Preliminary Findings from the Formative Research

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Preliminary Findings from the Formative
Research

• Lauren S. Blum
• Support for the study was provided by the Bill
  and Melinda Gates Foundation

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Objectives

• To identify local terminologies, beliefs and
  causal explanations associated with childhood
  diarrhoeal illnesses
• To delineate treatment patterns including home
  remedies and health seeking behaviours during
  diarrhoeal episodes
• To develop a culturally appropriate mass media
  campaign as well as messages to be delivered by
  health providers
• To develop standardized responses to common
  concerns and questions about zinc raised by
  community members

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Study Overview

• Stage 1 Examine the local explanatory model of
• diarrhoea and understand local perceptions of
• vitamins and minerals, especially related to zinc
• Stage 2 Develop zinc communication messages
• Stage 3 Test the draft messages
• Stage 4 Make revisions and develop final
  messages
• Stage 5 Develop provider-counseling cards

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Research Design

• One urban (Kamalapur) and one rural (Mirsarai)
  site
• Research methods include
• Key informant interviews (mothers, grandmothers,
  community leaders, health providers)
• Household observations of diarrhoeal cases
• Narratives of recent diarrhoeal cases
• Semi-structured interviews with mothers and other
  childcare providers and health practitioners
• Cognitive mapping procedures (freelisting, rating
  exercises)
• Group discussions (care providers and health
  practitioners)

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Progress to Date
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Health Care System

• Pluralistic in nature and comprised of
• Village doctors and medicine shopkeepersuntrained
  , prescribing allopathic medicines
• Homeopathstrained through homeopathic
  institutions or apprenticeships
• Kabirajherbalists following Ayorvedic medicine
  system and spiritual healers
• Jharani buaelderly women who give spiritual
  treatment
• Hujurreligious healers
• Fakirherbal and spiritual healers
• Trained cliniciansworking in NGO and government
  run facilities or private clinics. Physicians
  are commonly referred to as big doctors

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Beliefs Related to Diarrhoeal Illness

• Identified 29 diarrhoeal illnesses in both
  Kamalapur and Mirsarai
• Each illness has different terminology, symptoms,
  perceived causes and appropriate treatment
• Causal explanations for diarrhoeal diseases are
  commonly linked to hot/cold belief theories.
  Diarrhoeal illnesses are believed to be hot
  illnesses and therefore the first line of
  treatment generally involves cooling the stomach
• The majority of diarrhoeal illnesses have
  naturalistic causes and treatment, first
  involving food remedies and dietary modifications
  on the part of the breastfeeding mother and child

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Freelisting Results
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Patla Paikhana (Loose Motion)

• Signs and Symptoms
• ? Very loose, frequent stool
• ? Yellow in color
• ? Child becomes very weak
• Cause
• ? Mother consumed rotten/stale foods, dirty
  items
• ? Mother consumed hot foods, infecting lactating
  baby
• Treatment
• ? Green banana, soft smashed rice, green papaya,
  smashed potato, green coconut water
• ? Oral saline given to the baby or consumed by
  the mother
• ? Kabiraj (herbalist/spiritual healer) for
  blessed water and spiritual blow

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Dud Haga (Milk-like stool)

• Signs and Symptoms
• Whitish loose, watery stool child defecates at
  least 8-10 times a day
• Bad smell, similar to raw fish
• Weakness, upset stomach, fever, weight loss,
  mother has heavy breasts
• Cause
• ? Lactating mother comes in close contact with
  evil spirit or evil air contaminating the milk
• ? Mother has circulated in the community at the
  wrong time of day
• Treatment
• ? Kabiraj (herbalist/spiritual healer) or hujur
  (spiritual healer) give blessed water to baby and
  oil for mothers breast also give spiritual blow
  to baby and mother
• ? Herbal juice for baby

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Home Remedies

• Foods believed to contain cooling properties are
  given to the young child. The most common are
  green banana, green coconut water, green papaya,
  rice with smashed potato, rice water, starch from
  cooked rice, or water from flattened rice
• In Mirsarai, a primary concern is to give the
  child foods that will dry the inside of the
  body
• Food restrictions are placed on the breastfeeding
  mother and child, particularly related to the
  consumption of hot food (e.g. fish, meat, egg,
  milk)
• Mothers also make efforts to eat cold foods
• When the illness is associated with batash laga
  evil spirits, the breastmilk is believed to be
  contaminated and breastfeeding is reduced
• If the diarrhoea persists, either ORS or home
  prepared rehydration solution is also given as a
  home remedy

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We (breastfeeding mothers) avoid fish, meat and
dried fish during diarrhoeal episodes. These are
hot foods that make trouble in the childs
stomach and increase defecation. Also, the child
is not given these foods. If we eat green
banana, the stool becomes hard and output is
reduced. We also give the child green coconut
water and flattened rice water because these
foods help to make the stomach cooler.
(Breastfeeding mother of small child in
Mirsarai)I take smashed green banana, smashed
potato and smashed lentil and avoid fish and
meat. Fish or meat goes directly to the child
through my breastmilk. This would make the
stomach hotter and increase the illness.
(Breastfeeding mother in Kamalapur)
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Perceptions and Use of ORS

• High awareness of the importance of ORS but
  application during childhood diarrhoea appears to
  be infrequent and inappropriate
• Proportions are changed to conserve packet
• Care providers are unsure how long to keep the
  prepared solution
• Respondents are unaware of the appropriate age to
  start giving ORS
• Some respondents have been convinced through
  campaigns that ORS is only for watery diarrhoea
• Breastfeeding mothers frequently consume ORS to
  facilitate the recovery of the child during
  diarrhoeal episodes
• ORS is known to contain cooling properties and is
  believed to help the child recuperate from
  weakness and strengthen the body
• ORS is also commonly used by adults to treat
  weakness caused by physical work

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Perceptions and Use of ORS (continued)

• Respondents prefer ORS sold in packets because
  they are more confident in the ingredients and
  their effect on diarrhoeal episodes
• People feel that ORS will not stop the stool
  output and, therefore, the perception is that for
  more serious cases the child needs medication
• Poorer families perceive ORS to be too expensive
  and prefer spending money on medication that will
  stop the diarrhoea quickly

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Careseeking Outside the Household

• Seeking care from a health provider occurs when
  illness is perceived to be serious. Symptoms
  that inspire careseeking include
• increased stool output and frequency
• vomiting
• weakness
• refusal to eat breastmilk or complementary foods
• difficulty in holding head up
• The timing of careseeking also relates to the
  type of diarrhoeal illness the child is
  experiencing
• Money is the biggest barrier to seeking care

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Decision Making

• The majority of respondents indicated that the
  husband, who controls all finances, decides when
  and where to get treatment
• In extended family structures the in-laws,
  particularly the mother-in-law, also play a key
  decision making role
• Most mothers indicated they have limited
  involvement in decisions around treatment outside
  the household however, those women who have some
  control of money clearly have more authority

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Patterns of Careseeking

• First treatment is most commonly with a medicine
  shopkeeper and the expectation is to receive
  medicines
• If the condition is not reversed or becomes more
  serious, people seek care with a big doctor
• If the type of diarrhoea is linked to evil
  spirits or the mother is suspected of being
  afflicted by spirits (e.g. heavy or leaking
  breasts), treatment is sought with a spiritual
  healer who administers pani pora blessed water or
  jhara spiritual blow.
• It is also common to pursue concurrent treatments
• While some women indicated that homeopathic
  medicines, believed to be slow acting, are better
  for treatment of young children, most agreed that
  they are less appropriate for diarrhoeal
  illnesses which require a quick recovery

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Who Takes the Child

• Fathers most often take children for treatment
• In their absence, the paternal grandfather or
  grandmother may go
• In fewer cases, the mother may join the father or
  mother-in-law
• Womens mobility is restricted and, as a result,
  they are often unfamiliar with the location of
  health care providers. Restrictions are related
  to
• Social pressure, prestige
• Religious prohibitions
• Rules and regulations placed on breastfeeding
  women to reduce exposure to evil air
• Fears about circulating in the environment

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Why Shopkeepers/Rural Doctors

• Have good medicines (many specified syrups)
  that cure diarrhoea quickly
• Popular, familiar to family and understand family
  situation
• Less costly, treat on credit
• No consultation fee
• No transport cost
• Close proximity to households
• Offer services at least 12 hours a day, make home
  visits
• Short waiting period

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Views on Prevention

• Food restrictions aimed at maintaining hot/cold
  balance
• Restricting the mobility of the breastfeeding
  mother to avoid attracting alga batash
• Avoiding breastfeeding in front of others or
  lifting the child above the shoulders or head and
  attracting alga batash
• Prohibiting the child from leaving the household,
  indicating that s/he might attract nojor (evil
  eye) or alga batash

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Views on Prevention (continued)

• Limited understanding of biomedical concepts
  related to prevention of diarrhoea
• Recited messages about maintaining cleanliness in
  and outside the household. Issues emphasized
  include
• Covering food
• Avoiding stale or rotten food
• Preventing children from eating dirty foods (from
  the ground, street foods)
• Cleaning pots and plates
• Washing the child and his or her clothes
  regularly
• Respondents stated that measures require money
  and time and are difficult to maintain

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Zinc and Vitamins

• People are not aware of zinc
• Vitamins, which by some respondents are perceived
  as hot, are believed to increase the frequency
  of diarrhoea and stool output
• Another concern is that a child with diarrhoea
  will not benefit from vitamins during the episode
• Vitamins are given to strengthen the child post
  diarrhoeal episode

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Distribution of Zinc

• Kamalapur
• 12 brands of zinc are available, distributed by
  11 manufacturers
• Mirsarai
• 22 brands are available, distributed by 21
  manufacturers
• Zinc was introduced anywhere from 1 to 3 years
  ago and is widely available in medicine shops
• Costs range from 23 to 32 taka the perception is
  that the high price limits the market
• All products are sold in the form of a sweet
  syrup

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Zinc from the Perspective of Health Providers

• Shopkeepers, who know little about zinc,
  generally distribute with a doctors prescription
• Zinc is given to increase growth, reverse
  weakness, increase appetite and improve
  digestion. In some cases, physicians are
  prescribing for diarrhoeal illnesses
• Not prescribed to children less than six months
  of age
• Most shopkeepers prefer to distribute tablets to
  syrup
• Antibiotics or anti-diarrhoeals are often
  prescribed by allopathic healers during
  diarrhoeal episodes

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Preferred Characteristics of Medicines for
Children

• Syrup more appropriate
• Sweet taste
• Pinkish colour white was also mentioned because
  it is associated with mothers milk
• Not too thick (concern about getting stuck in
  throat)

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Experience with Zinc Administration

• Children like the sweet taste and have been
  generally receptive to zinc
• Many households do not have spoons and those
  available may be too big
• Mothers prefer using a cup or glass
• Respondents like the possibility of going
  directly to the shopkeeper to get medicine
• Adherence to the full treatment has been
  relatively good
• Compliance may relate to the detailed explanation
  and counseling provided to the mother

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Questions About Zinc

• Can we mix the tablet with breastmilk to dissolve
  it?
• Can we mix zinc with food?
• Can we mix ORS with zinc to dissolve it?
• Can children take the tablet by sucking on it?
• If we give the child zinc more than ten days,
  would it cause harm?
• What should we do if we miss a dose?
• Should we give our children another dose if they
  experience a second episode of diarrhoea?
• Can a breastfeeding mother take zinc instead of
  the child?
• Can children above five years take zinc? Would it
  work for them as it works for children under
  five?
• Can we give zinc to a child without illness as a
  preventative?
• How can we distinguish the zinc blister packs
  from other medicines?
• What time of day should we give zinc?

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Critical Aspects of Messages

• Respondents stated that messages related to
  reducing stool
• frequency and output and preventing future
  diarrhoeal
• illnesses are very important. In addition, they
  suggested the
• following
• Cures disease
• Provides quick recovery
• Is sweet in taste
• Has long term effect
• Does not have harmful side effects
• Is appropriate for all diarrhoeal illnesses, even
  those caused by alga batash
• Has strengthening and cooling power
• Needs to be endorsed by physicians
• A child requires the entire dose to get the full
  benefit

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Adherence to Medicines

• Respondents indicated that they generally do not
  administer entire
• doses of medication due to the following
• Because of financial constraints, people cannot
  afford to buy the full dose
• Do not understand the importance of giving full
  dose
• When signs and symptoms disappear, no need to
  continue
• Save medicines for later
• Forget to administer full treatment dose/pay less
  attention if child is out of danger
• Difficult to get the child to take full dose,
  particularly if feel better
• Mother too busy with household work
• May harm the child if s/he gets too much medicine

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Suggested Channels of Communication

• Mothers and Fathers
• Radio and television (Bangla movies or drama
  serial)
• Miking
• Projection of documentaries at village level
• Counseling by physicians during consultations
• Mothers
• Peer group meetings
• One-on-one interactions with the health attendant
• Posters in medicine shops
• Fathers
• Newspapers
• Movie theatres
• Distribution of leaflets in the market place
• Billboards
• Mosques

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Conclusions

• Need to develop a mixed communication package
  targeting a range of care providers
• In order to ensure more effective communication,
  local terminology and beliefs must be
  incorporated into the promotional messages
• Challenge will be to develop innovative
  strategies to reach and engage fathers
• Must work with multiple health practitioners in
  the distribution of zinc
• May have problems convincing people to give zinc
  to children afflicted by alga batash
• Endorsement by physicians, who have tremendous
  respect, will be critical to the success of
  scaling up

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Acknowledgements

• Nazneen Akhtar
• Kamalapur Team
• Nazmun Nahar
• Shaila Arman
• Shahana Parveen
• Sadid Ahmed
• Mirsarai Team
• Md. A. Halim Miah
• Md. Iftekhar Hussain
• Rowshan Jahan Simi
• Jasmin Khan
• Our respondents, who have given us extended time
• imparting their knowledge and experiences

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