Investigación original / Original research Perceptions regarding oral rehydration solutions for the management of diarrhea 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,