o-mosoeu (diphtheria), mala (stomach ache), lethopa (a boil), hloana, and mokhokhothoane.

In this study, hloana and letsoejana have been assigned into the subcategory "most serious lifuba" for these reasons: respondents reported that both illnesses were associated with coughing and fever, and both could be life-threatening and lead to a child's death. Several respondents said that when letsoejana occurs at the same time with phuana or hloana, the child may be near death. Furthermore, customary beliefs about the etiology of these illnesses are associated with the realm of the supernatural, presenting a challenge to health education efforts.

Aetiology of ARI-related illnesses

Respondents felt that ordinary lifuba require no explanations; they are associated with self-limiting illnesses in children. Other illnesses, like mokhokhothoane (whooping cough), may be attributed to exposure to adverse climatic conditions. Some explanations for ARI-related illnesses include ho hatsela (to get a chill), ho habola moea (to get a draft), ho hahlameloa (to inhale polluted air), and mocheso o moholo (excessive heat).

Respondents also offered biomedical explanations such as germs or lack of immunization against a disease (like measles) to explain the cause of ARI-related illnesses. A final group of etiologic explanations has supernatural undertones. Children could be ill from mehlala (bewitchment resulting from the child's mother walking across a tabooed place) and kokoana (a two-headed snake that enters the body of those who have been bewitched). Some felt that only traditional medicine could manage certain illnesses - especially phuana, hloana, and letsoejana.

Table 1. Basotho Childhood Illness Terms

LESOTHO ARI COMMUNITY STUDY, PHASE I, 1989

Sesotho Term	English Term
A. Illnesses and Symptoms Related to the Normal Growing Experience
ho melisa	(teething)
khohlela	(coughing)
mamina	(mucous)
mocheso	(temperature, body heat)
safolane	(flu)
sefubayana	(minor ARI)
thimola	(sneezing)
B. Serious, Life Threatening ARI Symptoms and Illnesses
feberu	(fever)
ho phofa	(delirium)
kokoana	(little insect, two-headed snake)
lefuba	(tuberculosis)
lehlatso	(vomiting)
lekhopho	(rash)
lethopa	(a boil)
letsoejana	("pneumonia", pain, little breast)
letsollo	(diarrhoea)
live	(sores)
lits,be	(infected ears)
mahlo	(eyes, infected eyes)
male	(stomachache)
'mesalese	(measles)
metso-o-mosoeu	(the throat that is white, diphtheria)
mokhathala	(fatigue or tiredness)
mokhokhothoane	(whooping cough)
motsoka-pere	(itch)
patara-potisi	(small pox)
phuana	(sunken fontanel)
sefuba	(cold, illness, the chest)
C. Core ARI Terminology
feberu	(fever)
kokoana	(little insect, two-headed snake)
lefuba	(tuberculosis)
letsoejana	("pneumonia", pain, little breast)
lehlatso	(vomiting)
letsollo	(diarrhoea)
'measelese	(measles)
metso-o-mosoeu	(the throat that is white, diphtheria)
mokhokhothoane	(whooping cough)
phuana (hloona)	(sunken fontanel)
sefuba	(cold, illness, the chest)

Health response to ARI in children

SOURCES FOR CARE AND TREATMENT OPTIONS In Lesotho, the most immediate sources of care are those found in or near the home. A mother living in these two pert-urban sites has a cluster of accessible and familiar sources in the homestead or in the village to assist her should her child become ill. These sources include the child's father, grandparents and other relatives, other experienced mothers, the village health worker, the chief, and sometimes the village clinic.

The child's mother or father may gather herbs, leaves, or roots used for medicines. The child's mother or paternal grandmother may prepare a herbal medicine from boiling leaves or herbs. The herbal treatments mentioned most often for sefuba and letsoejana were bloukomo and lengana. After these herbs are boiled, the caretaker holds the sick child near the steam rising from the mixture to make the child inhale the vapors. An inhalation tent may be made by spreading a cloth over the heads of the caretaker and child to make the inhalation process more efficient. In a group interview of 19 village health workers in Bethany, all were aware of this common treatment. In fact, the group dispersed momentarily to search for the herbs growing near the entrance to the clinic. Male and female village health workers knew the herbs and their use. Other herbal medicines used to treat lifuba are listed in Table 2.

If a traditional doctor is nearby, or if the grandmother is knowledgeable about traditional Sesotho medicines, ho phatsa may be administered to the child with letsoejana. The procedure requires making small incisions on the child's skin (the chest for letsoejana) and rubbing Sesotho medicines into the small wounds. Or, the child may tee taken to a religious hearer who might say some prayers and give the child treatments with teas or enemas.

Caretakers in the pert-urban areas also use over-the-counter medicines to treat children with ARI. In both study sites, we visited trade stores suggested by respondents and found over-the-counter medicines such as paracetamol elixirs, aspirin, and cough mixtures. These medicines are dispensed by store owners and clerks.

FEEDING AND DRESSING THE CHILD WITH ARI The responses to the questions regarding feeding and clothing the child with ARI suggest that the Basotho believe that adjustments to the child's clothing and diet can assist the recovering child. Most responses suggest that illnesses related to cold weather or temperature, should be counteracted with warm clothing and warm foods. Mothers generally felt that the garments of a sick child should be kept clean and the amount of clothing should be adjusted in response to the child's symptoms:

"I dress her in lots of clothes so that she will get warm and that will cure her."

"The clothes should be clean, the child should be wrapped up properly."

"The child would be clean, dressed in clean clothes washed in Sunlight soap. The clothing should not be too heavy or too light."

One interviewer probed a respondent to demonstrate what she meant by dressing the child properly. In response to the question about dressing a child with sefuba, the mother said, "The child should be kept warm." The interviewer called one of the respondent's children towards them and asked, "Show me what you mean? How would you dress this child if she had sefuba?" The woman pointed to her daughter dressed in a thin cotton dress and answered, "If she had sefuba today, she would be dressed all right." The interviewer noted that the child wore no diaper, shoes, or socks; however, from our observations, we know that Basotho mothers often carry their young infants and toddlers on their backs, tucked under the traditional Basotho blanket usually worn wrapped around a woman's shoulders or waist. Thinly clad children may therefore have the additional warmth of their mother's blanket.

Respondents were more specific when responding to the question regarding foods and drinks that were appropriate for children with sefuba than they were to the question regarding clothing. Some of their responses suggest that the Basotho dietary habits, like those of Pakistanis (Real et al 1982), may be grounded in local humoral theories about the balance of hot and cold foods. However, our limited data on the dietary habits of children with ARI in Lesotho do not permit us to explore this topic further.

"For letsoejane, no particular food item would be suitable or unsuitable. But a cold, salty food will make the cough worse."

"The child should be given water. He should be given liquid food, not papa or likhobe."

"Avoid hard and salty foods. Salt aggravates the cough. Hard foods won't digest properly. The child should drink water, but it should be boiled first."

"Avoid salty foods and sour things like likhobe. Give the child warm water, not cold water, to warm up the chest. Cold water would make the chest cold and make the child cold."

"I also give my child food like lesheleshele (soft porridge) and water, especially when she is ill."

"Only cook a little food at a time so that the child eats food while it is still fresh. Salty food makes the child cough and should tee avoided. Motoho (sour porridge) should not be given because it causes deliriousness. As for liquids, the child should be given water with a little sugar."

"I asked myself a lot of questions (about the child's illness) as the child was too small. I thought about giving our child cold food, thinking that maybe the mokhokotoane (whooping cough) was caused by hot food."

Table 2. Medicines Used by Basotho Respondents for ARI Illnesses

LESOTHO ARI COMMUNITY STUDY, PHASE I, FEBRUARY 1989

Traditional Medicines with English Translations
Bloukomo	(eucalyptus tree leaves)
Ho arubela	(inhalation of herbal steam or fumes)
Ho pheha lekhala	(to boil aloe leaves)
Ho phatsa	(little incisions in the skin)
Khokhotse	(mobu) (a red coloured soil that women mix with water and apply on their faces to smooth the skin)
Lebese la tonki	(donkey's milk)
Lebese la pere	(mare's milk, horse milk)
Metsi	(water)
Motsoka pere	(name of herbal plant)
Phate ea ngaka	(treatment from the healer)
Pitsa ea ngoana	(medicine for a child)
Sepeiti	(enema)

Other Traditional Medicines Cited
(We have no English translation for these terms)

Boluma	Lesooko	Qobo
Hloenya	Mofere-fere	Seshoasho
Khoara	Mohalakane	Tsikitlana
Lengana	Mosisili

The data do not suggest that mothers withhold food or drink from their children with ARI. Instead, they change the child's diet to softer, more easily digested foods. Salty or sour foods are avoided and preference is given to soft, bland porridges. In terms of fluids, the data suggest that warm drinks are preferred for children with ARI; cold drinks (or foods) are thought to aggravate the illness.

Although familiar and accessible, the previously cited sources and treatments may be inadequate to meet the needs of the severely-ill child. For further assistance, a mother may contact the nurse at the clinic, herbalists, or traditional Sesotho healers.

Sources of care away from the village

For people living in these two study sites, transportation to the hospital for critical illness could be arranged through the clinic staff. Both clinics have vehicles to transport patients to the nearest hospital. Obtaining treatment from traditional healers and herbalists may require a two- or three-hour walk, or even a day's journey for some.

Throughout the interviews, people often spoke of the prohibitive cost of taking a child to the health centre. However, even if renowned traditional Sesotho doctors charge more than the health centre, people still seek their help. For example, one woman confided that she had to find a goat to pay for medical treatment received from the traditional doctor. But unlike the clinic staff, some traditional doctors will allow payment by installments rather than "cash on the line".

The steps individuals take to seek help vary from the most immediate to the more distant form of help. A caretaker will usually start treating her child with ARI at home using home remedies or over the counter medicines. If a second level of care is needed, the caretaker will either continue home care, using the advice of a more experienced mother or a village herbalist, or change to another more distant source of care (e.g., the clinic or the traditional healer). As trust is developed in a method or person, distance seems to become a less significant factor.

Strategies for health education: Getting the message to the villages

The respondents suggested four methods of effectively reaching villagers with public health information about ARI: pitsos (community meetings), letters from the Ministry of Health sent to the village health workers, information for the clinic or health centre staff to pass to the population, and the use of the media (radio, newspapers) to inform primary school children of appropriate health behaviour. Pitsos, or community meetings, were the most frequently cited method. Respondents said that these meetings should provide opportunities for doctors or health experts to address the chiefs and the population.

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