oral rehydration solution in rural bangladesh...

J Diarrhoeal Dis Res 1988 Mar; 6(1):6-140253-8768/88 $ 1.00+0.1 b

@ 1988 Intematioml Ccntre for OiarrhoealDisease Research. Bangladesh

PERCEPTION OF DIARRHOEA AND THE USE OF A HOMEMADEORAL REHYDRATION SOLUTION IN RURAL BANGLADESH

A MUSHTAQUE R CHOWDHURY AND J PATRICK VAUGHAN'

Senior Research Demographer and Head. Research and Evaluation Division. Bangladesh Rural AdvancementCommittee, 66 Mohakhali CIA. Dhaka 1212. Bangladesh; 'Professor and Head. Evaluation and Planning Centre

for Health Care. London School of Hygiene and Tropical Medicine.Keppel Street. London WClE 7HT. United Kingdom

Abstract

Oral rehydration therapy (ORT) is being widely promoted in developing countries. but the socio-culturalaspects of diarrhoea are often poorly investigated prior to planning the programmes. Since 1980. theBangladesh Rural Advancement Committee (BRAC). a non-governmental organisation. has promoted ahOme-made ORT solution for use in all diarrhoeal episodes. called lobon-gu( solution (LGS). which is madefrom household lobon (salt) and gur (unr~fined sugar) using the 'pinch-and-scoop' method. One mother perhousehold is trained in its preparation and use during a half-hour home visit. By late 1986, over 7 millions ofBangladesh's 16-million households had been visited. Initial programme monitoring showed that mostmothers could prepare a safe and effective solution, but that its use was less encouragiang. A village studyundertaken to investigate this low use found that villagers recoginse four different types of diarrhoealillnesses, which are dud hagadue to breast-milk in infants; ajirno due to over-eating or bad food; amasa.amucoid diarrhoea. with or without blood and of unknown cause; and daeria which is severe watery diarrhoea,or cholera. LGS was most frequently used for daeria episodes which, although representing only 5% of allepisodes. are those most likely to lead to dehydration and death. Thus, the BRACmessagepromoting LGS'

.for all types of watery diarrhoea was understood by the people to be of most use for severe watery diarrhoea.

, The importance of this local classification of diarrhoea has only just received recognition, despite more than25 years of diarrhoeal disease research in Bangladesh.

, I

Key words: Diarrhoea; OrQI rehydration solutions; Oral rehydration therapy; Anthropology,Medical; KAP; KAP surveys.

Introduction

In Bangladesh diarrhoea is endemic (1) and morcthan 250,000 people. mostly children. areestimated 10 die from it every year (2). Oralrehydration therapy (ORT) is now a proventreatment for the dehydration due to diarrhoea (3).Since 1980. the Bangladesh Rural Advancement

Correspondence and requests for reprints should beaddressed to Dr AM R Chowdhury.

Committee (6\RAC). a national. non-governmentalorganisation (NGO).. has been teaching mothershow to make ORT solution at home by using athree-finger pinch of household salt {lobon}und a fistful of unrefined sugar (gur), Lholobon-gU( solution or LGS (4). By late 1986, morethan 7 millions of Bangladesh's 16-millionhouseholds had been visited by BRAC workers andthe method taught to the members. particularly themothers of each family. Hpwever. evaluationshowed that LGS was not much us~d during

.--_.

The paper is a part of the Ph. D. thesis submitted by the lirst author to the University of London and the work was donejointly with the second author.

Diarrhoea perception and use of ORS

.-episodes of diarrhoea in the rural community.

Epidemiological data have commonly been usedin planning national ORT programmes indeveloping countries, but the limitations of suchdata are less well recognised. A low rate of ORT

use, for eXdinple, maY ue due Loplanners ignorinyinformation on local beliefs and perceptionsconcerning diarrhoea (5). Few ORT programmesappear to have taken seriously these socio-culturalaspects into consideration (6). Kendall et al. haveshown how the use of ethnographic research('ethnomedicine') helped shape an ORTprogramme in Honduras (7) and other investigatorshiNe emphasised the need to consider localperceptions ",bout illness and its control indesigning health-care activities, such as an ORTprogramme (8, 9, 10).

Little work has been done in Bangladesh on howpeople's cultural beliefs and perceptions of adisease affect their practices in handling it (11).There has been no such study on diarrhoea, exceptthe one which was done in the tribal areas of

Chittagong (12). Although there was no in depthsocial/anthropological study for the original BRACORT programme in Bangladesh, experiences fromother rural development studies were generouslyused in its design. Frequent visits to theprogramme sites and conversations with villagers

I helped to make several changes in theprogramme; but when these ad hoc changes led tono significant improvement in the rate of usingLGS, there was clearly a need for an in depth study.We present here the results of a village study inwhich attempts were made to determine people'sbeliefs, perceptions and customs concerningdiarrhoea, and how these affected the use of theLGS. Some results from a subsequentcommunity survey are also given as theycomplement the results of the present study.

Background of the BRAC ORT programme

On the basis of pilot research emd held trials,BRACoovolaroo (1sovon-roint hO:111h rnossafjo forfl1othors 11110other liHnily rnomhors 1010i1ChIhol1\how to recognise dehydration; how to prepareORT solution from household lobon * (common._. --' ,-'--'._ou.- -"'-'.'" ... .....

. Trul1$liloraliol\ u:>cd hCf0 I\lIVC bCCI1 l<ikcll from .) book

given in the list of referel1ce$ (11).

7

salt), gU( (unrefined sugar) and water, based on the'pinch-and-scoop' method; how to feed a childproperly during and after diarrhoea; and how to

practise healthy habits to prevent diarrhoea (4),Female health workers, called oral replacementworkers (ORWs), taught one mother in each ruralhousehold the technique to prepare LGS and thensupervised her while she made the LGS herselfduring a face-to-face session lasting 25.30minutes. Mothers were instructed to use LGS if

their children had one or more loose motions perday, which was defined by BRAC as "diarrhoea"(1,4). A second group of workers, called monitors,assessed the quality of teaching and the ability ofmothers to remember the procedure and preparethe LGS one month after the teaching sessioncarried out by the ORWs. The results of such,monitoring proved the high quality of the training in90% of the mothers who were able to prepare a'safe and effective' solution with a sodiumconcentration in the range of 30-99 mmol/l (1). Therate of use of LGS amongst diarrhoea patients wasalso assessed which found that less than 20% of

all diarrhoeal episodes were treated with LGS overthe previous 2-week recall period. More detailsabout the BRAC programme have been reported,elsewhere (4)'.

Materials and methods

The village study was done during July toSeptember 1984 in two villages of 178 and 422households in Camilla district, Chittagong division.The villages are situated close to a riyer systemforming part of the riverine terrain of Bangladesh. Asimple low-cost method of. coilecting 'data wasused which included: a demographic survey of allhouseholds, weekly surveillance of households torecord diarrhoeal episodes and treatments used, indepth interviews with villagers selected torepresent a. cross-section of age, sex,socio-economic and occupational statuses,andinlormal disclissons with some of those peorlol ,The final method of collecting information was a~erius of ~evel1 focus group discussions" with

, InthissocialsCience' research method, groups of 6.10persons belonging to similar backgrounds (with respectto. for eXiJmple, socia-economic and occupational~il<Jlu;;C$)are brought together to discuss iJn iS$lJ8in thepresence of a facilitator (13).

8 J Diarrhoeal Dis Res Mar 1988

villClgers of sirnilm backgrounds. 11m 1esC);" chilPI..>!uilcl1 t clieu UI1 ilCCUII1U"llil1~ Ivid(~IICt: II(1111the different research methods outlined above, sothat qualitative conclusions can be drawn. Thistechnique has been termed the convergentevidence method of research (14). Weeklysurveillance information was used to identifysubjects for in depth interviews. The informationand ideas' arising out of such interviews wereexplored and revalidated in subsequent interviews.Conclusions were then further checked for

convergence or divergence through informal andfocus group discussions. Information found truefor one village was then tested in the other for itsconsistency.

Later on, a large community survey involving7.500 households randomly selected through athree-stage cluster sampling was conducted inthree programme areas covered by BRAe. Thissurvey aimed to measure the extent of use of LGSby asking questions on the occurrence of diarrhoeain the past two weeks and the treatment given. Inthe survey. questions were asked on the occur-ence of the four types of diarrhoeqdescribed in thepresent study (see below). More details of thislater study is given elsewhere (15). Data from thissurvey are provided here as they confirm the majorfindings of the village study.

Results

Perceptions

The study revealed four different types ofillnesses perceived by people. particularly themothers. which have some similarities with theclinical presentation of diarrhoea. These are asfollows:

1. Dud haga: This is a type of loose motion whichis attributed exclusively to breast-feeding: dud ismilk and haga" is purging in Bangia. The baby's

stools are wi'ltery and they cry. The belief is held'that breast-milk becomes polluted whicH caUsesits excessive flow. The colour of the stool, as

stated by villagers, may even "resemble what themother Has eaten" The action taken may eitherbe to stop breast-feeding or to stop the mother

. .

. Haga in colloquial Bangia means both purging andstool.

Chowdhury illld V<'Iughan

110111 (~;llillq qtl~(~ll vUq(~I;llJlu~;, ri~~I1,01 I1H~()I. nullJU!!,/ i., .II';'" 1:.1I1"d h.il.I::j h,!!..,. nil,.,:: i:: wi"d ;111<1"if a mother catches bad wind", informed one

mother. "her breasts will be heavy with pollutedmilk and when the child sucks the breast he will

have batas, haga,Many villagers consider dud haga a part of

growing-up and hence requires no treatment.Some try LGS out of curiosity. If the dud hagapersists, the mother may herself take and/or givethe baby pani pora (ritual water) or put on a tfJbiz(amulet) (11). Others may go to a local quack or a"barefoot" practitioner for a dud injection. A smallamount of breast milk is extracted and taken in a

cup and the practitioner takes 2 ml of it in a syringe.He then dilutes it with 1 ml of distilled water

(water-for-injection) and injects it into the mother'sarm. The belief is that the injection 'lightens' thebreast and cures the child. Most practitioners givethis treatment, but many would hesitate to admit.One who confessed put the following argument:'The mother comes to me and asks for it. If I don't

comply with the request she will find someoneelse and I lose my patient'. Some of them do notbelieve in dud injection and instead, give atropininjections to lighten the breasts.

2. Ajimo: The literal meaning of this term isindigestion and may also be called bod hajam. Thisdiarrhoea may be experienced by people of anyage. The main cause, it is believed, is indigestiondue to over-eating or food-poisoning leading to astool of variable consistency accompanied byabdominal distension and a griping of the stomach.

This is hardly considered a disease by villagers.According ta papular belief, one gets ajTrno whenthe stomach gets tired and hence the cure issimple - to ,restthe stomach. The head-master ofa local primary school had ajimo because he ate toomur.h. H0. look" 1i1l10. SClIt cmrl "llowed hisstomach to rest for a full day and was cured thefollowing morning. LGS may aggravate the ajTrnoas it contains gur", commented one bare-footpractitioner. .

3. Amasa: This type o("loose motions isexperienced by people of all ages. Most amasa

~ Gur is believed to have some laxative property.


..stool is not watery but it contains mucous. It mayor may not be accompanied by blood and if it isbloody it is called roktoamasa. This is consideredadisease but the cause is not clear to villagers.

The most popular tre<1tment for i'imc1sc1is /JoneiT.'which i~ an illlOll11al ~chool 01 medicine pracLisedby elderly women. There are some who practiseit for a fee. Most bonejT practitioners would notdisclose their recipes. They use different herbsand mix them with juices of fruits and othermaterials: such as honey. BonejT is different fromkabirajT (16). a socially and legally recognisedsystem of medical practice in the Sub-continent.

Any herb which is bitter is considered good foramasaand the most popularly used herbs are: tTamanka, khan kunT (Cantella asiatica), jute leaves,and black arum. Normal food is withheld. Soft

unfluffed rice of kaon type is sometimes given withmustard oil.

4. Daeria or Cholera: This is considered to be aserious disease which takes lives when it comes

(in epidemic form). In the words of avillage elder:"Daeria is dreadful and I prefer not to makemention of it. It used to be a big problempreviously but it is not so common now. If it getssomeone, he can hardly think of surviving withoutvisiting Matlab" (the field treatment centre of theInternational Centre for Diarrhoeal Disease

Research. Bangladesh (lCDDR,B). situated about50 kilometres downstream from the studyvillages).

"It is like Ajrail (the Angel who takes life). a cursefrom God and people can have it if they aredisobedient to Him", commented another villager.People can also get daeria, the villagers believe. ifthey walk through a graveyard or a crematorium.Others feel that this is caused by eating bad orrotten food. Children get it when they eat mud andsand. The common symptoms are stated to befrequent purging of stools which look likerice-cleaned water, weakness which makes it hardevon to wulk. sunkoll eyos. thirst. continualvomitino <Inrimrluc:orl urino.

UwJ /ldf}d dnL! dJllilO dru nut consldor ud tu heddelia, but severe ajTmo or dud haga whenaccompanied by vomiting may turn out to bedaeria. For daeria, the r><ltients are taken to theIroatrnent centre of Lho ICCDR.B (It MaLiab. buLbefore this is done treatments. such as LGS. are

9

tried. If one cannot afford to go to Matlab, a localbare-foot doctor or a registered medicalpractitioner may give the patient intravenous (i.v.) .saline and antibiotics. For daeria, accordil!g to ahmc foot r>ri1clitioner. LGS or packet saline may begiven but sulpha drugs are recommended to curethe patient.

Confirmation of the findings through communitysurvey

As stated in the methods, people's classificationof diarrhoea was probed in other parts of thecountry. During a community survey. followingthe present village study. we visited 11 of the 21districts of Bangladesh Through informal andfocus group discussions with villagers, the generalclassification of diarrhoea described above wasconfirmed. There were, however, differences in I ,the names used to denote a particular type ofdiarrhoea. For example, what was dud haga in thevillages of Camilla district was called buni haga inSylhet or bau batas in Barisal district; what wasrokto amasa in the study villages was called Ioukamri in Sylhet. and so on. We now examine theconsistency of this classification by referring to theresults from the community household survey.

Table I shows the percentage of episodes ofeach type of diarrhoea and th~ annual per-personrates estimated on the basis of a 2-week recall

period. It shows that the proportions of the fourtypes of diarrhoea are very similar in the threesample areas surveyed. although some differen-ces in incidence rates exist. An analysis of thetypes of diarhoeal episodes by age showed noparticular trend except for dud haga where allepisodes in all the areas occurred, as expected perits definition. in children less than 5 years of age(not shown in table)

Table II shows that the use of LGS is much

higher in episodes of daeria.compared with othertypes. with the lowest use in the amasa type.

nc'.T;O//S for ill<' il/f/oc/tluill tlse 01 L GS

I he weekly survey identified non-users of LGSand based on interviews with them and otherpeople. such as quacks. quasi-recognisedbinc-fool doctors and registered medicalpractitioners. a range of reasons emerged .to

10 J Diarrhoeal Dis Res Mar 1988 Chowdhury and Vaughan

IABLE I - % or- HEPOFHEO DIAIIIIHOI:Al. I:PISOl>I:S AND I:SliMA' I:LJANNUAl.INCII)INCtS OVIYPlSorDIAlHIIIOI/\IN ""II 1111111111NI "II()(III/\MMI /\111/\:;

Diarrhoea

types

DudhagaAjfrnb

'I Amasa, Daeria

All

No. of episodes

No. of house-

, hold surveyed

.* Episodes

t Estimated ann'ual incidence of diarrhoea per person

TABLE II - USE OF LOBON-GUR SOLUTION,EXPRESSED AS % OF ALL REPORTED DIARRHOEALEPISODES*, AMONG THE FOUR TYPES OF

DIARRHOEA IN THREE DIFFERENTPROGRAMME AREAS

* An episode means any diarrhoea irrespective ofwhether the patient received treiltrnenl or not.

explain why some people did not use the LGS.These are presented below.

Confusion with the definition of diarrhoea

The majority of non-users reported that they did

not use LGS, because their illness was not daeria."The ladies (meaning BRACORWs) told us to giveit for daeria or cholera. We don't have daeria or

cholera in the village" , was a typical answer from avillage woman when asked about not usin'Q.LGS totreat children with loose motions. A fisherman,when his young son had loose motions. went to hisaunt for boneji, rather than to use LGS. becausethe members of his family were not sure whetherhis son had ajirno or daeria.

)

Misconception about the curing ability of LGSp~nLLIehHb:

Soma parsons hnd usarltha solution pmviously.but it did not stop the loose motions on thoseoccasions and they losl faith in it. [The scientificobservation that a child with diarrhoea receivingORT remains safe inspite of his purging not beingcontrolled promptly-was not told during themothers' education on the preparation and use ofLGS] Thus. the poor villagers lost money for thetreatment of their children's diarrhoea, when theyhad to take them to doctors who gave thepatinents Lv. saline and capsules. A BRACfieldstaff witnessed a mother to refuse. even at the

a:IToj

pi01

I..

- -- ---.- -----.-.---------

Programrne Areas2 3

%of Aft %of Alt %of Altepis* epis* epis*

11.5 0.21 12.5 0.35 12.9 0.4850.4 0.91 52.4 1.50 47.9 1.7733.0 0.59 30.1 0.86 35.0 1.29

5.0 0.09 5.0 0.14 4.2 0.15

100 1.80 100 2.85 100 3.69

1023 1534 1940

2329 2289 2292

Diarrhoea ProgrammeAreastypes 1 2 3

- - -

Dud haga 2.0 12.2 12.3Ajirno 4.0 7.9 9.8AmasJ 1.6 2.9 4.0Daeria 25.6 31.6 52.2All diarrhoea 4.1 8.2 9.9


ICDDR,B treatment centre in Dhaka, to allow hersonto be treated with ORS. She wanted him to be

given i.v. fluid inspite of his dehydration notsevere enough to require it. A polite but futileattempt was made to convince her on theulluclivulluss ul 01-\I . Sllu Iillully luuk her SUIIaway.

Pooravailability of gU(

Non-availability of gu(was cited by villagers as areason for not using LGS. In the villages, onlyabout 10% of the households were found to

, possessgiJ(.The availabilityof 9fl( is alsoseasonaland coincides with the harvest of sugarcane anddate juice. Refined sugar was found to be asfrequently available as gu(. The price of sugar washigher, but many people preferred to use it,because they believed that they would command ahigher social status by doing so.

Method of preparationand feeding

To some busy persons, like head-master of avillage-school. the simple preparation of LGSappeared cumbersome. Some others felt that it isquite difficult to feed LGS to babies. In the opinionof a physician, who worked at the Dhaka Shishu(children) Hospital for some time, to feed ORS tothe babies is not easy. Other persons said that thechildren did not like the smell pr taste of thesolution.

Antagonistic attitudes of health practitioners

One of the authors talked with all types of healthpractitioners in the study villages, such as quacks,~omoeopaths, practioners of kabiraji herbalmedicine, bare-foot and registered doctors.Unfortunately, none appeared to actively promoteLGS. Some of them even regarded LGS to be oflow-status and not a very effective medicine. Thehead of the local government dispensary told usthat he always advises his patients to take LGS;bul whull ~UVUI,II ul III:; dldllhUU-l pdllulI!:; WUIIJ

o~kodwhut hud ho j..)loscIiLJod.LGS wus 1101

mentioned. Similar cross-checking with patientsof other practitioners indicated that thepractitioners exaggerated their role as promotersof LGS. (A strong governnient policy is to

11

iI

II

promote ORT for diarrhoea.) Intelligent personslike a teacher opined that a doctor cannot suggestlobon-gur which is against his business. Onemother confided, "the doctor said LGSdoes notwork". On the whole. the practitioners created asuutle impression that LGS is an inferior type ofcure.

Discussion

This paper explored the perceptions ofBangladeshi villagers about diarrhoea and itstreatment and how this affected their use ofhomemade ORT solution, viz. the lobon-gursolution or LGS. It showed that the Bangladeshivillagers studied have a classification of' fourdifferent types of loosemotions. eachperceivedasa different condition with a separate cause andtreatment. This finding was confirmed in otherdistricts of Bangladesh,although different nameswere usedto denote a particulardiarrhoeatype. Acommunity surveyprovideddatawhich substantia-ted these findings as it found consistently similarproportion in each type of diarrhoea in threedifferent sample areas.' The most infrequentlyoccurring type was daeriaand the signs of this. asmentioned by villagers, were those of severedehydration. However. data are not available toascertain the aetiologic nature of the four types ofdiarrhoeawhich will need further research.

Findings similar to ours have been recordedelsewhere. We know of empacho OJcaida demol/era, etc. in Honduras(7); the five types of folkillnesses in northceastBrazil (17); behdi, dosham,etc. in South India (18); or umsheko, kuhabula.etc. in Swaziland(10). All these arediarrhoea,butvillagers consider them to be different conditions.The percep'tionof diarrhoeahas not been studiedbefore in Bangladesh. which is surprising in acountry where diarrhoea research has been amajor activity for the last 25 years by ICDDR,B(formerly Pakistan-SEATO' Cholera ResearchLaboratory). It is also significant that a nationaJ ,

. Another ~tudy done in 1987 in 6 villages of Dhaka.Khulna and Rajshahi divisions also found the existence ofthe four types of illness as found here (Report on4ualitalive study on oral rehydration therapy. ,Dhaka:Fmnily Planning Social Marketing Project, June 1987). '

I ,


, :

and rural-based orgOllisatiol1,suchas rm/\c. h(~n;1I1:111 Of" PI()~JI;lIllllH1 witholll qivilHJ ;1f1"Cffl:iI,'

attention to assessing people's perceptions ondiarrhoea. How many carefully planned healthprogrammes can trace their failures to 'top down'planning which ignored the perceptions of thepeople - the very people who might benefit fromthese programmes?

The other important finding from the villagestudy relates to the reason for the infrequent use ofLGS. The mothers misunderstood what theywere taught by the oral replacement workers whoemphasised the word 'diarrhoea' which wasinterpreted by mothers as daeria or only severewatery diarrhoea or cholera. Hence LGS wasused infrequently to treat other types of loosemotions (Table II). However, since daeriawas themost infrequently occurring type (only 5% ofepisodes), the effect of a high use for this type wasminimal on the overall use. The major purpose ofORT is to prevent deaths due to dehydration. therisk of which is greatest in patients with daeria.The higher use of LGS in this type of loose motionsmay. thus, lead to a decrease in diarrhoeal deathsin rural Bangladesh. Studies being done by BRACwill test this hypothesis.

The passive and frequently negative attitudes ofall types of local health practitioners, despite BRACtrying to enlist their support suggest that the useof LGS is in direct competition with theirinterests. Research is needed to find ways ofobtaining a more positive support.

The poor or seasonal availability of gur is aserious limitation to the use of LGS. If the gur isavailable at home. it becomes much easier formothers to use LGS. Refined sugar is also notwidely available and it is more expensive than gur,but its social value, however. is much greater sinceits use carries status. Substitutes for gllr. such asrefined suqnr or rice powder. must hn consirlmerlfor use along with gu(. IholO wel () al~J()misconceptions on the part of the villagers thatLGS promptly cures purging. This belief needs tobe dispelled by informing villagers clearly that mostof the time LGS does not promptly cure purging.but in fact the purging may sometimes increase.However the patient does not become dehydratedand eventually the diarrhoea stops. BRAC hasbeen prompt to accept the findings of the study tomodify its programme. A new 7-point message

Chowdhury i1l1d Vaughan

h;1~:h(~CI1drvolopod which nmphnsisAsthA IISAofI r,c:; fnr 0;1<'11nf 1110fnllr tYf10~ of cklrrhnp;l (see!Appendix) and refined sugar is now reCOn1l110lHJouas a substitute for gur. /\ rcscmch study hlls beenundertaken to explore the capacity of mothers tomake a rice-based ORS at home and to investigateits acceptability. The new message alsoemphasises the rehydration property of LGS andthe mothers are told that it is not meant to cure theloose motions of their children promptly. but toprevent dehydration until the diarrhoea eventuallystops.

Acknowledgements

Financial and other assistance were provided bythe Swiss Development Cooperation and theBangladesh Rural Advancement Committee. Inparticular we wish to thank Dr. I Cornaz and Mr.F H Abed of these organisations for their supportand encouragement. Comments on an earlierdraft of this paper were received from Dr. K M AAzizof ICDDR.B which is gratefully acknowledged.However, it is to the people of the study villages towhom we owe a special thanks for sharing with ustheir knowledge and understanding on diarrhoealdiseases.

Referencp.s

1. EllerLrqck TV. Oral replacement therapy in ruralBangladesh with home ingredients. Trap Docl1981; 11:179-83.Guerrant RL. Cash RA. Infectious disease:treatment of cholera and other diarrheal illness. In:

Chen LC ed. Disaster in Bangladesh. Oxford:Oxford University Press. 1973:81-94.C;rsh riA. Oml th(1mpy for rlimrhof!;1, Tm(l Doct1979; 9:25-30.!111mI n I. IIoII'1nl1old Inilr.hinf) or orn in rtlll1l

Bangladesh. Assign Child 1983; 61/62:250-65.Hielscher S. Sommerfeld J. Concepts or illness andthe utilization of health-care services in a rural

Malian Village. Sac Sci Med 1985; 21 :469-81.Chowdhury AMR. Evaluating ORT programmes.Health Pol Plann 1986; 1:214-21.Kendall C. Foote D. Martorell R. Ethnomedicine andoral rehydration therapy: a case study ofethnomedical investigation and program planning.Sac Sci Med 1984; 19:253-60.

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Diarrhoeaperception and use of ORS

8. de Zoysa I. Ca"rson 0, Feachem RG. Kirkwood B,Lindsay-Smith E, Loewenson R. Perception ofchildhood diarrhoea and its treatment in rural

Zimbabwe. Sac Sci Med 1984; 19:727-34.Elmendorf M, Isely R. Public and private roles afwomen in water surply and sanitationprogramme. Hum Organ 1983; 42:195.Green EC. Troditional healers, mothers andchildhood diarrhoeal disease in Swaziland: the

interface of anthropology and health education.SacSciMed1985; 20:277-85.Maloney C, Aziz KMA, Sarker Pc. Beliefs andfertility in Bangladesh. Dhaka: International Centrefor Diarrhoeal Disease Research, Bangladesh,1981. 366p. (Monograph No.2).Nalin DR, Haque Z. Folk beliefs about choleraamong Bengali Muslims and Mogh Buddhists inChittagong, Bangladesh. Med Anthropal 1977;1:56-8.

Folch-Lyon E, Trost JF. Conducting focus groupsessions. Stud Fam Plann 1981; 12:443-9.

Chowdhury AMR. Evaluation oJ a communitybased oral rehydration programme in ruralBangladesh. London: University of London, 1986.303 p. (Thesis).Chowdhury AMR, Vaughan JP, Abed FH. Use andsafety of homemade ORS: an epidemiologicalevaluation from Bangladesh. Int J Epidemio/1988;17:655-65.Sarder AM, Chen LC. Distribution and

characteristics of non-government health

practitioners in.a rural area of Bangladesh. Sac SciMed 1981; 15A:443-50.Nations MK. Illness of the child: the culturalcontext of childhood diarrhea in north-east Brazil.

Berkeley: University of California, 1982. (Thesis).Lozoff B, Kamath KR, Feldman RA. Infection anddisease in south Indian families: beliefs about

childhood diarrhoea. Hum Org 1975; 34:353-8.

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APPENQIX

The Seven Points to Remember

I. YY!~.~ ~. ~I!~! ";ju:1_i!Ji!I!~!, ~!!!!J~:!, d.1'.!.'!.:.L~!C/IOlufJ utld IhLJiruudolfuclJ ?

Dud haga, ajimo, amasa. qaeria or-choleraetc.are all chafi.lcterised by loose motions. Witheach loose motion suit and water drain out

13

2.

from the body. It this draining out of salt andwater continues for sometime,' the bodybecomes dehydrated. Severe dehydrationmostly leads to death. So, action should betaken in time in case of dud haga. ajirno.amasa. daeria and cholera.

Symptoms of dehydrationThe dehydrated patient develops' certainsigns and symptoms such as sunken eyes,dry tongue, thirst, sunken fontanalle (in caseof a child). severe weakness, reduced volumeof urine, etc.

Simple management of loose motionsThe simple treatment for dehydration is toreplace salt and water lost ham the body.Remember, the patient dies of dehydq:ition(loss of salt and water). So, whenever a

'patient gets dud haga. ajJrno,amasa. daeria orcholera, give oral saline from the very onset ofthe disease (immediately after the first loosestool). '

Preparation of oral salineOral saline is prepared with a three fingerpinch (up to Ithe first crease) of laban and onefistful of gU[in half a seer" of drinking wat~r,'well stirred. Care should be taken to mixlaban, water and gU[ in right proportion. Afistful of (refined) sugar can be used if gU( isnot available.

Administration of oral salineAdult patients should take half a seer of oralsaline at a time after each loose motion.Children should be given only as much as theywant. but at frequent interVals- Once saline isprepared, it may be kept 4-6 hour$ only.Advice on nutritionDuringdud haga,ajirna. amasa or daeria.thepatient should be given plenty of water andfood-stuffs like rice, curry along with oralsaline. In case of children. breast milk/normaldiet should be continued. Increased amountof food should be given at least for 7 days..IIUI IuCIIVUIy, rhi:.; willlJl uvuflt lIIillflUtliliondlld wUdkIlU:;:;uf lilu pJliull1.PreventionTo save ourselves from this disease, we

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-------------.---.-.-.A seer is e4uivalent to 934 ml.


, Ishould drink tubewell water. In case tubewdl

: is not available, water from other sourcesshould be boiled and then cooled before uSP..Rotten food should never be eaten. Allfood-stuffs should be covered well so thatflies cannot sit on them. Hands and mouthmust be washed by soap or safe water before

Chowdhury and Vaughan

oalinq. I lands !;hould bo W:I!;hod by Soflp oriJsh altOi retl/ln "urn Inlrino nnt! ovnn I1l1nlcleaning the babies after defaecation.Remember that breast-milk is harmless.Childrenput to breast immediately after birthand breast-fed continuously rarely hDvedudhaga.

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oral rehydration solution in rural bangladesh...

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