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• ~ ~ 245.11 90S0 F°P (~OP~.~-$a’~ W~ ~ Sociocuiturai fFactors Influencing the fPrevaience of (Diarrhea 1 (Disease in Qural ‘Upper ~TEgypt An Ethnographic Study in Two Villages of Assiut 245.11—12689 ii !!l~ •u~ a~mIIu~~kIII 1i~ I ~ I •JIA~~ ~II II lII~~ i~I • ipir I I ~ pØ~i~ iNTERNATIONAL PFFERENCE CW4Ij~ FOR COMMUNITY WATER ~U~PL~ ANR SANITATION (IRC~ Sociocultural fFactors Influencing the !Prevaience of (Diarrhea 1 (Disease in T~urai‘Upper ~Egypt An Ethnographic Study in Two Villages ofAssiut LIBRARY, IN 1E?~A ~ ~ ENTRE FC)~_i1~~~~’ AND SANIIAT ~ P.O. Box I1~ Final Report Tel. (070) 8149 Submitted to Hania Copyright (C) 1990 - The United Nations Children’s Fund (UNICEF) Egypt Office. 8, Adnan Omar Sidki St., Off Mussadak St. Dokki - Cairo Egypt ISBN 92-8o6-a048-6 LSBN: 2636/91 - November 1990 The research findings presented in this report and its annexes do not necessarily reflect the policies or views of UNICEF or the Ministry of Health. The purpose of the report is to facilitate the rapid exchange of knowledge and perspectives and to stimulate discussion. All correspondence shouldbe addressed to~ Dr. Pierre-Emenc Mandi Chief, Research, Programme Publications and Library Section Programme Division UNICEF 3 UN Plaza NewYork, NY 10017 Tel: 1-212-326-7062 Fax~1-212-326-7096 - - -- Tlx: 175989 TRT Contents Page Foreword 5 Introduction and Methods 9 Central Research Findings: 1 Breastfeeding 13 2 OtherMilks 29 3 Introduction of Solid and Semi-Solid Foods 35 4 Diarrhea 45 5 Peisonal Hygiene 61 6 Domestic Hygiene 69 7 Water and Sanitation 79 8 Concernfor Hies 81 9 Health Services 83 Conclusion 89 Annex A: Village and Satellite Profiles 93 Annex B: Case Studies 103 Annex C: Glossary for Assiut 155 .fForeword: his book is one volume of a four-part senes of ethnographic studies on the T sociocultural factors of relevance to the incidence and prevalence of diarrheal disease in six villages of Upper Egypt. These studies were commissioned by UNICEF/Egypt in 1988 as part of the agency’s preparation for developing a program to reduce the incidence of diarrhea among young children in Upper Egypt. The first purpose of the studies was thus to explore sociocultural factors of relevance to the problem of the high incidence of diarrheal disease so that UNICEF could seek ways in which mothers and other community members could modify their behavior m the interests of improved child health. A secondary purpose of the research was to test the utility of the approach for undertaking qualitative studies of factors related to community health known as the Rapid Appraisal Procedure, or RAP, which had not previously been used in Egypt as such*. Smce the selection and testing of this research strategy had major implications for the manner in which the research was conducted, and therefore for its findings, it is descnbed in some detail below. The RAP manual was first developed by its authors, and has since been utilized by many others, to facilitate the study of “the effectiveness of pnmary health * Susan C. M Scrimshaw and Elena Hurtado, Rapid Assessment Procedures for Nutntion and Primary Health Care. Anthropological Approaches to Improving Programme Effectiveness Los Angeles~ UCLA Latin American Center Publications, 1987. 6 care programs and the relationship between users and providers” (Scnmshaw and Hurtado 1987, ix). It seeks to provide the benefits of the anthropological approach, which focuses on gaining in-depth understanding of systems of belief that underlie behavior, combined with close observation of the behavior as acted rather than as reported, and without the need to engage in lengthy periods of fieldwork. Thus the methods of classical anthropology have been streamlined and codified, and a uniform framework for undertaking of research, processmg of data, and presentation of fmdmgs derived. Field experience with the manual in 16 societies indicates that information of cntical importance to primary health care and nutrition programs can be collected in the relatively brief penod of four to eight weeks by professional anthropologists, and rapidly transmitted to program managers. The research reported here developed somewhat differently in terms of scheduling, as program design was to be based on research findmgs. Thus the research could help UNICEF not only to maximize program effectiveness, but actually to identify specific goals and modalities of intervention. Planning for the work, including adaptation of the RAP manual to the Egyptian context, selection of sample villages, arranging of research clearances, and introducing the research program to local officials, took place over a period of six months, beginning in August, 1988. The work was managed by a working group incluthng Nancy Terreri, Nagwa Farag, Ibrahim El Kerdany, and Magdi Bayoumi of UNICEF, and Haguer El Hadidi, Hania Sholkami, Saneya Wahba and Lmda Oldham as consultants. This group met monthly over the duration of the planning and research phases, and worked in close cooperation with Dr. Rifaat Saleh and Dr. Salah Madkour of the Mimstry of Health throughout. The RAP manual itself required substantial modification to meet the needs of this program, as the topics of key concem for the prevention of diarrheal disease are quite divergent from the evaluation of nutrition and primary health care programs. The working group therefore cast a wide net in defming the potential areas of mterest to amve at the research outline. Considerable attention was also paid to the identification of research sites, as the needs of UNICEF were for maximum representativeness of rural Upper Egyptin general, but at the same time qualitative research does not allow for random sampling. A number of selection strategies were investigated and discarded in the process. It was ultimately decided that two sites would be selected in each of three govemorates: Aswan, Sohag and Assiut. Within each govemorate, the selection would be based on the cnterion that paired villages, one a “mother”, or main village, the other one of its satellite villages, would be chosen, and that the latter should be FOREWORD 7 unserviced by a piped water supply system. The issue of representativeness was essentially left to the companson of results; to the extent that similar findings were obtained on a given issue in the six sites, or clear reasons for divergence could be identified, it would be tentatively assumed that a given result was representative of this kind of settlement across the region. ‘Where differences which could not be readily accounted for were found, representativeness would remain indeterminate, at least until further research could be undertaken. The names of the mother and satellite villages in all three research areas are not disclosed by these studies, and names of informants and case study subjects are disguised in order to respect their privacy. Sixty days were allocated for fieldwork, which was undertaken in two phases, one during February and March, the other dunng June and July 1989, in order to maximize exposure to seasonal differences in key vanables. Meetmgs of the working group were scheduled before, midway through, and after each of the phases, to share findings and discuss plans for future research activities. An mtenm report was submitted by each field researcher after the first phase, and a separate imal reporton each pair of villages at the conclusion of the overall research. This volume provides the detailed findings of the study in Assiut. Two companion volumes present data on Sohag and Aswan, and a fourth volume summarizes, compares and assesses the generalizability of the findings at the six research sites. L Qidham Introduction. cmci9v(ethlods If you Want tO understand what a science is, you should look in thefirst instance not at its theories or its findings, and certainly not at what its apologists say about it, you should look at what the practitioners of it do. Clifford Geertz, The Inteipi-etation of Cultures uided by the logic of Geertz, this report attempts to comprehend the reasons G for and the consequences of diarrheal diseases, by way of looking at how peasant communities and the individuals who form them conceptualize the issue at hand. In other words, the key premise of this work is that any attempt at saving infants and children who would otherwise suffer or die from diarrheal disease should be preceded by an understanding of child protection and the treatment of illness, as these occur in the context of everyday life. The report details the findings of research into factors of relevance to the prevention of diarrheal disease in two villages of Assiut Govemorate in UpperEgypt. It is based on 55 days of fieldwork, exclusive of travel time, undertaken during the period from February to July, 1989. The reason for stretching out the research time in this way was to account for the factors of seasonality. It may be worthwhile to state at the beginning that the conclusions that this report lays claim to fall within the realm of formulating the right questions rather than fmdmg the perfect answers. 10 This research was carned out in two villages of Assiut Govemorate: a large mother village with a population of 13,000, well provided with government institutions and various services, and a much smaller satellite village or hamlet (‘ezba / L~c) of about 150 households. Descriptions of the two settlements are provided in Annex A. The methodology employed for this work is qualitative, and seeks rn-depth understanding of systems of family practices, beliefs and environmental factors impinging on the potential prevention of diarrheal disease and the rnter-relationships among them. In-depth work was undertaken with 20 households in the mother village and 16 households in the satellite village. These households were visited a rnimmum of four times each, with visits lasting as little as two hours, but generally reaching five to six hours Meals were shared on at least three occasions in each household.

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