Gul Nayyer Rehman ( Federal ARI Cell, Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad. )
Shamim A. Qazi ( Federal ARI Cell, Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad. )
Dorothy S. Mull ( University of California, Irvine, California, U.S.A. )
Mushtaq A. Khan ( Federal ARI Cell, Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad. )
Pneumonia is a major child killer in the developing world; to prevent such deaths, mothers must be able to differentiate pneumonia from common cold. Local concepts regarding these illnesses were studied by interviewing 315 mothers of young children in their homes in Punjabi villages. Mothers described pneumonia differently from cough-and-cold but only a few volunteered fast breathing as a sign of pneumonia. Both illnesses were thought to be caused by “coldness,” and were initially treated with “heat-producing” home remedies and feeding was continued in both. Spiritual healers were not consulted for cough-and-cold or pneumonia. Virtually all mothers said that allopathic medicines were necessary for both illnesses and 2/3rd said that if a child did not improve after 2 days of a given medicine, they would change the medicine and/or the doctor (JPMA 44: 185, 1994).
Acute respiratory infections (ART) are now the leading causes of child mortality in the developing world1. It is estimatedthatatleast4 million children die of ARI every year, with pneumonia accounting for most of these deaths2. In Pakistan, studies have consistently shown that between 24 to 37% of pediatric hospital admissions are for ARI3-5, and in a community at large, up to 37% of child deaths are attributable to ARI, chiefly pneumonia6. Thus pneumonia is clearly one of the major causes of child morbidity and mortality in Pakistan. As at present, prevention of pneumonia is difficult. Although some cases can be prevented by immunization against measles and pertussis but most pneumonia are not associated with these EPI target diseases. Further, known risk factors for ARI such as overcrowding and household smoke4,7 are difficult to control. Thus for effective management of pneumonia timely case detection and early referral for antibiotic treatment is essential. A child with bacterial pneumonia cannot be cured with home remedies. Death from the disease can occur very rapidly (within 3 or 4 days) after symptoms of fast breathing appear8. Since early recognition of pneumonia by mothers is important, we studied the concepts regarding cough-and-cold and pneumonia in a village setting. Although U.S. researchers surveyed 35 women in Karachi squatter settlements and Punjabi villages in 19909, but this study is more comprehensive than others and it differs from hospital-based project carried out in Rawalpindi10-12 in that it focuses on a broad sample of mothers interviewed in their own homes rather than on a select group of women who brought their children to a health care facility.
Patients and Methods
Between January to March, 1991, 315 mothers or caretakers of children under 5 years were interviewed in depth at their homes in 4 villages near Islamabad. Primary health care centers were established in those villages so that simple curative care was available at the sites. Mothers had not received any instructions prior to the interview. Two interviewers were Women with Master’s degrees in anthropology who were accompanied to the villages by a trained physician. The sampling was purposive, i.e., the interviewers went house-to-house asking whether an under-S child lived there. The questionnaire used was developed with the assistance of ART- trained doctors, local health workers and an anthropologist. It included closed-ended (yes-no) and open-ended questions. Both cough-and-cold and pneumonia were covered with respect to local terminology used to refer to the illness; perceived prevalence; preceived signs and symptoms; preceived cause; home remedies used; feeding practices during the illness; perceived danger signs; and health-seeking strategies outside the home (patterns of resort), including expectations about how rapidly a child should show improvement after being given a medicine.
Of 315 respondents in four villages, 310 were mothers and 5 were other family members temporarily caring for the child. Most mothers were under 30 years of age and 71% were illiterate. Mothers had a mean of 1.8 children under the age of five. Eighty five percent of respondents said that there was an allopathic doctor available within walking distance of their homes. All villages were homogenous in respect to socio-economic and cultural characteristics. Tables I and IT show the terminology used, signs, symptoms and causes as pemeived by the mothers for cough and cold and pneumoniae respectively, home remedies, health care seeking behaviour and feeding practices during ART episodes.
Cough and Cold
Terminology of ”Nazla Khansi" and “Zookam” were the two usual letters recognized by the mothers for cough and cold. Catching a chill (“Thand lag gal” 49%) and sudden changeoftempemturefmmwannto cold ("Garam sard" 31%) were the most frequent perceived causes of cough and cold (Table I). Regarding danger signs, i.e., signs indicating that medical care should be immediately sought were fever (77%), fast breathing (“Saah tayz” 65%), failure to improve (16%) and difficult breathing ("Saah okhay" 10%) respectively. Seventy-four percent mothers said that they would use home remedies for treatment of coughs and cold. Various home remedies are given in Table I.
None of the mothers would stop feeding during cough and cold. Along with using home remedies, 83% of the respondents thought the children would not get better without some allopathic medication. Ninety percent mothers expected theft children to get better in two days. If they did not get better then 69% said they would change the medicine or the doctor.
All respondents were familiar with the term pneumonia and called it “numonia”. Other local words used were "dard" (literally, “pain” i.e. chest pain; 95%). “Goom numonia" (hidden pneumonia 3%) and “double numonia” (severe respiratory illness 2%). The phrase “double numonia” did not necessarily mean involvement of both lungs (Table II). Like cough and cold, catching chill (“Thand lag gai” 89%) and sudden change of temperature from warm to cold (“Garani sard” 10%) were again the two commonest perceived causes of pneumonia (Table II). When a child had pneumonia, the most alarming signs, i.e., danger signs. identified were difficult breathing (“okhay saah” 37%), failure to feed (35%), chills and fever (‘Palay nal bukhar” 30%) (Table II). Fifty three percent of respondents said they would use a home remedy for pneumonia initially. The remedy most often named was not a food however, it was tying the child\\\'s chest with strips of cotton woolandckflh after applying warm and sometimes even hot paste made, of tumeric and mustard oil, aprocedure known locally as "dard nu but (literally "tying the pain” 36%) (Figure and Table II).
For pneumonia; 95% of the respondents said they would take the child to an allopathic. doctor. Ninety seven percent mothers thought that pneumonia would not get better without allopathic medicines (Table II). Noneofthç mothers said that they would stçp fçeding4uring pneumonia.
This study represents the first large-scale survey of community beliefs and practices about cough and cold arid pneumonia to be conducted in rural Pakistan. The need for such studies is now widely recognized13. World Health Organization (WHO). recommended standard ARI case management approach relies upon tachypnoea, lower chest in drawing and presence of certain danger signs for classification and management of ART in under five children14. The recognition of these symptoms and signs are extremely important by the mothers for prompt seeking of health care. While many topics were covered, the overnding goal was to gauge mother’s ability to differentiate between relatively minor upper respiratory infcctionsandiife4hreatening pneumonia for which antibiotics arc needed. Investigation of local ideas about the cause of cough-and-cold and pneumonia showed widespread popular fear of cold, especially cold weather, and very little. emphasis on contagion. This finding has public health implications. Studies by other researchers10,11 show that some patents aM so afraid of exposure to cold that they are reluctant to unwrap an infant to check for chest in drawing; a late sign of severe pneumonia. It is difficult to promote hygienic measures such as avoidance of sneezing or coughing on others or use of handkerchiefs when contagion is not well understood. Questioning mothers about home remedies revealed a heavy reliance on those thought to produce warmth to counter the perceived "coldness" of the respiratory infection. These remedies arc largely innocuous except for the practice of tying the chest which can interfere with the breathing if done too tightly Reported feeding practices indicated it that continued feeding of children during respiratory illness was virtually universal. This is a welcome finding in view of evidence that some children are not fed during episodes of severe diarrhoea15 the other major child killer in the developing world. Mothers’ responses to yes-fib questions about danger signs suggested that in. cough-and-cold, 65% were aware of fast breathing as a sign for which a child. should be taken to a health professional,] 1% of difficult breathing and 2%of chest in drawing - all three signs being very good indicators of possible pneumonia. While this result was encouraging, its . validity is uncertain since a later open-ended question about signs and symptoms of pneunionia produced a different finding. There, 91% of mothers mentioned difficult breathing but only 13% mentioned fast breathing. Other studies conducted in Pakistan indicate that fast breathing is not an alarming or even salient sign for most mothers, some of whom attribute it to fever rather than to pneumonia9,11 Researchers have long recognized that yes-no questions may produce an over-optimistic picture of informants’ knowledge since they carry with them the risk of producing yes saving responses: Reported health-seeking patients outside the home indicated that there was heavy use of allopathic medicines for cough-and-cold as well as virtually universal use for pneumonia. This finding suggests overuse of antibiotics for simple. self-limiting upper respiratory tract infdetions - a pattern common in Pakistan as elsewhere in the developing world. Also, there was widespread belief (2/3 of informants) that if a child with either cough-and-cold or pneumonia did. hot improve within 2 days after the medicine was begun the medicine and/or the doctor should be changed. Again, this is worrisome because a minimum of 5 days of antibiotic therapy is necessary both for clinical efficiency in pneumonia and to avoid creating strains of drug resistant baetena. Only 1% of informants said that they would patronize a spiritual, healer .for pneumonia - a finding consistent with results from India16 and with mothers’ attribution of respiratory illness to “coldness’ not to sin or pollution9. The results of this study both confirm and extend results obtained in other areas of Pakistan9-11. For example the concept of go on pneumonia and the continuation of feeding during respiratory illness have not been previously documented. Further, the size of the sample, quite large for a household survey, lends considerable weight to the findings. The authors recommend that further community-based studies be Carried out to counterbalance the possible bias inherent in facility-based research in which only those individuals who have come to seek health care are informants. Future community samples should be randomly selected to ensure that iifforthants are representatives of the population from which They are drawn. Two other desirable features of such studies would be. first, evaluation of The are mothers ability to recognize danger signs in. actual infants with ARI and, second, collection of mothers’ narratives of actual illness episodes to confirm that survey findings reflect real-life behaviours.
A version of this paper was read by the last author at the Eleventh Biennial International Paediatric Conference of the Pakistan Paediatric Association, Karachi, on February 4, 1992. The study was carried out with the support of UNICEF, Pakistan, and with the special assistance of Dr. Rik Peeperkorn.
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