Investigación original / Original research

Perceptions regarding oral rehydration solutions for the management of in Guatemalan children: implications for diarrheal management in the Americas

Wences Arvelo,1 Jocelyn Degollado,1 Lissette Reyes,2 and Andrés Álvarez 1

Suggested citation Arvelo W, Degollado J, Reyes L, Álvarez A. Perceptions regarding oral rehydration solutions for the management of diarrhea in Guatemalan children: implications for diarrheal management in the Ameri- cas. Rev Panam Salud Publica. 2013;34(2):121–6.

abstract Objective. To describe knowledge and perceptions regarding the use of oral rehydration solution (ORS) for the management of diarrheal diseases among formal and informal health care providers and community caregivers in the Guatemalan department of Santa Rosa, and to recommend strategies to increase ORS use for management of diarrhea in children. Methods. From July to September 2008, in-depth, semi-structured interviews were conducted with formal health care providers; open-ended interviews were conducted with informal health care providers; and focus group discussions and pile sorting were carried out with community caregivers. Results. The study participants attributed episodes of diarrhea in children to culturally recognized or folk ailments (empacho, cuajo, and varillas) that are primarily treated by traditional healers. There were knowledge deficits about 1) dehydration as a manifestation of diarrhea, and 2) management of dehydration, including the use of ORS and the need to continue feedings during diarrheal episodes. Caregivers perceived bottled/ready-made ORS products and the more expensive over-the-counter antidiarrheal medications as superior to ORS packets in the treatment of diarrhea. Conclusions. In Guatemala, folk etiologies of disease differ from those of the biomedical establishment and influence the decisions made by caregivers when treating ill children, including those related to the use of ORS. Public health campaigns addressing the treatment and management of diarrheal diseases in Santa Rosa should recognize the ailments known as empacho, cuajo, and varillas and target them for ORS use by community caregivers as well as health care providers in both the formal and informal health sectors.

Key words Diarrhea; rehydration solutions; qualitative research; Guatemala.

Acute diarrheal diseases are among oping countries (1, 2). The deaths occur Since the introduction of ORS in 1978 as the leading causes of mortality in chil- mainly due to the severe dehydration a primary intervention to manage dehy- dren < 5 years old, particularly in devel- and fluid loss that occurs during diar- dration due to diarrhea, the estimated rheal episodes. Dehydration is prevent- mortality rate for children with acute 1 Centro de Estudios en Salud, Universidad del Valle able by increasing fluids and continuing diarrhea has fallen from almost 5 million de Guatemala, Guatemala City, Guatemala. Send feedings during diarrheal episodes, and to 1.3 million deaths per year (5). correspondence to Wences Arvelo, [email protected] administering oral rehydration solutions Despite progress in the management 2 Ministerio de Salud Pública y Asistencia Social de Guatemala, Área de Salud de Santa Rosa, Guate- (ORS), which consist of a combination of of diarrheal diseases and the global suc- mala City, Guatemala. sodium, carbohydrates, and water (3, 4). cess of ORS, a recent study showed that

Rev Panam Salud Publica 34(2), 2013 121 Original research Arvelo et al. • Oral rehydration for diarrhea in Guatemala many countries in Africa and Asia had who oversees government medical and interviews that included both closed and no significant 1) reduction in mortality public health activities. Four levels of open-ended questions were conducted from these diseases or 2) improvement government health care are available with pharmacy personnel. Open-ended in the use of ORS for treatment of diar- in Santa Rosa: 1) the Cuilapa Regional interviews were also conducted with rhea (6). The low use of ORS in these Referral Hospital; 2) health centers (one two traditional healers, one herbalist, countries may be attributed to several in each health district); 3) health posts and two midwives to collect information factors, including caregivers and health (56 in total); and 4) “convergence cen- about 1) their experience with health care workers not being well informed ters” (community outreach clinics that problems in the community, including about the proper management of child- provide health care through nongov- diarrhea, and 2) their knowledge and hood diarrhea and deficiencies in the ernmental organizations). Other sources experience with ORS. manufacturing and supply of ORS at the of health care include private clinics, national level (7, 8). Some studies have two small private hospitals, pharmacies, Community caregivers. Six FGDs were suggested that community perceptions midwives, and traditional healers. Study conducted with 5–10 women > 18 years regarding diarrhea and ORS play a key sites with a high incidence of diarrheal old, from rural and urban communities, role in determining choices for manag- diseases as reported from available diar- who were caring for children < 5 years ing a diarrheal episode (9, 10). rhea surveillance data were selected, and old at the time of the study. The women Diarrhea is a major cause of death in included the following villages: Tapa- were selected using convenience sam- Guatemala and is responsible for 18% of lapa (in the municipality of Casillas); El pling among persons visiting relatives all deaths in children < 5 years old (11). Astillero (in Chiquimulilla); El Astillero in Cuilapa Regional Referral Hospital. A household survey conducted in 2006 (in Taxisco); San Nicolás (in Barberena); The FGDs included questions about 1) in Santa Rosa, a rural lowland depart- Potrerillos (in Pueblo Nuevo Viñas); and participants’ experiences caring for ill ment in southeast Guatemala, reported Jumaytepeque (in Nueva Santa Rosa). children, particularly those with diar- that the use of ORS for the treatment of rhea, and 2) treatment-seeking behav- children with diarrhea was as low as 8% Data collection iors for various illnesses. A correlation (12). This is particularly worrisome con- matrix (illness–age) was used to identify sidering the recent cholera outbreaks in A phased approach was used for data illnesses that may be perceived as af- Haiti and the Americas, which highlight collection, with information collected fecting children of different ages. Ethno- the potential threat of cholera in the re- at earlier stages informing processes at anatomical sketches were used to help gion, although no cases of cholera have later stages. the participants identify ailments and been reported from Guatemala since the their relation to different parts of the late 1990s (13). Formal health care sector. In the first body. The discussion group facilitators Globally, there is limited understand- phase of the study, semi-structured in- probed about feeding practices and how ing of 1) the factors that affect ORS terviews were conducted with formal they are affected by illness. Knowledge use and 2) how to encourage caregiv- health care providers such as physicians and practices regarding the use of ORS ers to use ORS for children with diar- and nurses. Participants were identi- and home replacement fluids, and the rhea. To help fill this gap, a qualita- fied through the Guatemalan Ministry of need to continue feeding and breastfeed- tive assessment was conducted in Santa Public Health and Welfare. Eight physi- ing during a diarrheal episode, were Rosa, where ORS use is low, to examine cians participated in semi-structured in- also explored. In addition to the FGD knowledge and perceptions about the terviews about health problems in their participants, 10 persons from the com- use of ORS in the treatment of childhood communities. A focus group discussion munity with recent experience caring diarrhea among caregivers and health (FGD) was also conducted on a similar for a child with diarrhea were invited care providers in the formal and infor- topic with seven nurses identified by to participate in the study. For conve- mal health sectors. the participating physicians. Participants nience, women or men visiting an ill were asked specifically about diarrhea, child at the hospital were selected. With MATERIALS AND METHODS institutional and individual responses these 10 participants, the cognitive–sym- to diarrhea, and approaches for the suc- bolic dimensions of sickness and health, Study site cessful implementation of health pro- specifically in relation to diarrhea and grams in the community. the use of ORS, were explored using Santa Rosa, one of 22 departments in the pile-sorting technique. “Open” in- Guatemala, is located 80 km southeast Informal health care sector. Information terviewing methodologies were used of Guatemala City and includes 14 mu- provided by participants from the for- to allow for exploration of the more nicipalities comprising both rural and mal health care sector was used to iden- complex symbolic dimensions of the semi-urban areas. It has a population of tify participants from the informal health social constructs of health and disease. 308 522, about 3% of which is indigenous care sector, which included traditional In addition to the pile-sorting exercise, or Amerindian. Approximately 91% of healers and pharmacy staff. In Santa life histories of sickness were collected. its inhabitants are Spanish-speaking, and Rosa, pharmacies are operated by own- In the pile-sorting phase, participants more than a quarter of the population ers and family members who frequently were asked to arrange 20 flashcards has had no formal schooling. do not have a license or degree in a depicting various diarrheal treatments Santa Rosa’s municipalities roughly pharmacy-related discipline and were in perceived logical order based on how correspond to 14 health districts, each therefore considered informal health they function (part of the body targeted of which is supervised by a director care providers. Twelve semi-­­structured by the treatment, symptoms addressed

122 Rev Panam Salud Publica 34(2), 2013 Arvelo et al. • Oral rehydration for diarrhea in Guatemala Original research by the treatment, or effectiveness of the In response to questions about clini- have diarrhea, and whenever it is cuajo treatment). Similarities across treatments cal management, the participants said the diarrhea is white.” Treatment for cu- were explored. The cards included pho- that feeding should continue during ajo was explained as follows: “[The care- tos or illustrations of previously iden- a diarrheal episode but “fatty foods” givers] take [the children], suspend them tified medicines and other products/ should be avoided and preference given upside down and rapidly and repeatedly treatments commonly used to manage to “blander” foods. Most agreed that tap the soles of their feet.” The ailment diarrhea in Santa Rosa. The order of each breastfeeding should continue or be in- known as varillas (“rods”) was described participant’s stack of flashcards was then creased during diarrheal episodes. In as a diarrhea-related condition caused analyzed to determine perceptions of addition to ORS, the participants said by improper positioning of babies dur- and preferences for various treatments. they recommended home fluid replace- ing breastfeeding. In response to specific ments made from “plantain water,” “rice questions about ORS and diarrhea, the Data management and analysis water,” or “water with orange or lemon participants said they viewed ORS as juice and salt.” the primary treatment, but children do All interviews and FGDs were tape- Most participants viewed delays in not like to drink it, and parents do not recorded and then transcribed and ana- seeking health care as a major barrier to emphasize its importance. lyzed using NVivo version 7 (QSR In- adequate management of diarrheal epi- ternational, Melbourne, Australia) and sodes. Some said the delay was driven by Informal health care sector ANTHROPAC version 4.98 (Analytic perceptions among caregivers that diar- Technologies, Lexington, Kentucky, USA. rheal episodes are “normal occurrences.” Pharmacists. Participating pharmacy The NVivo software was used to code Participants also said that the use of tra- owners and employees reported that the and capture themes from the data de- ditional healers for diarrhea is a common main diseases for which they dispense rived from the interviews and the FGDs. practice. One of the physicians mentioned treatments included gastrointestinal and Consensus analysis and the pile-sorting “stigma” and “social shame” associated respiratory diseases, and that the ideal functions in ANTHROPAC were used with diarrhea (particularly being placed practice in response to questions about to conduct factor analysis to determine in a “rehydration room” for treatment, management of children with diarrhea patterns of agreement and scoring, and to and even the use of ORS itself) as barriers was to refer the customer to a health cen- compute the correlations of the data col- to properly managing diarrhea. ter or health post, or to provide ORS and lected in the pile-sorting exercise. a medicine that would “attack” what- Nurses. Participants said that the first ever was causing the diarrhea. Informa- Study ethics and informed consent line of care sought by caregivers of chil- tion provided to customers included dren with diarrhea is traditional healers, instructions about oral rehydration, hy- There was no risk to the study par- who use remedies made from herbs giene, and visiting a health provider. ticipants, and the information collected and roots, but if the ailments persist or Participants said community practices was confidential. Verbal, informed con- worsen, caregivers may consider taking that obstruct adequate treatment of chil- sent was obtained from all participants. the patient to a health center or post. dren with diarrhea include beliefs about Only persons > 18 years old were al- They also said that three culturally rec- medicine, and “favored brands”; the lowed to participate. The protocol re- ognized or folk ailments known as empa- use of home remedies; and the use of ceived approval from the institutional cho, cuajo, and varillas, which are treated traditional healers and midwives instead review board of the Universidad del primarily through traditional methods, of health care professionals. Although Valle de Guatemala (Guatemala City, are often associated with diarrhea, which most participants associated ORS with Guatemala). The protocol was also ap- often occurred before, during, or after the process of hydration, two admitted proved by the Guatemalan Ministry of the ailment. Empacho (“”) was not knowing about ORS or its function Public Health and Welfare. described as a condition caused by “eat- in treating diarrhea. ing food improperly”3 that is cured by RESULTS drinking 1) a carbonated beverage such Traditional healers. All participating as lime water with aspirin effervescent traditional healers described four main Formal health care sector tablets or 2) a caffeinated cola product ailments associated with diarrhea: empa- with common over-the-counter antidiar- cho, cuajo, varillas, and lombrices (worms). Physicians. The participating physicians rheal remedies such as Santamicina or Empacho and lombrices were described reported managing around 70 diarrhea Sulfatiazol (sulfathaziole). The partici- as conditions that can affect persons of cases per month in children < 5 years pants also mentioned purgas (laxatives) any age, whereas cuajo and varillas were old. The fluctuation in the number of as treatments for empacho. Cuajo (literally described as ailments affecting mainly cases was attributed to rainfall. The par- translated as “rennet,” the en- infants. ticipants reported that 1) they prescribed zyme that induces coagulation in milk) The diarrhea-related ailment reported ORS to every child with diarrhea but was believed to be the result of some most frequently by participants was em- suspected many patients do not use it type of physical irritation. “When chil- pacho, a condition attributed to eating too because of its “unpleasant flavor,” and dren start walking, and fall, or they sit, quickly, overeating, or eating after a pro- 2) ministry health centers and health and develop an irritation, they begin to longed period of fasting. According to posts have an appropriate supply of participants, manifestations of empacho ORS but “sometimes do not have any 3 As the nurses explained, empacho was previously included hijillos (small nodules that oc- salt packets.” understood as “intestinal .” cur under the skin, usually on the hands

Rev Panam Salud Publica 34(2), 2013 123 Original research Arvelo et al. • Oral rehydration for diarrhea in Guatemala or arms); ; vomiting; abdominal Community caregivers syrups, which are given in small doses pain; headaches; fever; diarrhea; consti- such as spoonfuls rather than larger pation; and bloating. The type of diar- Focus group discussions. Based on the volumes usually required for adequate rhea that occurs during an episode of results of the FGDs, community care- hydration. empacho was described as “fatty and givers recognize that children are ill foamy.” The main treatment for empacho when they cry, and when they are Pile sorting. In the pile-sorting exer- is known as sobada, a massage performed not eating, breastfeeding, or playing cise, the participants arranged the 20 on the abdominal area while the patient as usual. Stomach diseases were most flashcards depicting various diarrheal is in a supine position that consists of commonly associated with babies, chil- treatments, including the ORS formu- a series of circular, deep strokes. For dren, and adolescents. According to lations shown in Table 1, based on people with severe illness, empachos are these participants, when children are the instructions described above (in treated with purgas such as oils, milk ill with a stomach disease they should perceived logical order by 1) part of of magnesia (magnesium hydroxide), be fed soft, bland food, which can be the body targeted by the treatment, 2) sulfates, citrates, grape salts, or carbon- complemented with atole (a traditional symptoms addressed by the treatment, ated beverages. Those with very severe cornstarch-based hot drink); their de- or 3) effectiveness of the treatment). episodes of empacho may undergo co- sire to breastfeed decreases; and they Most participants arranged their cards lonic cleansing with water and herbs. In should not be “required” to breastfeed. by stomach problem addressed by the response to questions specifically about They also said that while health centers treatment (which included the folk ail- diarrhea, participants said the condition or health posts are the first line of care ments empacho, varillas, and cuajo, as frequently occurs as a manifestation of for most diseases, for empacho, cuajo, well as other commonly recognized empacho but should be treated with ORS and varillas, with or without diarrhea, gastrointestinal symptoms such as diar- when it occurs on its own. they prefer the services of traditional rhea, , and stomach ache). The Manifestations of the ailment known healers, unless “there is no money,” participants were then asked to classify as varillas include small rods descend- in which case they visit a health cen- the cards in different groups based on ing from the palate of the mouth behind ter or health post, where services are effectiveness in treating diarrhea (“al- the molars. Other manifestations of the free. To treat diarrhea, participants said ways effective,” “sometimes effective,” condition include a noise (tronido, liter- they used aspirin effervescent tablets “rarely effective,” and “never effective ally translated as “thunderclap”) made with lime, rice, or plantain water, or for diarrhea”). According to most par- by the infant during breastfeeding; poor a solution of salt and sugar in boiled ticipants, the best treatments for diar- feeding; diarrhea; and fever. Participants water. While most participants did not rhea, in descending order, were Sal de said they attempt to treat varillas by know the terms “oral rehydration solu- Andrews (citric acid, magnesium sulfate, manipulating the “rods” back to their tion” and “ORS,” they recognized the and sodium bicarbonate); bismuth sub- original position using their index fin- ORS packets provided by health centers salicylate; agüitas (infusions); and the gers to press on the gums in the posterior and health posts, and understood that ORS packets. None of the treatments maxillary area of the mouth. This treat- they are administered to treat diarrhea. were classified by participants as “not ment was sometimes preceded by other There was no consensus among the effective for diarrhea.” treatments similar to the ones used for participants on whether ORS packets The final step of the exercise consisted empacho. were used to cure diarrhea or to man- of choosing the flashcards that showed Manifestations of cuajo (known else- age dehydration. the best treatments for diarrhea. Of the where in Central America as caída de la When asked about ORS preparation, 11 caregivers, five chose Sal de Andrews mollera or “broken crown”) include a participants said the contents of the ORS and bismuth subsalicylate, four chose sunken fontanel, genital inflammation, packet should be dissolved in treated or the bottled/ready-made ORS products, diarrhea, and vomiting. Hijillos, previ- boiled water and administered to pa- and two chose the ORS packets. ously described as a manifestation of tients “in small amounts” so that it can empacho, can also occur in cuajo, in which be better tolerated. The wide range of TABLE 1. Brand name and type of oral case the nodules can usually be found in packaging and labeling for the various rehydration solutions available in Santa Rosa, the groin area. Treatment for cuajo con- brands of ORS caused confusion among Guatemala, 2008 sists of holding the ill child face down participants about how ORS should be Brand name Type Flavor from the ankles and lightly tapping the prepared. They also reported that fla- soles of the feet. This is usually repeated Sales de Rehidratación Oral Sachet None vored ORS is considered more accept- BP several times, particularly in those with able than unflavored ORS. Most partici- Suero vida oral Sachet None severe illness. pants said that bottled/ready-made ORS UNICEF Sachet None Worms (lombrices) can also cause diar- products were superior to ORS packets, Suero Oral Ancalmo Sachet Multiple rhea. According to participants, worm based on the reasoning that a higher Suero Oral Vitaminado Sachet None increase during heavy rains price should translate to better quality Ancalmo and are exacerbated by consuming (bottled/ready-made solutions in Santa Electro Dex Sachet None spicy or very heavy foods. Lombrices Rosa are 40 times more expensive than Glucosoral Sachet None Vida Sachet None are treated with baths in garlic-infused the packets). Participants also said that Pedialyte Bottled Multiple water and are considered the least severe the bottled/ready-made ORS products Oralyte Bottled None of the four diarrhea-related ailments de- were often administered like bottled Levu Bottled None scribed by traditional healers. medicines such as antibiotics or cough

124 Rev Panam Salud Publica 34(2), 2013 Arvelo et al. • Oral rehydration for diarrhea in Guatemala Original research

DISCUSSION of diarrhea creating a barrier to scaling culturally recognized or folk ailments up effective prevention interventions known as empacho, cuajo, and varillas. This qualitative assessment demon- was documented in efforts to scale up Therefore, public health campaigns to strated that in Santa Rosa, Guatemala, household water treatment in devel- address treatment and management of diarrhea is perceived to be largely a oping countries (19, 20). The current diarrheal diseases in Santa Rosa should symptom of one of three culturally rec- study found that, similar to other coun- recognize these ailments and target ognized/folk ailments: empacho, cuajo, tries with declining ORS use, in Guate- them for ORS use by caregivers as well and varillas. These finding are similar to mala, there is a wide variety of products as health care providers in the for- other studies in Central America show- marketed for oral rehydration, many of mal and informal health sectors. Edu- ing that folk etiologies of disease differ which are acquired through pharmacies cational campaigns should 1) increase from those of the biomedical establish- (21). Wide availability of rehydration knowledge of dehydration as a severe ment and influence decisions made by products with different instructions for consequence of diarrhea (regardless of caregivers when treating ill children (14– use and formulations could lead to inap- whether it is perceived as the principal 16). When diarrhea is perceived to be a propriate product use or adverse conse- condition or as a manifestation of em- manifestation of one of the folk ailments, quences and pose a threat to appropriate pacho, cuajo, or varillas); 2) promote the traditional healers are the preferred management of diarrhea (22). proper use of ORS and continued feed- source of treatment. In some cases, the ings throughout diarrheal episodes; and treatments used for these ailments may Limitations 3) describe the various brands of benefi- worsen a diarrheal episode. In other cial treatments available in the commu- cases, the diagnosed folk ailments may The findings from this study are sub- nity, and how they should be prepared represent severe manifestations of diar- ject to several limitations. First, the and administered. Particular attention rhea. In any case, the traditional methods study was not conducted during the ro- should be given to the proper use of rarely manage the underlying dehydra- tavirus season reported for Guatemala bottled/ready-made ORS products, tion. Despite the perceptions revealed in (23). ORS is the primary treatment mo- which are considered superior to ORS the study, it has been well documented dality for rotavirus diarrhea, so the cur- packets within the community. These that in Guatemala, modern biomedical rent findings might have been different products are often administered like care plays a major role in the treatment if the study had been conducted during bottled medicines, such as cough syrup, of childhood diarrhea, suggesting that the rotavirus season, when health care resulting in dosing in small quantities public health campaigns, particularly worker and caregiver awareness of ORS rather than the administration of large those conducted by the formal health as a treatment for diarrhea is higher. volumes usually required to ensure ad- care sector, should incorporate folk ail- Second, the study area was limited to equate hydration. ments as proxies for diarrhea and there- the department of Santa Rosa, so the fore targets for ORS use (17). findings can not be generalized to other Acknowledgments. The authors The discrepancy between medical ver- populations. Despite this limitation, the thank Kim Lindblade of the U.S. Cen- sus cultural or folk conceptions and findings from this study could be ap- ters for Disease Control and Prevention definitions of diarrhea pose considerable plicable to other, similar communities (CDC), for her technical contributions; challenges to the implementation of pre- in Guatemala and throughout Central collaborators at the Guatemalan Minis- vention interventions and surveillance America. try of Public Health and Welfare, partic- activities. Similar challenges have been ularly the physicians, nurses, and health reported in Africa, where perceptions Conclusions promoters that work in Santa Rosa; and and beliefs about childhood diarrhea the study population in Santa Rosa. were limiting the validity of community- Caregivers in Santa Rosa, Guatemala, based diarrhea surveillance (18). An- perceived some episodes of diarrhea in other example of popular perceptions children as manifestations of several Conflicts of interest. None.

REFERENCES

1. Kosek M, Bern C, Guerrant RL. The global 4. Liu L, Johnson HL, Cousens S, Perin J, Scott S, 7. Sodemann M, Jakobsen MS, Molbak K, burden of diarrhoeal disease, as esti- Lawn JE, et al. Global, regional, and national ­Martins C, Aaby P. Management of childhood mated from studies published between causes of child mortality: an updated system- diarrhea and use of oral rehydration salts in 1992 and 2000. Bull World Health . atic analysis for 2010 with time trends since a suburban West African community. Am J 2003;81(3):197–204. 2000. Lancet. 2012;379(9832):2151–61. Trop Med Hyg. 1999;60(1):167–71. 2. Black RE, Cousens S, Johnson HL, Lawn 5. Santosham M, Keenan EM, Tulloch J, Broun 8. Victora CG, Bryce J, Fontaine O, Monasch JE, Rudan I, Bassani DG, et al. Global, re- D, Glass R. for R. Reducing deaths from diarrhoea through gional, and national causes of child mortal- diarrhea: an example of reverse transfer of oral rehydration therapy. Bull World Health ity in 2008: a systematic analysis. Lancet. technology. Pediatrics. 1997;100(5):E10. Organ. 2000;78(10):1246–55. 2010;375(9730):1969–87. 6. Boschi-Pinto C, Bahl R, Martines J. Limited 9. Scrimshaw SC, Hurtado E. Anthropological 3. Claeson M, Merson MH. Global progress progress in increasing coverage of neonatal involvement in the Central American diar- in the control of diarrheal diseases. Pediatr and child-health interventions in Africa and rheal disease control project. Soc Sci Med. ­Infect Dis J. 1990;9(5):345–55. Asia. J Health Popul Nutr. 2009;27(6):755–62. 1988;27(1):97–105.

Rev Panam Salud Publica 34(2), 2013 125 Original research Arvelo et al. • Oral rehydration for diarrhea in Guatemala

10. Nichter M. From aralu to ORS: Sinhalese per- fantile diarrhea in Lima, Peru. Soc Sci Med. enough evidence for scaling up now?”. ceptions of , diarrhea, and dehydra- 1983;17(17):1257–69. ­Environ Sci Technol. 2009;43(14):5542–4; au- tion. Soc Sci Med. 1988;27(1):39–52. 15. Smith GD, Gorter A, Hoppenbrouwer J, thor reply 5545–6. 11. Pan American Health Organization. Salud Sweep A, Perez RM, Gonzalez C, et al. The 20. Schmidt WP, Cairncross S. Household wa- en las Américas. Washington: PAHO; 2012. cultural construction of childhood diarrhoea ter treatment in poor populations: is there Available from: http://new.paho.org/salu in rural Nicaragua: relevance for epidemiol- enough evidence for scaling up now? Environ denlasamericas/index.php?option=com_ ogy and health promotion. Soc Sci Med. Sci Technol. 2009;43(4):986–92. docman&task=doc_view&gid=210&Itemid=] 1993;36(12):1613–24. 21. Green EC. Diarrhea and the social marketing Accessed 13 January 2012. 16. DeClerque J, Bailey P, Janowitz B, Dominik R, of oral rehydration salts in Bangladesh. Soc 12. Arvelo W, Padilla N, Henao O, Jordan H, Pez- Fiallos C. Management and treatment of diar- Sci Med. 1986;23(4):357–66. zarossi N, Reyes L, et al. Community house- rhea in Honduran children: factors associated 22. Quereshi UA, Bhat JI, Ali SW, Mir AA, hold survey to describe healthcare utilization with mothers’ health care behaviors. Soc Sci ­Kambay AH, Bhat IN. Acute salt poison- practices and risk factors for diarrheal dis- Med. 1992;34(6):687–95. ing due to different oral rehydration solu- eases in the department of Santa Rosa, Guate- 17. Goldman N, Pebley AR, Gragnolati M. tion (ORS) packet sizes. Indian J Pediatr. mala—2006. In: Proceedings of the forty-fifth Choices about treatment for ARI and di- 2010;77(6):679–80. annual meeting of the Infections Diseases arrhea in rural Guatemala. Soc Sci Med. 23. Cortes J, Arvelo W, Lopez B, Reyes L, Kerin Society of America; San Diego: IDSA; 2007. 2002;55(10):1693–712. T, Gautam R, et al. Rotavirus disease burden 13. Brunkard J, Talkington, DF. Notes from the 18. Kauchali S, Rollins N, Van den Broeck J. among children < 5 years of age—Santa Rosa, field: identification of Vibrio cholerae sero- Local beliefs about childhood diarrhoea: im- Guatemala, 2007–2009. Trop Med Int Health. group O1, serotype Inaba, biotype El Tor portance for healthcare and research. J Trop 2012;17(2):254–9. strain—Haiti, March 2012. MMWR Morb Pediatr. 2004;50(2):82–9. Mortal Wkly Rep. 2012;61(17):309. 19. Clasen T, Bartram J, Colford J, Luby S, Quick 14. Escobar GJ, Salazar E, Chuy M. Beliefs re- R, Sobsey M. Comment on “Household wa- Manuscript received on 17 July 2012. Revised version garding the etiology and treatment of in- ter treatment in poor populations: is there accepted for publication on 29 July 2013.

resumen Objetivo. Describir los conocimientos y las ideas que tienen las personas que pres- tan atención de salud en el sector convencional, el sector no convencional y los cuida- dores de la comunidad con respecto al uso de las soluciones de rehidratación oral en Ideas con respecto a las el tratamiento de las enfermedades diarreicas, en el departamento guatemalteco de soluciones de rehidratación Santa Rosa y recomendar estrategias encaminadas a aumentar la utilización de estas oral en el tratamiento de soluciones en el tratamiento de la diarrea en los niños. Métodos. De julio a septiembre del 2008 se llevaron a cabo entrevistas exhaustivas la diarrea de los niños semiestructuradas a los profesionales de salud y entrevistas con preguntas abiertas guatemaltecos: repercusiones a los proveedores no convencionales de atención sanitaria y se organizaron debates sobre el tratamiento de la en grupos de opinión y ejercicios de ordenamiento de tarjetas con los cuidadores de diarrea en las Américas la comunidad. Resultados. Los participantes en el estudio atribuyeron la causa de los episodios de diarrea en los niños a dolencias culturalmente aceptadas o populares (empacho, cuajo y varillas), que tratan principalmente los curanderos. Se observaron deficiencias en los conocimientos acerca de 1) la deshidratación como una manifestación de la diarrea y 2) el tratamiento de la deshidratación, incluido el uso de las soluciones de rehidratación oral y la necesidad de continuar la alimentación durante los episodios diarreicos. Los cuidadores consideraron las soluciones de rehidratación embotelladas o preparadas y los medicamentos antidiarreicos de venta libre, que son más costosos, como mejores opciones para el tratamiento de la diarrea que las soluciones de rehi- dratación oral. Conclusiones. En Guatemala, el concepto popular y el de las instituciones biomédi- cas sobre la causa de las enfermedades es diferente e influye sobre las decisiones que toman los cuidadores al tratar a los niños enfermos, por ejemplo, las relacionadas con el uso de soluciones de rehidratación oral. Las campañas de salud pública que abor- dan el tratamiento y el manejo de las enfermedades diarreicas en Santa Rosa deben incorporar las dolencias conocidas como empacho, cuajo y varillas y fomentar el uso de las soluciones de rehidratación oral en estos casos, por parte de los cuidadores de la comunidad, los profesionales de salud del sector convencional y los proveedores de atención del sector no convencional.

Palabras clave Diarrea; soluciones para rehidratación; investigación cualitativa; Guatemala.

126 Rev Panam Salud Publica 34(2), 2013