Formative Research

PROJECT DESCRIPTION

This research report forms a backdrop for interventions planned around the WHO-UNICEF 7 point plan for diarrhoea treatment and control. The objective of this study is to undertake an exploratory research on behaviours associated with prevention and care of diarrhoea among children under the age of five. Specifically, the current formative research study aims to:

 

  • Gain insights on prevalent social behaviours, cultural norms and practices around control and prevention of diarrhoea among children under the age of five.
  • Understand how external factors influence specific behavioural practices around childhood diarrhea management- qualitative enquiry
  • Investigate personal preferences and rationale behind people’s choice of specific diarrhea prevention and curative practices - doers and non-doers analysis
  • Analyse the findings and build perspective on specific behaviours, suggest motivating factors that influence change using Designing for Behaviour Change framework
  • Understand community mobilization needs and suggest strategies based on the findings from the study for community participation in diarrhoea control and management.

 

METHODS

The study follows a three stage design process, beginning with the design of research tools, followed by survey methodology and sampling. A sequential mixed method approach to data collection is adopted where data collected in one phase provides inputs to data collection in the subsequent phases. This design framework combines qualitative and quantitative approaches to data collection, whereby the qualitative phase precedes the quantitative. The qualitative phase (Phase 1) involves Focus Group Discussions (FGD) with caregivers of children followed by In-Depth Interviews (IDI) with caregivers as well as providers of health services (such as ASHAs, AWWs and Doctors). The broad objective of the qualitative enquiry is to elicit group and individual sentiments and ideologies on diarrhea management. The subsequent quantitative household surveys (Phase 2) would integrate the inputs from the FGDs and IDIs to ensure parsimony and pertinence of the questions presented around diarrhea management. The current report presents findings from Phase 1.

10 FGDs and 60 IDIs were conducted in 4 districts of Uttar Pradesh (UP) and Uttarakhand.

 

OBJECTIVES

The objectives of the qualitative interactions were to:

  1. Validate findings from the baseline study and supplement them with additional insights on Knowledge, Practice and Belief barriers around diarrhea prevention and cure.
  2. Identify recurrent themes from FGDs that will further identify areas of priority for subsequent In-Depth Discussions (both of which will eventually help focus and streamline the probes for the Structured Surveys).

Elicit group responses on external factors that lead to specific behaviours being practiced or not practiced; and confirm them with individual responses

 

FINDINGS

Knowledge on Identification & Causes: Diarrhea was reported to be a common illness among infants and children. Diarrhea was identified primarily with frequent loose stools. Other symptoms associated with diarrhea (as reported by the participants) included vomiting, weakness, dullness, fever, watery eyes, inability to sleep, stomach ache, dehydration and blood in motion. A majority of respondents’ related diarrhea to some form of indigestion and consequently cited bad eating habits as a cause for diarrhea. Other causes cited were related to weather conditions such as summer heat, besides teething and mucus in the stomach. No superstitious beliefs or myths were cited as a cause for diarrhea.

Diarrhea Management & Treatment: Medical treatment from a doctor was sought in all instances (usually on the 2nd day of diarrhea), which was preceded by administration of home remedies such as salt sugar solutions or ORS sourced from an ASHA worker. Doctors were considered the most trusted source on treatment of childhood diarrhea as parents were unwilling to risk their child’s health. An assessment of knowledge, beliefs and practice levels of respondents on specific preventive and curative steps on diarrhea management reveals the following:

 

          Knowledge

           Practice

              Belief

Immunization

Vaccination was perceived as a method towards prevention of diseases such as chicken pox and polio. Respondents were not aware of the inter-relationship between diarrhea and immunization either in UP or Uttarakhand.

The practice of immunization was entirely driven by the efforts of the ASHAs and AWWs who provided the vaccination service for the respondents’ children.

Only a couple of respondents were of the belief that vaccinations could hurt their child and cause fever and therefore decided against getting their children vaccinated.

 

Exclusive Breast Feeding (EBF)

Respondents were aware of exclusive breast feeding practices and its associated health benefits for the child. However, mothers were unaware of the relationship between diarrhea and exclusive breast feeding.

 

Mothers reported to breastfeed the child even during times of child diarrhea.

Breast feeding was cited as a cause for diarrhea particularly during summers by a couple of respondents (Dikauli and Raghunathpur, UP).

Hand Washing with Soap (HWWS)

In general, awareness on the importance of handwashing with soap in prevention of diarrhea and other diseases was observed.

 

Respondents indicated that they washed their hands in a bowl or bucket which contained soap water before eating and after defecation. However, interactions with providers indicated that people do not take this practice seriously.

 

No cultural biases, norms or beliefs were associated with HWWS.

 

 

          Knowledge

           Practice

            Belief

Community Sanitation and Water Usage

Open defecation and unclean surroundings were cited as primary drivers for spread of diseases and infections and also believed to cause diarrhea. Importance of boiling and filtering water was not well established in UP.

Participants reported defecating in the open, with minimal toilet facilities available in the village. Maintaining cleanliness in the household was a common challenge for participants as the houses are surrounded by domestic refuse, mud and dirt. Boiled water was given to the child only at times of illness and not otherwise.

 

No cultural biases, norms or beliefs were associated with community sanitation and water usage.

ORS

ORS was associated with ‘medicine in a pouch’, ‘drinking medicine’, ‘Electral’ particularly in UP where respondents were largely unaware of the term “ORS”. Caregivers from Uttarakhand were largely aware of its role in diarrhea management and its method of preparation.

 

Respondents sourced ORS from an ASHA worker or a Medical Practioner (typically unregistered), whoever was the nearest; and respondents reported to have waited not more than one day of onset of diarrhea.

Largely no cultural beliefs were associated with ORS.

Zinc

About a quarter of respondents were aware of Zinc tablets (identified as ‘Red Tablets’ or ‘Yellow Tablets’) across UP and Uttarakhand.

Zinc consumption was driven by the efforts of ASHAs and doctors.

Respondents believed it was not effective and did not provide relief to the child.

 

Provider Assessment: Health workers were largely aware of the causes of diarrhea, its symptoms, prevention and treatment methods. However, knowledge dissemination by doctors on prevention strategies was low. ASHAs and AWWs were constrained by limited supply of medicines, most often having to purchase them from local medical shops.

 

CONCLUSION

Key enabling factors include the support of ASHAs in prevention and cure of diarrhea. Limiting factors include lack of institutional support and monetary constraints in access to diarrhea treatment and prevention. Greater focus is required to enhance awareness levels on treatment methods such as Zinc; as well as the inter-relationship between important preventive steps such as EBF, immunizations and diarrhea.