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Abstract. Background: Globally, diarrhea remains a leading killer of young children. In Sierra Leone, one in seven children die before their fifth birthday and diarrhea is a leading cause. Studies that emphasize the demand-side of health interventions – how caregivers understand causation and prevention of diarrhea – have been neglected in research and programming. Methods. We undertook applied qualitative research including 68 in-depth interviews and 36 focus group discussions with mothers, fathers and older female caretakers to examine the causes and prevention of childhood diarrhea in villages near and far from health facilities across four rural districts. Verbal consent was obtained. Results: Respondents reported multiple, co-existing descriptions of causation including: contaminated water and difficulties accessing clean water; exposure to an unclean environment and poor food hygiene; contaminated breast milk due to sexual intercourse, overheated breast milk or bodily maternal conditions such as menstruation or pregnancy; and dietary imbalances and curses. Respondents rarely discussed the role of open defecation or the importance of handwashing with soap in preventing diarrhea. Conclusions: Categorizing behaviors as beneficial, harmful, non-existent or benign enables tailored programmatic recommendations. For example, respondents recognized the value of clean water and we correspondingly recommend interventions that reinforce consumption of and access to clean water. Second, respondents report denying “contaminated” breast milk to breastfeeding children. This is a harmful practice that merits attention. Third, the role of open defecation and poor hygiene in causing diarrhea is less understood and warrants introduction or clarification. Finally, the role of exposed feet or curses in causing diarrhea is relatively benign and does not necessitate programmatic attention. Further research supportive of communication and social mobilization strategies building on these findings is required to ensure that improved understanding regarding diarrhea causation translates into improved diarrhea prevention. © 2013 McMahon et al.; licensee BioMed Central Ltd.
This qualitative research was embedded within a broader study that purposefully focused on four of the most marginalized districts in Sierra Leone. The qualitative study design was informed by and adhered to principles of applied qualitative research [9,24] that focuses on a specific illness (diarrhea), addresses programmatic concerns related to diarrhea (identifying local causes, terminology), and draws from experiences of actual cases of sick children. Research sought to understand the perspectives of caregivers based in three types of villages: those with a community health center (CHC), those with a health post, and those without any government health facility (located 3-20 miles – or 2-5 hours via foot or transport – from a health facility) with the intention of exploring differences in understandings by distance to facilities. Distinctions have been classified in the data as near village (those with some kind of peripheral government health facility) and far village (remote villages with no government health facilities nearby). Participants were selected with assistance from health centre staff and village aides appointed by the chief; in addition, data collectors canvassed the village and invited those present to participate. Sampling was purposively focused on seeking mothers, fathers and older female caretakers from households that included children under 5 years of age. Teams of 4–5 local investigators were trained for five days in sessions that included interview ethics, probing for child illnesses including presumed diarrhea (three or more watery stools a day), piloting interview guides, using tape recorders and writing field notes. Investigators were multi-lingual, college-educated, Sierra Leoneans trained as teachers, nurses, social sciences graduate students, a guidance counselor and a linguist. All investigators had previously engaged in health research. Following training, teams divided by language group and began data collection with a field supervisor. Two phases of qualitative data collection in April 2010 and July 2010 were undertaken with focus group discussions and in-depth interviews conducted in local languages with mothers, fathers and older caregivers of children under 5 years of age. Following receipt of verbal consent, 36 focus group discussions and 68 in-depth interviews were completed in 12 villages (8 near; 4 far) (See Table 1). Observation guides were also completed in each village describing the availability of health care, water supply and other amenities. Supervisors conducted daily debriefing sessions with interviewers to collectively discuss findings, refine interview guides and identify questions for follow-up interviews. In-country debriefings with national stakeholders following data collection further refined the basis for thematic analysis. Respondent groups by district and data collection method aAll participants returned for a follow-up FGD on the following day. All interviews were audio-recorded, transcribed into English and assessed for completeness and quality. This study drew upon thematic analysis [25]. A list of hierarchical codes was developed and validated by a co-investigator using debriefing notes collected during data collection and an initial coding of information-rich interviews. Once validated by investigators, the codebook was applied to all transcripts using Atlas/ti [26]. Following this process, codes were grouped into themes related largely to diarrhea terminology, causation and prevention. Across respondent groups, data collection methods and sites, data was compared to arrive at triangulated descriptions of terminology, causation and prevention. Following analysis that emphasized these domains, we sought to prioritize key programmatic interventions into behaviors that are beneficial, harmful, non-existent or benign. The study received approval from the Government of Sierra Leone Office of Science and Ethics Review Committee, Ministry of Health.
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