Mothers' fear of child death due to acute diarrhoea: a study in urban and rural communities in northern Punjab, Pakistan

Understanding Adolescents' Perceptions of Diarrhea: A Formative Research Study of a Visual Scale to Measure Self-Reported Diarrhea in Low-Resource Settings

Introduction: Although water, sanitation, and hygiene interventions are effective in reducing diarrhea, there are methodological issues regarding the research tools used to evaluate their health impact. Moreover, there is limited research on individuals' subjective interpretations of diarrheal illness which may introduce further limitations in relying on self-reported data. Therefore, we conducted a study that aims to understand adolescents' perceptions of diarrheal illness in rural Tamil Nadu, India. Next, we wish to explore the acceptability of the Bristol Stool Form Scale to assess self-reported diarrhea in water, sanitation, and hygiene interventions involving adolescent participants in low-resource settings.

Materials and Methods: The study was conducted as part of the formative research phase in the cultural adaptation of Project SHINE, a school-based educational water, sanitation, and hygiene intervention in Thirumalaikodi, Tamil Nadu, India. A convergent parallel mixed-methods study design with a purposive sampling strategy was used. Qualitative data included 10 in-depth interviews with student participants aged 13–14. Quantitative data were collected through interviewer-administered face-to-face surveys (n = 14) and one-week stool diaries (n = 14). Each data set was analyzed separately and compiled during the interpretation of the findings.

Results: Across all data sets, diarrhea was reported to be perceived as unhealthy and an irregular occurrence among participants. Participants also reported diarrheal-taboos, local methods to cure or control diarrhea, and discussed how diarrheal illness can lead to absenteeism or withdrawal from school and social activities. Moreover, participants were able to understand and answer questions about their stool using the Bristol Stool Form Scale, suggesting that is an acceptable tool.

Discussion: Visual tools demonstrate promise in improving self-reported diarrheal illness among adolescents in low-resource settings in India. However, until we address diarrhea-related taboos it will be difficult to address methodological issues in the assessment and reporting of diarrheal illness among adolescents.

Predictors of diarrheal mortality and patterns of caregiver health seeking behavior in in Karachi, Pakistan

Background

Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care–seeking behavior and other predictors of diarrhea–related mortality in children in selected low–income peri–urban communities of Karachi, Pakistan.

Methods

A mixed methods study (qualitative and quantitative) using matched case–control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children  <5 years of age who died within 60 days of developing an episode of MSD. Controls were age–matched children who survived after 60 days of an episode of MSD. Demographic, clinical, and care–related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported.

Results

Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR = 0.2, 95% confidence interval (CI) 0.05–0.91). Refusal for hospital admission (OR = 8.9, 95% CI 2.6–30.8), and delays in reaching the health facility (OR = 3.6, 95% CI 1.0–12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common.

Conclusion

Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan.

Mental Health Concerns for Indian Women

This article studies the mental health problems of women, especially in the Indian context. As per World Health Organization (WHO) estimates, depression is expected to be the second largest contributor to disease burden by 2020, and with one in every three women worldwide being afflicted by common mental disorders including depression, the mental health of women is a serious issue indeed. While studying the psychological construct of mental health, we come to understand that it is deeply embedded within an individual’s social and socioeconomic relationships. Since women worldwide, and more so in India, face gender-based discrimination at every stage of their lives, their psychological well-being becomes a cause for great concern. This note attempts to explore the various risk and protective factors affecting the mental health of women. Considering the gravity of the matter, urgent remedial measures such as understanding the underlying causes of psychological distress among women, adopting a gender-sensitive approach, working towards women’s empowerment and formulating women-friendly health policies could work wonders for the mental health of Indian women.

Elder authority and the situational diagnosis of diarrheal disease as normal infant development in northeast Thailand

Research was conducted in rural Northeast Thailand to understand how mothers perceive children's acute illness episodes, and their resulting illness management strategies. Although diarrheal disease is one of the leading causes of illness among young children in Thailand, interviews revealed that mothers frequently do not classify infantile diarrhea as an "illness." Infantile diarrhea is commonly labeled thai su, a type of diarrhea believed necessary to "lighten the body" so that the infant can attain a new developmental stage, such as sitting up, standing, or walking. Consequently, mothers do not perceive infection-related diarrheal illness as common in infants, and therefore do not direct much attention to prevention, nor manage diarrheal cases in a manner consistent with biomedical recommendations. In this article I describe local explanatory models of diarrheal illness, and discuss the role of situational factors and elder authority in determining how illness episodes are assessed and managed.

Bridges and Barriers to Health: Her Story—Emirati Women's Health Needs

Health care services in the United Arab Emirates have developed rapidly in the last 30 years fueled by oil revenues. These services have been planned and provided predominantly by non-nationals, with mixed success. The authors identify aspects of the health care system and the sociocultural environment that create both barriers and bridges to holistic health for Emirati women. Barriers include early/consanguineous marriage, frequent childbearing, polygamy, and care that is lacking in competence and cultural sensitivity. Bridges include Islam, folk medicine, cultural traditions, and the opportunity to travel abroad for health care. Maids are seen as both a barrier and bridge at different times. Recommendations for future improvements include listening to Emirati women and providing more gender-appropriate, holistic, and culturally congruent programs.

Women's management of the household health environment: responding to childhood diarrhea in the Northern Areas, Pakistan

This paper examines mothers' management of water, sanitation, hygiene, and childhood diarrhea in a mountain community in the Northern Areas, Pakistan. It draws upon qualitative data obtained from 65 in-depth interviews and other ethnographic field methods. The analysis shows that respondents were familiar with diarrhea control interventions carried out in the study site, and associated childhood diarrhea with oral-fecal transmission routes such as poor water quality, unhygienic behaviors, contaminated food, and inadequate sanitation practices. Findings also demonstrate the continuance of long-established cultural patterns of perception and behavior with regard to childhood diarrhea and the influence of socio-economic constraints to instituting new management practices.

The importance of cultural and linguistic issues in the emergency care of children

BACKGROUND

Rapid growth in the diversity of the US population makes it increasingly likely that emergency clinicians will encounter greater numbers of patients from different cultures, but little is known about the importance of culture and language in the emergency care of children.

OBJECTIVE

To conduct a critical review and synthesis of published studies on culture and language in the emergency care of children.

METHODS

PubMed was used to perform a literature search (using 17 search terms) of all articles on culture, language, and the emergency care of children published in English or Spanish from 1966 to 1999.

RESULTS

More than 2000 citations initially were identified; consensus review yielded 400 papers that were photocopied. A final database of 117 articles revealed the following: certain normative cultural values, such as the Navajo hozhooji (the importance of thinking and speaking positively), can have profound effects on informed consent and discussions of medical risk. For limited English proficient children and their families, studies document that medical interpreters frequently are not used, there is a lack of trained interpreters, there are more access barriers, and those who need but do not get interpreters have poor understanding of their diagnosis and treatment. Numerous folk illnesses, such as among Latinos, can affect care, because symptoms often overlap with important biomedical conditions, the first clinical contact may be with folk healers, and certain folk remedies are harmful or even fatal. Certain parent beliefs and practices can result in serious morbidity and fatalities (from lead poisoning, liver failure, and other causes), costly or unnecessary medical evaluations (eg, Fenugreek teas), and clinical findings easily confused with child abuse (eg, coining). Biased provider attitudes and practices can have profound clinical consequences, including ethnic disparities in prescriptions, analgesia, test ordering, sexual history taking, asthma care quality, and diagnostic evaluations.

CONCLUSIONS

Failure to appreciate the importance of culture and language in pediatric emergencies can result in multiple adverse consequences, including difficulties with informed consent, miscommunication, inadequate understanding of diagnoses and treatment by families, dissatisfaction with care, preventable morbidity and mortality, unnecessary child abuse evaluations, lower quality of care, clinician bias, and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluations.

Baby, souls, name and health: traditional customs for a newborn infant among the Hmong in Melbourne

In this paper, I discuss childrearing beliefs and practices in Hmong culture. In particular I focus on issues related to souls and ceremonies for a newborn infant in Hmong society. The Hmong believe that each living body has three souls. For a newborn infant, the first soul enters his or her body when he or she is conceived in the mother's womb. The second soul enters when the baby has just emerged from the mother's body and taken its first breath. The third soul, however, will have to be called on the third morning after birth, as will be discussed in this paper. If all three souls are secured in the infant's body, he or she will be healthy and hence thrive well. On the contrary, the infant may become ill and eventually die if all three souls do not reside in his or her body. This, therefore, makes a soul calling ceremony on the third morning after birth essential in Hmong culture. I will show that for Hmong society to survive, the Hmong strongly adhere to their cultural beliefs and practices related to a newborn infant. These beliefs and practices tie the Hmong with not only their family and their society at large, but also the supernatural world.

Severity signs of childhood diarrhoea in north eastern Nigeria

Oral Rehydration Therapy (ORT) use in Nigeria is currently far short of the national Control of Diarrhoeal Diseases (CDD) programme goals. Towards designing health education strategies to improve this, maternal lay health concerns during diarrhoea in under-fives were examined among two large ethnic groups, the Kanuris and Buras, in northeastern Nigeria. Over half of the respondents judged the severity of diarrhoea by more than one sign and expected ORT to stop diarrhoea. Severity signs frequently described (averaging from a quarter to a half of respondents) included weakness and refusal of food; frequent stooling and fever were more frequently used by the Kanuris (p < 0.001) compared to Buras and weight loss and dehydration by the Buras (p < 0.01) compared to Kanuris. Generally, rural residents were less concerned with dehydration and weight loss (p < 0.0001 and 0.003 respectively, compared to urban residents) and more concerned with restlessness, including excessive crying (p < 0.07 to 0.0001). Stool characteristics and vomiting were rarely used as severity signs although the Kanuris in focus group discussions related severity to diarrhoea typology. Concerns with persistent diarrhoea, and diarrhoea associated with measles, were rarely expressed by participants, irrespective of ethnic group and domicile, suggesting that health education aimed at increasing awareness in relation to these two serious illnesses is urgently needed in Nigeria. Several of the lay health concerns expressed by participants in the study could form a useful basis for promoting ORT use in Nigeria and elsewhere.

Treatment of childhood diarrhea in rural Egypt

The Egypt National Control of Diarrheal Diseases Project, implemented between 1983 and 1991, is widely regarded as one of the most successful national oral rehydration programs. Data from a longitudinal household survey conducted in 1990-91 in rural Egypt indicate substantial increases in both knowledge and use of oral rehydration salts during the 1980s. However, the same data show that treatment of acute diarrheal episodes is still far from optimal. In particular, the use of oral rehydration during diarrheal episodes is far from universal, the prescription of antibiotics is still too frequent, and antidiarrheal drugs of no therapeutic value are still widely used. Analysis of the factors associated with different treatment patterns shows that children with severe diarrhea, those aged 6-23 months and those from poor households were more likely to be given ORS; boys were somewhat less likely to receive ORS than girls, but mother's education showed no consistent effects. The type of treatment received is strongly influenced by the source of care. Government clinics are more likely than private physicians or pharmacies to prescribe ORS, whereas children taken to the latter two sources of care are more likely to be given antibiotics and antidiarrheals. To improve diarrhea treatment patterns in Egypt, not only must the public service educational campaign be reinstated and strengthened, but training programs must also be targeted at the treatment practices of private physicians.

'A bothersome death'--narrative accounts of infant mortality in Cape Town, South Africa

Traditional measures of health status such as mortality rates and cause-of-death information give limited insight into the role of caregivers and health care providers in infant illness and death. To the extent that the behaviours of these parties can be accurately mapped, they may reveal important sites for effective community interventions and the improvement of medical care. This possibility is explored in relation to infant mortality in Cape Town, South Africa, by analysing verbal histories provided by the caregivers of 70 infants in the course of obtaining police death certification. From these verbal histories it appears that acute respiratory infection and diarrhoeal disease caused the majority of deaths. Infants with a respiratory condition were likely to have been taken for medical attention prior to death. By contrast, the parents of infants with diarrhoeal disease, while more active towards these infants, were less likely to seek medical care--these infants typically being found dead in bed or dying en route to the hospital or clinic. A story of infant death at home following recent medical care was obtained in over half the cases. This study demonstrates a simple method for the examination of the content and structure of lay accounts of illness and death. The implications for health care of such accounts are discussed in terms of the behavioural antecedents of infant mortality due to acute respiratory infections and diarrhoeal disease.

Local knowledge: research capacity building in international health

Processes of building research capacity in international health projects and their implications for anthropology are addressed using examples from the Applied Diarrheal Disease Research project funded by the United States Agency for International Development. Two aspects of training are examined: the way interdisciplinary methods--qualitative and quantitative approaches--are presented to researchers, given the context of international health research culture; and how researchers' local knowledge and local concerns in pursuing health research relevant to policy led them to become interested in anthropology. The consequences for anthropology's place and product in future capacity building efforts in international health research are discussed.