The cultural context of childhood diarrhoea among Gogo infants

Socio-cultural factors for breastfeeding cessation and their relationship with child diarrhoea in the rural high-altitude Peruvian Andes - a qualitative study

Background

In some areas of the world, breast milk is seen as a potential source of child diarrhoea. While this belief has been explored in African and Southeast Asian countries, it remains vastly understudied in Latin American contexts. We investigate socio-cultural factors contributing to breastfeeding cessation in rural high-altitude populations of the Peruvian Andes. The role of socio- cultural factors in the local explanatory model of child diarrhoea, and whether these perceptions were integrated in the local healthcare system were assessed.

Methods

Within the framework of a randomised controlled trial, we conducted semi-structured interviews with 40 mothers and 15 health personnel from local healthcare centres involved in the trial.

Results

Cultural beliefs on breastfeeding cessation included the perception that breast milk turned into “blood” after six months and that breastfeeding caused child diarrhoea. We identified eight local types of child diarrhoea, and women linked six of them with breastfeeding practices. “Infection” was the only diarrhoea mothers linked to hygiene and the germ disease concept and perceived as treatable through drug therapy. Women believed that other types of diarrhoea could not be treated within the formal healthcare sector. Interviews with health personnel revealed no protocol for, or consensus about, the integration of the local explanatory model of child diarrhoea in local healthcare and service provision.

Conclusions

The local explanatory model in rural Andean Peru connected breastfeeding with child diarrhoeas. Cultural beliefs regarding diarrhoea management may increase home treatments, even in cases of severe diarrhoeal episodes. Future national breastfeeding support programmes should promote peer-counselling approaches to reduce negative attitudes towards breastfeeding and health practitioners. Local explanatory models should be incorporated into provincial and regional strategies for child diarrhoea management to promote equity in health and improve provider-patient relationships.

"When I Breastfeed, It Feels as if my Soul Leaves the Body": Maternal Capabilities for Healthy Child Growth in Rural Southeastern Tanzania

The burden of childhood stunting in Tanzania is persistently high, even in high food-producing regions. This calls for a paradigm shift in Child Growth Monitoring (CGM) to a multi-dimensional approach that also includes the contextual information of an individual child and her/his caregivers. To contribute to the further development of CGM to reflect local contexts, we engaged the Capability Framework for Child Growth (CFCG) to identify maternal capabilities for ensuring healthy child growth. Ethnographic fieldwork was conducted in Southeastern Tanzania using in-depth interviews, key informant interviews, participant observation, and focus group discussions with caregivers for under-fives. Three maternal capabilities for healthy child growth emerged: (1) being able to feed children, (2) being able to control and make decisions on farm products and income, and (3) being able to ensure access to medical care. Mothers’ capability to feed children was challenged by being overburdened by farm and domestic work, and gendered patterns in childcare. Patriarchal cultural norms restricted women’s control of farm products and decision-making on household purchases. The CFCG could give direction to the paradigm shift needed for child growth monitoring, as it goes beyond biometric measures, and considers mothers’ real opportunities for achieving healthy child growth.

Postpartum sex taboos and child growth in Tanzania: Implications for child care

The social context and cultural meaning systems shape caregivers' perceptions about child growth and inform their attention to episodes of poor growth. Thus, understanding community members' beliefs about the aetiology of poor child growth is important for effective responses to child malnutrition. We present an analysis of caregivers' narratives on the risks surrounding child growth during postpartum period and highlight how the meanings attached to these risks shape child care practices. We collected data using 19 focus group discussions, 30 in‐depth interviews and five key informant interviews with caregivers of under‐five children in south‐eastern Tanzania. Parental non‐adherence to postpartum sexual abstinence norms was a dominant cultural explanation for poor growth and development in a child, including different forms of malnutrition. In case sexual abstinence is not maintained or when a mother conceives while still lactating, caregivers would wean their infants abruptly and completely to prevent poor growth. Mothers whose babies were growing poorly were often stigmatized for breaking sex taboos by the community and by health care workers. The stigma that mothers face reduced their self‐esteem and deterred them from taking their children to the child health clinics. Traditional rather than biomedical care was often sought to remedy growth problems in children, particularly when violation of sexual abstinence was suspected. When designing culturally sensitive interventions aimed at promoting healthy child growth and effective breastfeeding in the community, it is important to recognize and address people's existing misconceptions about early resumption of sexual intercourse and a new pregnancy during lactation period.

What is the qualitative evidence concerning the risks, diagnosis, management and consequences of gastrointestinal infections in the community in the United Kingdom? A systematic review and meta-ethnography

BACKGROUND

Gastrointestinal (GI) infections cause a significant public health burden worldwide and in the UK with evidence pointing to socio-economic inequalities, particularly among children. Qualitative studies can help us understand why inequalities occur and contribute to developing more effective interventions. This study had two aims: 1. Conduct a systematic review to determine the extent and nature of UK qualitative evidence on gastrointestinal infections; 2. Use meta-ethnography to examine the influences of the differing social contexts in which people live.

METHODS

MEDLINE, Scopus, Web of science, CINAHL and JSTOR were searched for UK qualitative studies engaging with the risk, diagnosis, management or consequences of gastrointestinal infections from 1980 to July 2019. Five reviewers were involved in applying inclusion and exclusion criteria, extracting and synthesising data (PROSPERO CRD 42017055157).

RESULTS

Searches identified 4080 studies, 18 met the inclusion criteria. The majority (n = 16) contained data relating to the risk of gastrointestinal infection and these made up the main synthesis. The tenets of meta-ethnography were used to glean new understandings of the role of social and environmental contexts in shaping the risk of gastrointestinal infection, specifically with respect to foodborne GI illness. Three main explanations concerning risk emerged from the data: explanations of risk in the community were underpinned by understandings of 'bugs', dirt and where food comes from; risks were negotiated in households alongside diverse processes of decision making around food; and resources available to households shaped food practices.

CONCLUSION

This systematic review highlights the scarcity of UK qualitative evidence examining gastrointestinal infections. Apart from risk, questions around diagnosis, management and consequences of illness were largely untouched. No studies investigated patterning by socio-economic status. Nevertheless, the meta-ethnography yielded wider contextual theories and explanations as to why people might not follow food hygiene guidance, giving pointers to the types of qualitative enquiry needed to develop more effective interventions.

'He usually has what we call normal fevers': Cultural perspectives on healthy child growth in rural Southeastern Tanzania: An ethnographic enquiry

Introduction

While parents’ construction of and actions around child growth are embedded in their cultural framework, the discourse on child growth monitoring (CGM) has been using indicators grounded in the biomedical model. We believe that for CGM to be effective, it should also incorporate other relevant socio-cultural constructs. To contribute to the further development of CGM to ensure that it reflects the local context, we report on the cultural conceptualization of healthy child growth in rural Tanzania. Specifically, we examine how caregivers describe and recognize healthy growth in young children, and the meanings they attach to these cultural markers of healthy growth.

Methods

Caregivers of under-five children, including mothers, fathers, elderly women, and community health workers, were recruited from a rural community in Kilosa District, Southeastern Tanzania. Using an ethnographic approach and the cultural schemas theory, data for the study were collected through 19 focus group discussions, 30 in-depth interviews, and five key informant interviews. Both inductive and deductive approaches were used in the data analysis.

Results

Participants reported using multiple markers for ascertaining healthy growth. These include ‘being bonge’ (chubby), ‘being free of illness’, ‘eating well’, ‘growing in height’, as well as ‘having good kilos’ (weight). Despite the integration of some biomedical concepts into the local conceptualization of growth, the meanings attached to these concepts are largely rooted in the participants’ cultural framework. For instance, a child’s weight is ascribed to the parents’ adherence to postpartum sex taboos and to the nature of a child’s bones. The study noted conceptual differences between the meanings attached to height from a biomedical and a local perspective. Whereas from a biomedical perspective the height increment is considered an outcome of growth, the participants did not see height as linked to nutrition, and did not believe that they have control over their child’s height.

Conclusions

To provide context-sensitive advice to mothers during CGM appointments, health workers should use a tool that takes into account the mothers’ constructs derived from their cultural framework of healthy growth. The use of this approach should facilitate communication between health professionals and caregivers during CGM activities, increase the uptake and utilization of CGM services, and, eventually, contribute to reduced levels of childhood malnutrition in the community.

Home Care of Children With Diarrhea in Bangui's Therapeutic Landscape (Central African Republic)

We explore how the therapeutic landscape of Bangui, capital of the Central African Republic, shaped and reflected caregivers' home care of childhood diarrhea. Using interviews, group discussions, and participant observation, we found that caregivers described several categories of diarrhea, but in practice, adopted an experimental approach to home diarrheal care. Many managed incertitude by initially dosing children with street medicines and herbal infusions; they delayed seeking professional medical care to avoid expenses, observed their children's symptoms, consulted social networks, and used therapeutic foods. The logics underpinning these practices emerged from caregivers' conviction that diarrhea necessitated medical therapy and restricted choices within Bangui's therapeutic landscape, a consequence of lengthy political economic crisis. This crisis impoverished Bangui populations, eroded formal health care, and sharpened religious differences, discouraging care seeking from traditional healers. Analyses of therapeutic landscapes illuminate why caregivers embraced specific practices and logics and should guide the elaboration of more effective public health interventions.

Gender Determinants of Vaccination Status in Children: Evidence from a Meta-Ethnographic Systematic Review

Using meta-ethnographic methods, we conducted a systematic review of qualitative research to understand gender-related reasons at individual, family, community and health facility levels why millions of children in low and middle income countries are still not reached by routine vaccination programmes. A systematic search of Medline, Embase, CINAHL, Cochrane Library, ERIC, Anthropological Lit, CSA databases, IBSS, ISI Web of Knowledge, JSTOR, Soc Index and Sociological Abstracts was conducted. Key words were built around the themes of immunization, vaccines, health services, health behaviour, and developing countries. Only papers, which reported on in-depth qualitative data, were retained. Twenty-five qualitative studies, which investigated barriers to routine immunisation, were included in the review. These studies were conducted between 1982 and 2012; eighteen were published after 2000. The studies represent a wide range of low- to middle income countries including some that have well known coverage challenges. We found that women's low social status manifests on every level as a barrier to accessing vaccinations: access to education, income, as well as autonomous decision-making about time and resource allocation were evident barriers. Indirectly, women's lower status made them vulnerable to blame and shame in case of childhood illness, partly reinforcing access problems, but partly increasing women's motivation to use every means to keep their children healthy. Yet in settings where gender discrimination exists most strongly, increasing availability and information may not be enough to reach the under immunised. Programmes must actively be designed to include mitigation measures to facilitate women's access to immunisation services if we hope to improve immunisation coverage. Gender inequality needs to be addressed on structural, community and household levels if the number of unvaccinated children is to substantially decrease.

Sociocultural determinants of anticipated vaccine acceptance for acute watery diarrhea in early childhood in Katanga Province, Democratic Republic of Congo

Rotavirus and oral cholera vaccines have the potential to reduce diarrhea-related child mortality in low-income settings and are recommended by the World Health Organization. Uptake of vaccination depends on community support, and is based on local priorities. This study investigates local perceptions of acute watery diarrhea in childhood and anticipated vaccine acceptance in two sites in the Democratic Republic of Congo. In 2010, 360 randomly selected non-affected adults were interviewed by using a semi-structured questionnaire. Witchcraft and breastfeeding were perceived as potential cause of acute watery diarrhea by 51% and 48% of respondents. Despite misperceptions, anticipated vaccine acceptance at no cost was 99%. The strongest predictor of anticipated vaccine acceptance if costs were assumed was the educational level of the respondents. Results suggest that the introduction of vaccines is a local priority and local (mis)perceptions of illness do not compromise vaccine acceptability if the vaccine is affordable.

Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

Treatment of diarrhoea in rural African communities: an overview of measures to maximise the medicinal potentials of indigenous plants

Diarrhoea is a major cause of morbidity and mortality in rural communities in Africa, particularly in children under the age of five. This calls for the development of cost effective alternative strategies such as the use of herbal drugs in the treatment of diarrhoea in these communities. Expenses associated with the use of orthodox medicines have generated renewed interest and reliance on indigenous medicinal plants in the treatment and management of diarrhoeal infections in rural communities. The properties of many phenolic constituents of medicinal plants such as their ability to inhibit enteropooling and delay gastrointestinal transit are very useful in the control of diarrhoea, but problems such as scarcity of valuable medicinal plants, lack of standardization of methods of preparation, poor storage conditions and incertitude in some traditional health practitioners are issues that affect the efficacy and the practice of traditional medicine in rural African communities. This review appraises the current strategies used in the treatment of diarrhoea according to the Western orthodox and indigenous African health-care systems and points out major areas that could be targeted by health-promotion efforts as a means to improve management and alleviate suffering associated with diarrhoea in rural areas of the developing world. Community education and research with indigenous knowledge holders on ways to maximise the medicinal potentials in indigenous plants could improve diarrhoea management in African rural communities.

Home management of childhood diarrhoea in southern Mali--implications for the introduction of zinc treatment

Diarrhoea remains one of the leading killers of young children. A recent meta-analysis demonstrated that a two-week course of zinc tablets once daily significantly reduces the severity and duration of diarrhoea and mortality in young children (Bhutta et al., 2000. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials. American Journal of Clinical Nutrition, 72(6), 1516-1522). Formative research is being conducted in a number of countries to prepare for the large-scale promotion of this new treatment. In-depth and semi-structured interviews with parents, community health workers, and traditional healers were conducted to examine the household management of diarrhoea in the Sikasso region of southern Mali in preparation for the introduction of a short-course of daily zinc for childhood diarrhoea at the community level. Supporting data from a subsequent household survey are also presented. Although nearly all parents knew oral rehydration solution (ORS) could replace lost fluids, its inability to stop diarrhoea caused parents to seek antibiotics from local markets, traditional medicines or anti-malarials to cure the illness. The notion of combining multiple treatments to ensure the greatest therapeutic benefit was prevalent, and modern medicines were often administered simultaneously with traditional therapies. As parents often deem ORS insufficient and judge that an additional treatment should be combined with ORS to cure diarrhoea, the concept of joint therapy of zinc and ORS should be well accepted in the community. Mothers-in-law and fathers, who play a significant role in decisions to seek treatment for sick children, as well as traditional healers, should also be considered when designing new programs to promote zinc. Similarities with formative research conducted for a previous generation of diarrhoea control programmes are discussed.