Topic | Local Culturally Determined Knowledge, Beliefs, and/or Solutions Identified From CHWs Through Sharing Histories | Standard Messages Taught to CHWs by PHC Staff Without Sharing Histories | Messages Given by PHC Staff Who Are Trained to Facilitate Sharing Histories and Learning With Picture Cards |
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Pregnancy | Danger signs in pregnancy were not recognized as such. For example, female CHWs did not know that a mother could die if she is bleeding during pregnancy and may consider such bleeding as “normal.” Did not identify pain and frequency of urination as a problem. Heavy work or lifting is continued as normal. Pregnant women eat less to have smaller baby and easier birth. Many foods are specifically avoided during pregnancy, such as fish which may “impede healing.” | Danger signs not generally taught in a way to ensure understanding. | Picture cards are discussed with motivational stories of pregnant women with danger signs and how they can end in death, or how they can end well if care is sought. Mothers should spare their energy by working less and eating more so the infant can have more energy. Picture cards with various images of danger signs are discussed with indications to seek care. |
Birth | Institutional birth is not considered desirable due to fears of male health providers and horizontal birth. Women are terrorized by the idea of an episiotomy or cesarean delivery that requires transfer to a hospital distant from home and family. Care by a traditional midwife in the presence of family members is valued. Distance is a major barrier at night and holidays when no means of transport are available. | Home births are illegal. Institutional births are obligatory. | CHWs need to help mothers seek institutional birth with support from family and community members for transport. |
Newborns | Newborn danger signs that were recognized as potentially fatal were infant not wanting to eat and infant being flaccid or agitated. Danger signs that were not recognized as such included an odorous umbilical stump. Newborn is placed to one side to first attend the mother immediately after a home birth, sometimes uncovered due to simple negligence. | Information on birth and newborns is not discussed with CHW or mothers: CHWs and mothers “don’t need to know”. Only professional birth and checkups are allowed. | Need for immediate drying and wrapping of newborn and placement with mother for warmth and immediate suckling at the breast. No bath the first day to stay warm. Picture card images of danger signs are provided and discussed with indications to seek care. |
Breastfeeding | Insufficient breastmilk is a family trait, so a mother will expect it and nothing can be done if female family members had little milk. Breastmilk is withheld to avoid harming the infant if mother is angry, ill, or is pregnant again. Herbal tea is given frequently (for colic and infant thirst). Dozens of myths surrounding breastfeeding practice are expressed. | Generally, PHC staff are not trained in local breastfeeding beliefs and practice or in correct breastfeeding techniques. Infants are taken away for immediate newborn care and not returned quickly to the mother. Free formula samples are handed out. | All mothers can breastfeed if measures are taken to stimulate milk supply. Herbal tea should not be given to infants, rather the mother should drink the tea. Trainers detect local myths through CHW shared histories and use those to discuss how to avoid insufficient breastmilk and maintain exclusive breastfeeding for 6 months. |
Complementary feeding | When a child aged over 6 months does not want to eat, mothers give only breast milk. Mothers value giving liquid soups and semiliquid foods to infants (over semisolids). Animal-source foods are acceptable to give but are not available. | PHC staff recommend taking child off the breast and only give solid food. If breast milk then dries up, give milk formula or cow’s milk. | Continue breastfeeding and try giving small amounts of mashed food more frequently during the day. Soups are mostly water, which fills the infant’s stomach and does not allow space for the food they need to grow. Add citrus juice to legumes to make them more nutritious (increase iron bioavailability) but animal-source foods should be given as much as possible. |
Diarrhea | Diarrhea occurs when someone looks at the child with an “evil eye.” When diapers are damp from being hung out to dry overnight, the dampness in the diaper can “enter” the child and cause diarrhea. Traditional healers “pass a cuy (guinea pig)” or “pass an egg” over the child’s body to draw out bad energy. Dirt or lack of hygiene is not associated with diarrhea. | PHC staff promote use of oral rehydration fluid and care-seeking for diarrhea. Use hygiene for prevention (without discussion of local beliefs on causation). | Dirt on hands or on prepared food can cause diarrhea in some cases, aside from other believed causes. Thus, it is best to use hygiene practices to avoid such cases (i.e., handwashing, keep animals out of the home, keep the child off the ground or dirty floor, use correct treatment for drinking water, others). |
Abbreviations: CHW, community health worker; PHC, primary health care.