Soc. Sri. Med. Vol. 23, No. 4, pp. 35J

Pnnted m Great Bnuin INTERNATIONAL REFERENCE CENTRE

FOR COMMUNITY WATER SUPPLY ANDSANITATION (IRC)

DIARRHEA AND THE SOCIAL MARKETING202.686 DI

0277;9536'/86 $3:DO"+"6."bcT•' Pergairion Journals Ltd

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ORAL REHYDRATION SALTS IN BANGLADESH^ > £i:; L£ ^* '

EDWARD C. GREENAcademy for Educational Development, Washington, D.C., U.S.A. O

z o^ ^ a:Abstract—An anthropological study of knowledge, attitudes and practices relating to child diairhelPand" 'ojspecifically to ORS was carried out in Bangladesh. The purpose of the study was to help/flesignjaculturally-sensitive social marketing program. Information was gathered on indigenous classifijtgtion of^ pdiarrheas, patterns of therapy recourse and diarrhea management, and understanding of petyydiStioirj; 2-symptoms as well as use and attitudes regarding ORS. Among the findings were that 58% ofihcgSsefioldr ^sampled had tried ORS at least once; ORS was perceived as a medicine with several positivfe attributes^literacy was positively related to ORS use; and there were no significant cultural barriers to ORS #5brlribrt3- o

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INTRODUCTION\

Anthropological studies have become fairly commonadjuncts to the planning of diarrheal disease pro-

-/ grams that emphasize oral rehydration salts (ORS)and operate in developing countries [1]. Yet in aspecial and relatively new type of diarrhea/ORSprogram that shows considerable promise, namelysocial marketing, anthropology has yet to becomeestablished in the planning process. Social marketingattempts to use commercial marketing techniques topromote products desirable from a public healthviewpoint, such as contraceptives or ORS [2]. Thebasic idea is to market a product through existingretail channels in order to reach the maximum num-ber of 'consumers.' The product tends to be sold ata relatively low, subsidized price at first but some

t degree of program self-sufficiency is usually sought.The growing interest in social marketing on the partof the U.S. Agency for International Development(AID) is reflected in the recent awarding of a 21

('J million dollar contract for a worldwide contraceptivesocial marketing project.

In January, 1985 the AID mission in Bangladeshrequested assistance from Primary Health Care Tech-nology, an AID project implemented by a consortiumof private consulting firms, to assist in the planningof both an anthopological study and a marketingresearch study in order to develop an ORS socialmarketing plan. The program is to be implementedby the on-going, AID funded Social MarketingProject of Bangladesh.

Social marketing programs often rely on prelimin-ary marketing research, but generally not as much asa commercial firm would in launching a new product[3]. In the present case, AID requested a marketingresearch study to help determine the price, packag-ing and brand name of ORS to be marketed inBangladesh. Due to its recognition of the value ofanthropological studies in diarrheal disease programsgenerally, as well as the value of behavioral andattitudinal studies in various types of family planningprograms, the AID mission also requested an anthro-pological study or operations research that wouldcomplement the marketing research study in both

methodology and focus. The anthropological studywas to be an essentially qualitative study that wouldreveal knowledge, attitudes, and practices related todiarrhea and ORS. Approximately 3 months wereallocated for the study [4]. The anthropologist was tobe personally involved in all stages of research design,data gathering, and analysis. Assistance in fieldworkas well as in other aspects of the study was to beprovided by a local research firm, Market ResearchConsultants of Bangladesh.

The study was carried out as planned except thatthe starting date was delayed until May instead ofMarch 1985 as originally planned. This paper is asummary of the study's findings and implications.

RELATIONSHIP TO OTHER STUDIES

AID and Primary Health Care Technology wereconcerned that the anthropological study did notduplicate the work of previous ongoing research ondiarrhea or ORS, but instead focus on topics relevantto the social marketing of ORS that were not wellresearched. Of most relevance to the ORS socialmarketing program was the ongoing evaluation ofthe National Oral Rehydration Program carried outby Mehta Currey and her associates at the Inter-national Center for Diarrheal Disease Research,Bangladesh (ICDDR,B). I was able to read a draft ofthis Research Report toward the end of my fieldresearch. Another ICDDR,B study headed by NajmaRisvi included observation of the management ofdiarrhea cases over a period of many months inseveral Tangail district villages. It was not expectedthat data from this study would be analyzed in timefor the development of the ORS social marketingplan.

Relevant previous studies in Banglandesh includedone by Shahid et al. [5] that found among otherthings that some mothers were not using ORS fordiarrhea accompanying measles in children becauseORS was believed to stop diarrhea, while in the caseof measles, diarrhea was thought to purge the bodyof harmful wastes. Another study by Faruque et al.[6] in north-east Bangladesh found that 71% ofrespondents attributed the cause of diarrhea to dirty

357

358 EDWARD C. GREEN

water and smaller majorities cited food, worms anddirty environment. 69% of this sample knew aboutsome sort of oral rehydration therapy and 42% ofthis group believed ORS stops diarrhea. Only 3%thought ORS replaces lost fluids. Herbal medicinesand dietary remedies for diarrhea! diseases weredocumented in a five-village study in Bangladesh byAshraf [7]. Improper food intake was the only specificcause attributed to diarrhea, although interviewersalso mentioned the will of God, evil spirits and evileye as causative factors. No negative beliefs, attitudesor practices relating to ORS were found in this study.Other studies in Bangladesh have shed light on thevariety of indigenous health practitioners available inBangladesh, and on recourse to therapy during vari-ous illnesses including diarrhea! diseases [8] and onthe importance of diet in disease management [9],

Elsewhere on the subcontinent, Bentley [10] com-bined quantitative methods with a year-long eth-nographic study of household management of childdiarrhea in three villages near Delhi. Findings fromthis study are referred to elsewhere in this report. Inanother north India study Kuman et al. [11] foundthat while most mothers recognized symptoms ofdehydration, these were not associated with diarrhea.Likewise Lozoff et al. [12] in a south Indian studyfound that dehydration symptoms were called dos-ham and were seen as life-threatening, but were notassociated with diarrhea by most. This study alsodescribed local classification of diarrheal diseases.'Continuous green diarrhea,' for example, was be-lieved to be pollution-related (in the Hindu sense) andtherefore required family and ritualistic treatmentrather than cosmopolitan or biomedical medicine. Astudy in Goa [13] found that only 5% of a sample ofmothers of under-5 yr children believed dehydrationsymptoms to be related to fluid loss in the body. Thevarious Indian studies also described food restrictionsduring child diarrheas, home remedies such as herbalinfusions and special drinks or porridges and theimportance of the 'hot-cold' dichotomy in localperceptions of disease and in therapies.

Among the topics relevant to ORS social market-ing not adequately researched in Bangladesh wereindigenous perceptions of dehydration symptoms;local classification of, or differentiation between,diarrheal diseases; and local perceptions of ORS andits effects on children.,The present study was designedin part to shed light in these areas.

METHODS

There are strengths, weaknesses and advantagetrade-offs for each of the research methods com-monly used to gather data for the development ofsocial marketing programs, namely direct obser-vation, focus group interviews, in-depth interviewsand surveys [14]. Given the needs of the SocialMarketing Project and the plan for a complementarymarketing research study, it was decided that ananthropological study of diarrhea and ORS couldcombine aspects if not advantages of both survey andin-depth interviewing methods. Survey questionswere therefore all designed as open-ended and prob-ing techniques were developed to ensure greaterdepth in answers. National representativeness was

approximated by selecting respondents in five widely-separated districts of Bangladesh. 240 Bangladeshis,of whom some 66% were women and 85% lived inrural areas, were interviewed in five districts with adistribution as follows: 45 in Khulna, 47 in Syhlet, 53in Chittagong, 48 in Tangail and 47 in Rangpur. 68%of respondents were non-literate.

Purposive rather than random sampling was usedin order to ensure an adequate number of inter-viewees who had experience with, and opinionsabout, ORS. Those selected were most often parentsof children under the age of 5 although older re-spondents were also selected. Typically, one male andtwo female interviewees were interviewed in eachvillage section. Sometimes interviewers would chooseas respondents the first people encountered; othertimes protocol required that a senior male familyhead nominate respondents. All respondents wereover 18. There was a selection bias in favor of thesomewhat better off and not-so-remotely situatedbecause time limitations prevented us from inter-viewing in homes situated more than a half-hourwalk from the nearest road. Although time andbudgetary limitations did not afford us the luxury offollowing random sampling procedures, our findingsproved to be within 4-16% of certain key findings ofthe National Oral Rehydration Program study (seebelow) such as the percentage of respondents whichhad heard of or which had ever used ORS. Thedivergence in findings between the two studies wereentirely predictable: the incrementally better off andless remote respondents in our sample were likelier tohave ever tried ORS than the generally poorer andremoter respondents in the larger, national survey.The purpose of the anthropological study was not tocompete in accuracy of measurement with othersurveys but to complement the findings of these byilluminating or discovering beliefs, attitudes and be-havior.

Interviewers consisted of the anthropologist, afull-time male interviewer assistant and sometimesinterpreter for the anthropologist and 10 part-timefemale interviewers who were already residing in thedistricts selected for interviewing. The interviewerassistant had a masters degree in geography and theinterviewers were all medical or other students atdistrict universities, except for two who were recentlyqualified physicians. Interviewers had had previousexperience in social and/or marketing research; theywere trained in this study's interview schedule by theanthropologist and the interviewer assistant. All localstaff was recruited by Market Research Consultantsof Bangladesh. Quantifiable data from the anthro-pological study were tabulated by hand calculatorsrather than by computer.

It should be noted that private, one-to-one inter-views in the villages proved all but impossible. Kins-men and neighbors gathered around the place ofinterview—whether or not the foreign anthropologistwas present—and sometimes made commentsinfluencing the interviewee. Of course their verypresence exerted an influence. Some of the advan-tages of focus group interviewing can be realized insuch circumstances, i.e. feelings, values and attitudescan emerge spontaneously and in a natural context.On the other hand, standard analysis of data based

Diarrhea and the social marketing of ORS in Bangladesh 359

on respondent characteristics becomes invalid to theextent that responses are influenced by others. Sincestandard, statistical data analysis was not part of thestudy plan, the fact that interviews were non-privatewas not much of a problem.

Interviews took an averge of 40 min to conduct.Answers were recorded verbatim and were sub-sequently grouped in inductively-derived categoriesfor frequency tabulations. Interviews were conductedbetween May 29 and July 25, 1985.

TYPES OF DIARRHEA RECOGNIZED

Diarrhea is defined by Bangladeshis as the passingof loose, watery stools. There are several Banglaterms for diarrhea of which dasto may be the mostcommonly used general term. The English term diar-rhea has also found its way into fairly common usage.

When asked to name or describe the types ofdiarrhea recognized, 74% of respondents mentionedgeneral, plain, ordinary or simple diarrhea; 63%mentioned diarrhea accompanied by continuousvomiting and weakness (5% of this group used theEnglish term cholera for this type); 30% mentionedbloody diarrhea or bloody dysentery (amashaya inBangla); and 28% mentioned greenish or yellowishdiarrhea or diarrhea with mucus (sometimes calledbuniaga). (Multiple responses were allowed for allquestions in which response categories were notmutually exclusive.) Less frequently cited were diar-rhea with weakness (but no mention of vomiting)(12%); stomach ache (8%); diarrhea with fever (4%);diarrhea from worms (3%); and diarrhea associatedwith teething in young chldren (1%). When askedwhich types of diarrhea are dangerous, bloody dys-entery (amashaya) was cited most frequently, fol-lowed by vomiting diarrhea or cholera. However, alltypes were cited with some regularity. Ordinary diar-rhea was said to be dangerous if it continued for morethan 3-4 days.

Very few respondents were able to attributedifferent causes or describe different treatments forvarious types of diarrhea recognized. Instead, re-spondents mentioned general causes and treatmentsfor diarrhea. The most frequently attributed causewas bad, spoiled or indigestible food (60%) [15];followed by dirty or contaminated water (23%), heator hot weather (7%); flies or exposed food (7%);worms (6%), evil spirits, evil eye, bad air or God'swill (4%); bad or spoiled breastmilk, or breastmilkunqualified (3%) [16]; and dirty hands or body (2%).17% of respondents claimed they didn't know thecause of diarrhea.

It should be kept in mind that respondents may feelconstrained to mention mystical causes to better-educated strangers in the context of an impersonalinterview and that villagers tend to tell interviewerswhat they think the interviewers want to hear. Onlythe unqualified allopaths were able to specify causesand treatment for different types of diarrhea. Theyseemed to have a rough idea about the role of broadclasses of microorganisms involved in diarrhea! dis-ease.

In a related and subsequent question respondentswere asked if food or drink contributed to diarrhea:90% said yes and 10% didn't know. Among the

former, stale, spoiled or exposed food was mentionedby 40%; impure water by 34%; hard or hard-to-digest food by 22%; overeating by 13% jack-fruit,mangos and certain other fruits by 13%; meat andfish by 7%; and miscellaneous other answers (includ-ing breastmilk) by 5%.

Regarding treatment, 'doctors treatment' (usuallyfrom unqualified allopaths) was the most commonlymentioned recourse, cited by 53%. This was followedby ORS or homemade sugar-salt solution (48%);homeopathic medicines (14%); herbal treatments(10%); mystical or religious treatments (7%) andhome remedies such as green coconut water andporridges (4%). Only 5% claimed they did not knowhow to treat diarrhea.

Answers to a single, direct question on diarrheatreatment can be misleading. For example, Bangla-deshis appear not to think of the various gruels,porridges and special beverages given during diarrheaas treatments per se, therefore information on suchhome remedies—many of which have rehydratingeffects—may be underreported. In the present survey,a good deal of information on home remediesemerged when questions were asked about appropri-ate diet during diarrhea episodes. This information ispresented below.

Respondents were asked if they knew of any waysto prevent various types of diarrhea. Again, theypreferred to answer about diarrhea in general and notabout different types of diarrhea. If interviewersprobed an answer such as "one should avoid badfoods" with the question, "what about bloodydysentery?" the respondent would typically then sayhe or she didn't know.

Regarding prevention, 42% of respondents saidthey knew of none for diarrhea; 31 % said personalcleanliness and hygiene and avoiding contact withpeople who have diarrhea; 25% said avoiding bad,spoiled or cold foods; 24% said avoiding con-taminated or unprotected water; 7% said avoidingfood exposed to flies; 5% said taking 'doctors' med-icines'; 4% said maintaining clean surroundings; and3% or seven respondents said taking ORS orsugar-salt solution.

A few of the 'don't knows' made comments like,"only God can save one from diarrhea." And someof those who mentioned avoiding bad food madecomments like the woman in Khulna who said "Weknow what foods to avoid but we are poor and so wecan't be choosy in what we eat."

GENERAL PERCEPTIONS OF DIARRHEA

As we saw in the preceding section, at least fourseparate types of diarrhea can be distinguished byBangladeshis, yet functionally (i.e. in terms of per-ceived etiology, treatments and preventions) the var-ious diarrheas tend to be regarded as one generalsyndrome. The different types recognized may onlybe important in indicating the severity or danger ofthe diarrhea—and this is significant for ORS market-ers and health educators.

A study by Shahid et al. [5] in Bangladesh sug-gested that at least one type of diarrhea, that associ-ated with measles in children [17], was thought topurge harmful wastes from the body. Since it is

360 EDWARD C. GREEN

important to know if people regard diarrhea ashaving a positive function we asked a general ques-tion, "Can diarrhea ever cleanse the body or rid it ofimpurities?" 58% said yes, 24% didn't know and18% said no. Several of the 'yes' respondentsidentified the impurities that are purged as things thebody cannot digest, as well as 'bad blood' or poisons.There were also a few comments like, "unfortunatelygood elements are washed out of the body along withbad elements."

We then asked if diarrhea was ever good for thebody. 42% said no and 16% didn't know. Theremaining 42% thought that diarrhea might usefullypurge bad elements from the body in cases of indi-gestion or gas, upset stomach, constipation, measlesor teething in young children. Upon probing theseanswers, it seems that Bangladeshis feel it is better notto have diarrhea in the first place, but if one becomesafflicted with certain illnesses diarrhea may usefullyserve to flush bad elements from the body. Thesignificance of this for social marketing is that for atleast certain types of illness, Bangladeshis may notalways want to stop diarrhea, at least immediately.

In this connection it is significant that Bangladeshisseem not to use purgatives, as is common practice inother parts of the world where diarrhea is thought toflush impurities from the body [18]. This was deter-mined by discussing purgatives with respondents whowere indigenous practitioners.

UNDERSTANDING OF DEHYDRATION

Although numerous studies relating to diarrhea!disease in Bangladesh exit, the question of indigenousperceptions of dehydration remained largely un-explored at the time of developing the questionnairefor the present study. In order to avoid influencinganswers, we asked "What complications or1 symp-toms do you see if diarrhea continues?" in the contextof child diarrhea. 75% said weakness, immobilityand/or fatigue [19]; 35% said the patient might die;20% said fever or body heat; 17% said sunken eyes;17% said weight loss; 15% said loss of appetite ordecreased digestive ability; 11 % said cold or clenchedhands or feet; 6% said thirst or water loss; 4% saidstomach pain; 3% said loose skin; and there wereseveral infrequently cited answers such as weak pulseand dry skin. Only one of 240 respondents mentionedsunken fontanelles.

Respondents were then asked if they had ever seenthe prominent symptoms associated withdehydration—associated by the medically trained,that is—although this and other questions referringto dehydration were devoid of terms that denote orconnote dehydration. Instead, symptoms such asdepressed fontanelles, sunken eyes and loose, dry skinwere described to the respondent. 34% claimed theyhad seen all the symptoms; 34% had seen some of thesymptoms; and 32% had not seen them or did notknow. As with the answers to the previous question,sunken fontanelles seemed to be the least recognizedsymptom.

Next, respondents were asked the cause of thesymptoms just described to them, as well as if thesymptoms can be treated (cured) or prevented. Re-garding cause, 33% didn't know; 33% thought the

symptoms were caused by or related to diarrhea,cholera or dysentery; 6% said bad water; 6% saidworms; 6% said bad food; 6% said the symptomswere evidence of evil spirits or evil air; 5% said thesymptoms mean the child or older patient is gettingworse and might even die, and there were miscel-laneous answers such as heat or fever. Only 2% saidthe symptoms were due to water loss.

Regarding treatment of dehydration symptoms,44% of respondents said only a 'doctor' knows.Perhaps surprisingly, 35% said ORS, home-madesugar-salt solution or glucose mixed in water is thetreatment for dehydration symptoms. Another 8%mentioned gruels, coconut water or plain water astreatments; and 8% said treatment by mystical orreligious practitioners was needed. Regarding pre-vention of dehydration symptoms, a clear majority(68%) didn't know or couldn't say; 8% said theywould take a doctor's advice; 6% said they would useORS or intravenous (i.v.) saline solution; and theremainder repeated the preventive measures they hadmentioned for diarrhea such as maintaining personalhygiene and avoiding contaminated food and water.

After respondents were offered opportunities tospontaneously make connections between dehy-dration symptoms and diarrhea, they were asked ifthe symptoms described earlier were related to diar-rhea or to something else entirely. Interviewers werecarefully instructed to refer only to the previouslydescribed symptoms and not to diarrhea, water lossor anything else. 58% of respondents said the symp-toms were caused by, or somehow related to, diar-rhea; 28% said the symptoms were unrelated todiarrhea; and 14% didn't know.

Finally, respondents were asked if any Bangla termdescribes the symptoms under discussion. Althoughresearchers working in other parts of the subcon-tinent have found local terms to describe dehydrationsymptoms [20], evidence was strong even before thepresent study that no such term was in use amongBangla speakers. Nevertheless, it was felt that an-swers to such a question might provide insights intoindigenous perceptions of dehydration. 48% saidthere was no term or they knew of none; 34%answered with various Bangla (and occasionallyEnglish terms) for diarrhea, dysentary, or cholera;12% said kosha or constipation; and 6% said kamelarog which means jaundice or hepatitis.

Since indigenous perceptions of dehydration are ofkey importance in the social marketing of ORS, thesignificance of findings in this area should be sum-marized. First, the weakness, immobility and deathcited by most respondents as symptoms or con-sequences of persistent diarrhea do not relate only todehydration. Only a minority of respondents men-tioned relatively unambiguous dehydration symp-toms such as sunken eyes. On the other hand, some68% of respondents claim they had seen all or someof the outstanding symptoms associated with dehy-dration that were described to them and about halfthe respondents associated the symptoms in someway with diarrhea or with causes of diarrhea. Evenallowing that some proportion of answers may havebeen influenced by the context of the interview, thereseems to be a basis for social marketers and healtheducators to assume that a significant proportion of

Diarrhea and the social marketing of ORS in Bangladesh 361

Bangladeshis see a connection between dehydrationsymptoms and diarrhea.

The findings that 35% of respondents believe ORSor sugar-salt solution to be appropriate treatment fordehydration symptoms was probably also influencedby the survey context, and possibly by the phrasingof the question by some interviewers, but the find-ing probably also reflects knowledge gained fromthe recent Bangladesh Rural Advancement Commit-tee campaign to promote home-made sugar-saltsolution.

DIARRHEA MANAGEMENT

Based on impressions gained during interviewingas well as on responses to certain questions, re-spondents appear to lack self-confidence in healthmatters. They seemed to exhibit a feeling of help-lessness, perhaps even of fatalistic resignation, whenillness occurs—as if they would rather have someonetell them what to do than to make decisions them-selves and then take responsibility for treating illness.This should not be surprising since poverty and lackof education do not inspire self-confidence generally,and especially in an area such as health care wheremedical professionalism and mystique can be in-timidating.

This feeling of helplessness is reflected to somedegree in home treatments for child diarrhea. 42% ofrespondents claim they do nothing. Among the 140respondents who do something, 53% claim they usehome-made sugar-salt solution or packeted ORS;24% use gruels, porridges or coconut water; 21 % useherbal remedies such as the leaves of pineapple,spinach or cucumber; and the remainder rely on diettherapy (see below) or on mystical/religious treat-ment by practitioners who visit the home. Aspresented in the section to follow, 58% of all re-spondents claimed they had tried ORS at least once.Even allowing for a little exaggeration on the part ofrespondents, and allowing for respondents forgettingto mention ORS in response to a general questionabout diarrhea treatment, 58% is a significantlyhigher figure than the 31% of all respondents (53%of the 139 respondents who do something) whomentioned using ORS specifically for child diarrhea.This discrepancy could mean that there is a per-centage of discontinuers, or people who have triedORS once but then not continued. This may accountfor about 10%, since 48% of respondents mentionedORS or home-made solution in response to a generalquestion about diarrhea treatment. In fact, this isconsistent with our finding presented in the section tofollow that 11 % of ORS users found results of ORSto range between fair and poor. The 58-31 % discrep-ancy could also mean that ORS is less commonlyused for children than for adults. There were twocomments by respondents during the course of inter-viewing that suggest some parents may believe thatORS is not appropriate for small children. Moreresearch in this area is needed.

When asked about child diarrhea treatments out-side the home or involving outside help, 80% ofrespondents said they sought allopathic practitioners(usually unqualified) or medicines; 36% said theyconsult mystical/religious practitioners; and 7% said

they sought homeopathic treatment. In addition,14% commented that they receive some sort ofORT and 5% said they receive i.v. treatment frompractitioners.

It was difficult to establish a consistent pattern inrecourse to therapy. It should be noted that mothershave most of the responsibility for management oftheir childrens' illness, although Islamic purdah(female seclusion) means that men tend to be the oneswho travel away from home to buy medicines (includ-ing ORS) and initially consult practitioners. In anycase, women tend to know more than men abouthome remedies and appropriate diet during illnessand some women respondents described patterns intheir own management of child diarrhea.

Virtually all mothers restrict certain foods andemphasize others—known collectively as pathya—thought to be appropriate for illnesses like diarrhea.Some give their child herbal remedies, then try ORS,then take the child to an unqualified allopath (daktar)and finally, if the condition persists, the mother oranother person of influence might decide that evilspirits or other mystical causes are involved, and thechild will be taken to a mystical/religious prac-titioner. A practitioner such as a moulana , kobiraj,fakir, ojha or mulla then gives 'holy water' and praysover the child, perhaps blowing on the child andperhaps preparing a special tablet (tabiz) containinga Koranic inscription to be worn by the child. Otherwomen, but perhaps a minority, seek amystical/religious practitioner before going to a doc-tor or unqualified allopath. Some mystical prac-titioners, notably the kobiraj, may give aryuvedic oryunani herbal medicines.

Further mention of the roles of indigenous healthpractitioners should be made at this juncture. Amongthe non-biomedically trained practitioners reliedupon for various illnesses including diarrhea are:

1. Daktars (from the English 'doctor'), or allopathswho are not formally trained in medicine. They areessentially self-trained, or they learn through appren-ticeship with another daktar. Some have undergoneskill-upgrading in government sponsored or ap-proved short courses. From interviews with andabout daktars in the present survey, they appear totreat various diarrheas with ORS, i.v. saline solution,antidiarrheals, antibiotics and sometimes analgesics,depending on their diagnosis and perhaps on otherfactors.

2. Homeopaths, to whom 14% of the presentsample turn in cases of diarrhea. Some homeopathsmay advise patients to foresake all other medicineswhile taking homeopathic medicine for diarrhea, buton the whole they seem not to be opposed to ORS.

3. Religious faith healers including ascetics (fakirs),priests (moulanas) and those thought to possessspiritual healing powers gained through dreams,meditation, study or spirit possession. Faith healersprepare and administer "holy water" in cases ofdiarrhea. They also pray and blow over the patient aswell as prepare the tablets (tabiz) described earlier.

4. Kobirajs and totkas, or herbalists whose knowl-edge derives from both the ayurvedic and yunanitraditions and who may combine shamanistic ele-ments in their treatments. A shamanistic healer

362 EDWARD C. GREEN

known as ojha and who seems to be best known fortreating snake-bite, is also consulted for some diar-rheas, according to respondents.

Rather striking differences in reliance on hometreatments were found by region. For example 83%of Chittagong respondents claimed they used nohome treatments (but see the analysis section forORS usage by district). At the other extreme, only2% of Rangpur respondents made such a claim.However, reliance on 'doctors'—usuallyunqualified—was consistent throughout the five dis-tricts surveyed.

Since diet proscriptions and prescriptions are de-termining factors in diarrhea and can influence theapparent effects of ORS, we asked which foods arerestricted when a child has diarrhea. 75% of re-spondents claimed that all or most solid foods arerestricted during diarrhea, although this may notreflect actual behavior [21]; 11% said they withholdrice, grains, pulses, bread and other non-meat staples(especially if spiced); 10% said they withhold spoiledor exposed food; 5% mentioned fruits believed tocause or exacerbate diarrhea such as jackfruit ormango; and miscellaneous answers referred to vegeta-bles, milk, unsafe water and spicy foods. In responseto a separate question about breastfeeding, 68%claimed that breastfeeding continues during infantdiarrhea; 8% said it is discontinued and 14% (mostlymen) did not know [22].

Suspecting that the use of potentially rehydratinggruels, drinks and porridges might be underreportedin response to a question on treatments, we askedwhat foods are given during diarrhea. There wasconsiderable variation in the answers by district,depending on the presence of certain crops. Overall,however, 27% said barley water (thin barley soup);21% said a sago-based drink; 18% said glucosewater, sugar water, sugar-salt solution or ORS (ORSuse is underreported here because ORS is not usuallythought of as a food); 3% said lemon water or juice;and 16% mentioned such foods as wheat porridge,soft rice, breastmilk and coriander gruel.

We next asked when normal diet is resumed afterdiarrhea symptoms stop. Of those 180 able to give ananswer, 49% said in less than 2 days; 32% saidbetween 2 and 3 days; 7% said between 4 and 5 days,and the remaining 12% gave answers ranging be-tween 6 days and over 2 weeks. The later the re-'sumption of normal diet, of course, the greaterlikelihood there is for malnutrition and related prob-lems.

To shed further light on decision-making in themanagement of diarrhea, we asked, "Who in thefamily and/or immediate community can advise onthe treatment of your child's diarrhea?" Male re-spondents often replied that they make their owndecisions (23% of all respondents) and females oftenmentioned their husband's advice or decision-makingfirst (37%). Also cited are parents or parents-in-law(25%); neighbors, friends or elders (18%); 'doctors'(15%); other family members (8%); indigenoushealth practitioners (4%); and local leaders (1%).Three people commented that they would take advicefrom anyone who gave it. A number of womenmentioned that they would never make a decision on

their own without guidance from their husbands andperhaps their husband's parents as well.

We next asked about other sources of informationrelating to diarrhea and its treatment. 60% mentionradio (and occasionally television); 37% mentionedextension workers [23]; 35% mentioned 'doctors'; 7%mentioned friends and neighbors; 6% said they hadno sources and therefore knew noithing about diar-rhea; 3% (notably daktars and the better educated)mentioned print media; and 1% mentioned schoolsor school children. Since many of the radio citationscame in response to a probe in which radio wasmentioned, 60% is probably an inflated figure. How-ever, the BRAC radio campaign promoting home-made ORT has reached people all over Bangladeshand it was clear from questioning that BRAC was theprimary and perhaps even the sole source of re-spondents' radio-derived information on ORT. Infact, there is little competition on the airwaves; therehas apparently been no promotion or advertising ofpacketed ORS on Bangladesh radio.

Ideally, a social marketing program makes use ofall available channels of communication, each chan-nel being developed to communicate that which it isbest at communicating. However, in practice in devel-oping countries with serious manpower and trans-portation constraints, radio often becomes the mostimportant medium for communication. Althoughsome respondents in the present survey noted thatradio was their only source of information abouttreating diarrhea, there were other comments like, "Ilisten to the radio but I don't believe what they say."

ORS KNOWLEDGE, ATTITUDES AND USE

A variety of questions were asked about ORS andoral rehydration therapy (ORT). First we asked ifrespondents knew what ORS is. 92% claimed theyknew. This parallels the finding of the ICDDR,Bevaluation of the National Oral Rehydration Pro-gram (hereafter, NORP study) which found that 88%of respondents from a randomly-derived nationalsample of 2500 knew something about or were awareof ORS [24].

We next asked what ORS is used for. 86% saidORS cures or helps treat diarrhea, dysentary orcholera; 16% said it overcomes or prevents water lossin a person; 4% said it keeps the stomach or body'cool' or it'overcomes upset stomach; 2% said itprevents diarrhea; and 2% said it quenches thirst ina person with diarrhea. Some of the 16% that seemedaware of dehydration mentioned symptoms such asweakness and sunken eyes. The significance of thewidely held belief that ORS cures diarrhea is dis-cussed at the end of this section.

Respondents were then asked if ORS is a bettertreatment for diarrhea or for the symptoms of dehy-dration described to them earlier in the interview. Ofthe 131 who answered this (most of the rest simplysaid ORS was a good treatment), 73% said ORS isbetter for diarrhea and 27% said it is better fordehydration symptoms. Two women commented thatORS was better for older people whereas herbalremedies were better for children.

Respondents were asked if they or anyone in theirimmediate family have ever used the labon-gur

Diarrhea and the social marketing of ORS in Bangladesh 363

(sugar-salt) rehydration solution promoted byBRAC. 59% said yes and 42% said no. 127 of the 146who had tried the ORT solution commented on theirsatisfaction. Of these, 92% said results were good orsatisfactory in treating diarrhea; the remaining 8%were dissatisfied.

We then asked about experience with packetedORS. 58% of respondents had used ORS at leastonce. In the 1985 NORP study, 40% of respondentswho had experienced a case of diarrhea in the familywithin 2 weeks of the interview (some 450 re-spondents) claimed they had used ORS. And of theentire NORP sample of approx. 2500 respondents,42% were found to have used ORS at least once [24].Thus our finding, based on a purposive sample biasedsomewhat in favor of the not-so-old, not-so-poor andnot-so-remotely situated, is about what would beexpected in terms of ORS usage.

Of the 144 from the present sample who had usedORS, 94% reported they used it for diarrhea, dys-entery or cholera; 4% used it for water loss; and 1 %could not say why they—or their wives—used ORS.Results were reported as good or satisfactory by 84%of respondents; poor or not good by 6%; fair by 5%and 4% said ORS seems to only quench thirst. Inanother question, respondents were asked if ORSstops or reduces diarrhea. 10% of all respondentssaid no; 10% had no opinion; and 3% said ORS doesnot stop diarrhea but it has other beneficial effects. Ofthe 77% who thought ORS does stop or reducediarrhea, 38% said diarrhea is stopped within 1-2days; 19% said within one day; 15% said within 3-4days; 3% said within 5-6 days; 2% said within 1week; and 18% could not say (perhaps because theyhad not used ORS) but they nevertheless believedORS stops or reduces diarrhea.

We next asked if ORS has any bad effects. 80% ofrespondents said no; 14% didn't know; and 6% saidyes or possibly. One of the 'yeses' said that intake ofa watery remedy serves to increase the diarrhea;another said ORS "creates problems in the stomach;"another complained of taste, and others could not bespecific although negative effects were sometimesmentioned in response to other questions.

It is perhaps surprising that such a high percentageof respondents, including many who have tried ORS,believe that ORS stops diarrhea. While there isevidence that rice-based ORS such as that used by theInternational Center for Diarrhea Disease Research,Bangladesh actually reduces stool output [25], andthere is some evidence that the same may be true forORS with trisodium citrate, there is no scientificevidence that the standard World Health Or-ganization approved ORS formula used in most ofBangladesh has the effect of reducing stool output. Itseems likely that since many diarrheas are self-limiting, ORS users believe that ORS contributes tothe cessation of diarrhea. And it is to be expected thatin the absence of clear understanding about dehy-dration, people would assume that a medicine to beused during diarrhea would do something for thediarrhea itself.

However, it is also surprising that those who haveused ORS for diarrheas requiring antibiotic or anti-parasitic treatment did not express disillusionmentwith ORS. Some proportion of this group may have

received appropriate drugs from daktars and thenattributed relief from symptoms at least in part toORS taken, but there must still be a fairly sizeablegroup for whom taking ORS did not stop diarrhea.

In response to a question on the local source forobtaining ORS, 31 % of respondents said local 'doc-tors;' 26% said they bought ORS at bazaars ormarkets; 25% said pharmacies; and 18% said healthcenters or hospitals.

We next tried to uncover any negative perceptionsof ORS. Aware of what has been called the 'Asiancourtesy response,' namely villagers giving what theythink are polite, positive responses to interviewers, weasked a variety of questions about possible negativeperceptions of ORS, then probed answers whenappropriate. The first was, "Are there any reasonsnot to use ORS?" 83% said no; 13% didn't know orsay; 2% said their children refuse to swallow ORS;2% said that their 'doctor' must prescribe ORSbefore using it (in only one case was an unqualifieddoctor described as opposing ORS); 2% said thereare occasions when ORS should not be used (threerespondents specified "when the patient has fever"and the other couldn't or wouldn't elaborate); and2% said they don't like or understand ORS or theysimply prefer other medicines. Only one person men-tioned the expense of ORS.

Illustrating the pitfalls of expecting anything ap-proaching complete and valid data from a single,direct question, a subsequent question on the con-venience of obtaining ORS produced 23 respondentswho volunteered that locally-available ORS was pro-hibitively expensive for them. Follow-up on theseresponses revealed that in some districts, notably inremoter areas of Chittagong, an ORS packet whichsells for TK.2.50 in cities can sell for between TK.5.00and 9.00 [26]. Thus, ORS can be a substantial expensefor poor families who have several children sus-ceptible to diarrhea and who must use several packetsof ORS for each episode of diarrhea. A few re-spondents commented bitterly that pharmacists andlocal 'doctors' exploit the poor by raising prices ofmedicines like ORS. Others remarked with equalbitterness that although they had heard that ORS wassupposed to be distributed free of charge from hospi-tals and local health centers, poor people had littlechance of service let alone free products at suchfacilities.

Following up on the indication that babies mayrefuse to swallow ORS, we asked about this in aseparate question. Of the 136 or 57% who providedan answer, 74% said babies in their family refuse ordon't like ORS (36% of this group volunteered thecomment that they nevertheless force-feed babieswho refuse ORS); and 26% said babies accept ORS.It would seem from this evidence that taste might bea constraint to ORS use. Little is known aboutwhether Bangladeshi mothers use effective and ap-propriate force-feeding techniques for ORS; researchin this area is needed. The Social Marketing Projectshould consider training unqualified allopaths andother paramedicals in force-feeding techniques.

Following this we asked, "Is ORS incompatiblewith any foods, medicines or conditions associatedwith diarrhea?" 53% said no; 21% said they didn'tknow; 18% said ORS should only be given with

.SSM- 2J.-4—B

364 EDWARD C. GREEN

foods appropriate for diarrhea such as barley water;17% further commented that regular diet should berestricted while taking ORS; 5% said that ORS isincompatible with certain porridges (such as therice-based chira) or other home remedies for diar-rhea; 2% said other medicines should be restrictedwhile giving ORS; and one person said yes butcouldn't be specific. In spite of some opinion to thecontrary, most respondents saw no incompatibilitiesbetween ORS and traditional diarrhea remedies orfoods, and many commented that ORS goes particu-larly well with porridges like chira or with drinks suchas coconut water or lemon water.

Bangladeshis like other peoples of the subcontinentand elsewhere tend to think of foods, medicines andstates of body as being either 'hot' or 'cool.' Since ahot (gorum) illness like diarrhea requires a cool(tanda) antidote, whether in medicine or food, wewere interested in discovering how ORS is perceivedin this regard. 67% of respondents believed ORS tobe cool, 29% didn't know, and only 3% thoughtORS to be hot. A few of the comments from the latter3% (n = 8) belie the apparent significance of theiranswer. For example, one respondent observed thatORS warms the body but cools the stomach. Anothersaid ORS overcomes the cold hands and feet associ-ated with persistent diarrhea. We can probably con-clude that there are no problems with ORS in termsof hot/cold perceptions.

We also felt it important to know whether or notORS is considered a real medicine, one regarded asequivalent to, e.g. intravenous (i.v.) solution or anti-diarrheal or other pills. Most (71%) said ORS is asgood as or better than pills for diarrhea, althoughperhaps not as effective as i.v. solution; 22% didn'tknow; and only 7% thought ORS inferior to othermedicines. Two respondents thought that i.v. solu-tion is better because it costs more than ORS, andone said that ORS works slower than i.v.s [27].

Next we tried to determine what sort of reputationORS has locally. 66% said ORS has a good or goodenough reputation; 33% said they didn't know; andonly 1 % said ORS has a poor reputation. We furtherasked if there were any bad or negative rumors aboutORS or any opposition to ORS on the part ofindigenous practitioners or other local leaders. Of the220 who answered the first question, 99% said no;and of the 230 who answered the second question,99% again said no. The following negative commentswere recorded:

(1) "I heard a rumor that a patient died fromtaking ORS."

(2) "Our Kobiraj (herbalist) doesn't allow ORSunless the condition is serious."

(3) "Our daktar discourages using packeted ORS."(4) "There is a rumor that ORS is not good but our

daktar or kobiraj has never advised against it."

Finally we asked what other effects ORS has on achild with diarrhea, and specifically whether or notORS strengthens or nourishes a child. 49% of re-spondents said ORS strengthens or energizes a child;34% said it nourishes; 5% said it helps digestion; 2%said it quenches thirst and 12% couldn't answer. 13%of the total said ORS doesn't strengthen and 5% saidit doesn't nourish. There were also miscellaneous

positive comments that ORS "normalizes the stom-ach," "normalizes excretion," "controls the stom-ach" and "improves health."

Summarizing ORS knowledge, attitudes and usage,it can be concluded from the findings that there areno significant cultural constraints to ORS use: ORSis not seen as incompatible with existing remedies ordiets for diarrhea and there appears to be no substan-tial opposition to ORS from indigenous practitioners,religious leaders or local political leaders. 58% of oursample had used ORS at least once (although the42% finding of the NORP study is more representa-tive of Bangladesh as a whole) and users seem to berelatively happy with the product. The more im-portant problems reported related to availability, costand small children refusing to swallow ORS. A socialmarketing program can help ameliorate the first twoproblems and as suggested above, part of the pro-gram can involve the training of daktars in ORSforce-feeding techniques.

A small minority of respondents believed that ORSdoes little more than quench thirst; or that givingORS to a child actually increases diarrhea (whichmay be true); or that ORS is incompatible withexisting diarrhea remedies; or that a local opinionleader opposes the use of ORS; or that ORS is bador harmful. Most respondents seem to regard ORS asa medicine which gradually stops diarrhea and hasother beneficial effects such as strengthening or nour-ishing a child.

ANALYSIS

This research effort was not designed as a quan-titative study amenable to statistical analysis. How-ever, relationships between certain variables did seemto emerge. Respondents who were more educated andless remotely situated in the hinterlands tended toknow more about ORS. Regional variation in ORSusage (i.e. proportion of sampled population whohad ever used ORS) was also noted: Chittagongdistrict led with 85% usage, followed by Rangpur(57%), Tangail (50%), Khulna (49%) and Syhlet(45%). Without Chittagong, which in fact hadslightly more respondents than any of the otherdistricts sampled, overall usage would drop from 58to 50%. It is not known why Chittagong has asignificantly higher percentage of people who havetried ORS than other parts of Bangladesh surveyed.

Tangail district on the other hand had the highestpercentage (92%) respondents who had tried home-made ORT at least once. This was possibly due to theinfluence of CARE, since extension workers from thisorganization were mentioned by a number of Tangailrespondents as being active locally.

Chittagong respondents were also likeliest to ex-press the opinion that ORS is as good or better atreatment for diarrhea as pills (85% of respondents),followed by Rangpur (70%), Tangail (65%), Syhlet(49%) and Khulna (44%). It would seem from thisand from the regional variations in ORS usage thatspecial ORS marketing, including supportive healtheducation is needed in Syhlet and Khulna districts.

There did not appear to be significant differencesin ORS usage by age or sex, probably because usewithin the immediate family rather than individualuse was asked about. However, there was a slight

Diarrhea and the social marketing of ORS in Bangladesh 365

Table I. Use or non-use of ORS, by literacy"

Literate

Non-literate

Users40%(48)60%(72)

Non-user21%(19)79%(72)

Chi-square = 8.73 (1 df). Level of significance =0.004. 'Data incomplete on literacy.

Table 2. Use or non-use of ORS, by belief that ORS eitherstrengthens or nourishes a child with diarrhea (n = 221)

ORS strengthens or nourishes

ORS does not strengthen or nourish(including 'don't knows')

Users67%(85)33%(42)

Non-user53%(50)47%(44)

Chi-square = 4.29 (1 df). Level of significance = 0.04.

Table 3. Use or non-use of ORS, by belief that diarrhea rids the bodyof impurities* (n = 205)

'Diarrhea rids impurities

Diarrhea does not rid impurities

Users63%(77)37%(46)

Non-user74%(61)26%(21)

Chi-square = 3.11 (1 df). Level of significance = 0.08. ''Don'tknows' not counted.

tendency for those reporting use to be youngeralthough this may be because respondents under theage of 35 are likelier to have children and childrentend to be especially susceptible to diarrhea.

Literacy, on the other hand, seems to be positivelyrelated to ORS use, or more accurately to havingtried ORS at least once (Table 1). It should be bornein mind that in the absence of a random sample, noclaims of national representativeness are made.

We also sought possible associations between useof non-use of ORS and: (1) the belief that ORS hasnegative effects; (2) the belief that ORS stops orreduces diarrhea; (3) the belief that ORS eitherstrengthens or nourishes a child with diarrhea; (4) thebelief that diarrhea rids the body of impurities. Theassociations, if any, seemed insignificant except thatthere was a somewhat greater tendency for ORS users[28], rather than non-users, to believe that ORS eitherstrengthens or nourishes a child suffering from diar-rhea (Table 2). There was also a slightly greatertendency for ORS non-users, compared to users, tobelieve that diarrhea rids the body of impurities(Table 3).

The association presented in Table 2 is to beexpected: behavior tends to follow belief; in this caseORS use follows from a belief that ORS has positivebenefits. The second association might also be ex-pected: if one believes diarrhea can rid the body ofharmful elements, and if ORS is believed to stop orreduce diarrhea (as 77% believe), then one may behesitant to use ORS because it would inhibit thepurging of harmful elements. However, the associ-ation is so slight that this belief—which has objectivemerit—seems not to inhibit ORS use significantly.Indeed this belief can be viewed as compatible withthe fact—recognized by most respondents—that diar-rhea tends to continue for several days even aftertaking ORS. To go a bit further, it may be that

Bangladeshis are willing to take a product perceivedas a diarrhea remedy, even though diarrhea willcontinue for some time after taking the product.Perhaps this helps explain why ORS usage is as highas 42% in a country where ORS has never beenpromoted over the potentially most effective massmedium, the radio.

Finally, although sex of respondents did not relatesignificantly to ORS use, women seemed to knowmore about dehydration symptoms—or to at leastrecognize them—than men. Women also knew moreabout home remedies and were likelier than men totalk about consulting mystical or religious prac-titioners. Men, on the other hand, emerged as moreself-reliant in decision-making including choice oftherapies for diarrhea. An ORS social marketingprogram aimed at child diarrhea must thereforetarget or address both mothers and fathers, but insomewhat different ways. Men need to be persuadedto make the decision to use ORS and then to actuallybuy or otherwise obtain ORS. Women are morefamiliar with the child's illness and are more directlyinvolved in home-based therapies including the prep-aration and administration of ORS.

SOCIAL MARKETING IMPLICATIONS

The findings have several implications for a socialmarketing program. First, ORS can be promoted asa medicine that combats symptoms such as weakness,immobility, sunken eyes, weight loss and thirst in achild with diarrhea. These symptoms can further berelated to water loss from diarrhea (consistent withthe message of the Bangladesh Rural AdvancementCommittee sugar-salt solution campaign) and theexisting belief that the symptoms signal danger can bereinforced. ORS can also be promoted as a medicinethat can prevent the appearance of dehydrationsymptoms and that should be taken if diarrheapersists. The belief expressed by 44% of respondentsthat doctors know best about treating dehydrationsymptoms can be challenged to the extent that Ban-gladeshis, especially in rural areas, come to believethat they can and should mix and administer ORSthemselves and not simply rely on outside profes-sional help. On the other hand, people should beadvised to consult medical or paramedical help—orthe closest to this available—if diarrhea and/or dehy-dration symptoms persist.

ORS can also be marketed as a medicine whichhelps strengthen a child suffering from diarrhea. Thisconclusion was also reached by Shahid et at. [5] basedon research in north-east Bangladesh. The marketingmessage regarding strengthening must be designedand pretested carefully so that ORS does not becomeregarded as a tonic that can be given to well children,although the salty taste of ORS should constrain suchpractice.

The marketing question arising from the findingsthat most respondents including ORS users believethat ORS stops diarrhea—albeit gradually over aperiod of days—is more problematic. Although itwould be easier to reinforce an existing belief than tochallenge this and instead attempt to teach a largelyuneducated peasantry about dehydration, the fact isthat standard, glucose-based ORS does not cut downon stool output. If the Social Marketing Project were

366 EDWARD C. GREEN

to switch to rice-based or trisodium citrate-addedORS in the future, the marketing message that ORShelps reduce diarrhea could be considered.

The advice and services of daktars seem to besought more often than that of other practitioners,therefore it is important that their influence be takeninto account in the development of an ORS socialmarketing program. Daktars are already moderatelyfamiliar with, and well disposed toward, ORS. TheSocial Marketing Project should therefore train dak-tars in use of ORS and develop them as links in themarketing chain—just as SMP has done in socialmarketing contraceptives. Teaching daktars aboutdehydration as well as the correct preparation anduse of ORS could do much to educate the generalpublic, since daktars are significant opinion leaders inhealth matters.

It is noteworthy that sugar and salt is added toflavor most drinks, gruels and porridges used inBangladesh, thereby improving their potential forrehydration. The World Health Organization, recog-nizing the value of such traditional remedies, hasrecommended the promotion and encouragement ofsuch home remedies in public health programs. TheSocial Marketing Project should also encourage thecontinued and increased use of such pathya (appro-priate foods for illness) giving regional emphasis tofoods commonly used in each region. At the sametime, the practice of discontinuing solid, staple foodsshould be discouraged. Where food restrictions aresevere, a child may die of malnutrition even whilebeing given ORS.

Acknowledgements—The author wishes to acknowledge thevaluable assistance of Salim Momtaz, Jack Thomas, BillSchellstede, Najma Risvi, Mehta Currey, Sue McLaughlin,and the staff of the Bangladesh Social Marketing Project.

REFERENCES

1. See for example Kendall C., Foote D. and Martorell R.Anthropology, communications, and health: the massmedia and health practices program in Hondoras. Hum.Org. 42, 353-360, 1983; Zoysa I. de el al. Perceptionsof childhood diarrhoea and its treatment in ruralZimbabwe. Soc. Sci. Med. 19, 727-734, 1984; GreenE. C. Traditional healers, mothers and childhooddiarrhea! disease in Swaziland: the interface of anthro-pology and health education. Soc. Sci. Med. 20,277-285, 1985.

2. Kotler P. Marketing for Nonprofit Organizations.Prentice-Hall, Englewood Cliffs, N.J., 1975; Kotler P.and Zaltman G. Social marketing: an approach toplanned social change. J. Market. 35, 3-12, 1971.

3. Altman D. and Piotrow P. Social marketing: does itwork? Pop. Rep. 21, J393-J436, 1980.

4. In addition to time constraints on the part of AID andthe Social Marketing Project, the author was interestedin demonstrating the value of simple, low-cost and rapidmethodologies for anthropological investigations ofdiarrhea and ORS (see also de Zoysa et al., p. 729).

5. Shahid N. et al. Beliefs and treatment related to diar-rheal episodes reported in association with measles.Trap. Geog. Med. 35, 151-156, 1983.

6. Farruque A. S. G. et al. Community perception anddiarrhea management practices during outbreaks inrural Bangladesh, Dhaka, ICDDR.B, nd.

7. Ashraf A. Home Remedies and Rural Health Care,Christian Commission for Development in Bangladesh,Dhaka, November 1984.

8. Aziz K.. M. A. Present trends in medical consultationprior to death in rural Bangladesh. Bangladesh med. J.6, 53-58, 1977.

9. Risvi N. Nirog: a native food category for nutritionalmanagement in Bangladesh, Dhaka, ICDDR,B, nd.

10. Bentley M. E. The household management of childdiarrhea in rural north India. Paper presented at theThird Asian Conference on Diarrhoeal Diseases, June10-14, 1985, Bangkok.

11. Kuman V. et al. Maternal beliefs regarding diet duringacute diarrhea. Indian J. Pediat. 48, 599-603, 1981.

12. Lozoff B., Kamain K. and Feldman R. Infection anddisease in South Indian families: beliefs about childhooddiarrhea. Hum. Org. 34, 353-358, 1975.

13. Srinivasa D. K. and Afonso E. Community perceptionand practices in childhood diarrhea. Indian Pediat. 20,859-864, 1983.

14. Booth E. M. and O'Hara C. The future of qualitativeresearch in the design and implementation of edu-cational programs in developing countries: a reportfrom the field. Academy for Educational Development,Washington, D.C., September 1984.

15. Bad food was found to be second commonest cause(after hot weather) attributed to diarrhea in a study inNorthern India. Bentley [Ref. 10], Table 1.

16. Some Bangladeshis believe that nursing mothers withdiarrhea can pass the illness along to their infantsthrough breastmilk.

17. We found in the present study that measles is notordinarily thought of as a diarrhea! disease, even thoughthe associated symptom of diarrhea is recognized.

18. Green E. [Ref. 1].19. Weakness was found to be the outstanding symptom

associated with persistent diarrhea in a local study innorthern India. Bentley, personal communication7/15/85.

20. Lozoff et al. [Ref. 12] for Tamil speakers.21. Anthropologists in Bangladesh and northern India who

have directly observed management of diarrhea casesover periods of months have found that foods andfluids, including breastmilk, are not withheld fromchildren with diarrhea to the extent usually reported tointerviewers. Risvi N. personal communication 25/6/85;Bentley M. personal communication 15/7/85.

22. Direct observation in Tangail district also indicates thatmost mothers continue breastfeeding their childrenwhen the latter have diarrhea. However, breastfeedingmay be discontinued when the mother was diarrheasince the illness is believed by many to be transmissable(Risvi, 1985).

23. Respondents were usually unable to tell where extensionworkers come from but many or most were said to befemale. Again, this may refer to the Bangladesh RuralAdvancement Committee .oral rehydration therapymotivators! but occasionally an organization likeCARE was mentioned by name and a number ofwomen visitors were referred to as family planningworkers. This can be taken as evidence that oral re-hydration therapy and family planning programs can be

, integrated. In fact, improving the health and survival ofchildren by ORS use should make parents more recep-tive to the idea of having fewer children.

24. Currey M. personal communication, July 2, 1985, basedon findings of NORP Evaluation, Dhaka, ICDDR.B (inpreparation).

25. Molla A. M. el al. Cereal based oral rehydrationtherapy project, Dhaka, ICDDR.B, nd.

26. At the time of interviewing the official exchange ratewas about TK26 = $1.

27. I.v.'s are well-known in Bangladesh and i.v. kits can bepurchased without prescription at pharmacies.

28. 'Users' is a shorthand way of referring to respondentswho reported ORS use in their immediate family.