Ethnographic insights on caring for young children in Nepal
This post relates to my previous post on ethnographic methods where I suggest that we need to put our ears to the ground and listen to those we intend to serve if we are to meet their aspirations for care and design acceptable healthcare interventions.
Here I'd like to focus on two examples of how grounded qualitative methods expand our understandings of healthcare patterns of resort as they relate to caring for young children in settings of poverty and low material resources. I draw here from my experiences volunteering, working, and conducting research in several districts in Nepal's far northwest between the years of 2004 and 2010.
Plural ethnomedical beliefs shape care decisions for children. When mothers seek out medicines or healers for children, they do so as part of a universe of healing modalities that includes local systems of faith healing, religious practices, and the use of informal home remedies, such as medicinal herbs, roots, and plants. Mothers also evaluate the socio-physical properties of drugs for their children (size, shape, color, texture, origin), and these are closely tied to expectations and practices surrounding their use and efficacy. I discovered this both during and in the wake of short-term "health camp" I volunteered at nearly ten years ago when I observed visiting Euro-American pediatricians trying to provide Albendazole (a broad-spectrum anthelmintic) to every child under-5 who presented at the camp. To their dismay, mothers routinely refused these small red pills that would rid their children of potential parasitic infestations. The color red, we learned after interviewing traditional healers in two of the local languages, was an inauspicious color for many, foretelling the possibility of further sickness, of over-heating, of anger or envy. Colors and foods intersect with naturalistic ideas about diet and balance of body temperature - and balance of relationships - part of local therapeutic modalities known to most Nepalis. Foods are classified as either possessing inherently hot or cold properties, and so eating has nutritional as well as other vital implications for maintaining the body’s balance. We distributed a green generic brand of Albendazole instead, and mothers on the last two days of the health camp accepted and gave them to their children.
Land holdings and agro-pastoral schedules are key drivers of healthcare utilization. In a study conducted by Possible to determine the drivers of under-utilization of skilled birth attendance in our catchment area, one finding indicated that families with more land were less likely to deliver in a healthcare facility. This may seem counter-intuitive, as land can be seen as a primary measure of SES in still largely subsistent communities where families still derive much of their livelihood from farming and animal husbandry practices. Over the course of conducting dozens of interviews with families for my own research, gendered patterns surrounding seeking care emerged, where women and girls received much less attention, particularly around busy agricultural times. In one village I stayed while conducting research for my dissertation in 2010, three infant girls passed away over the course of six weeks during such a time. From all accounts, this was atypical. However, the parents of all three girls said they could not spare the time away when there were crops to protect from animals, beans to be harvested, and animals to be grazed. They were unable to walk 2 days north to the district hospital, and they suspected that health posts nearby would be unstaffed and under-equipped. "Baby girls are not able to fight through the winter," one father told me. Feeding families often trumped adding to them, as another of the fathers told me. "I have already 4 mouths to feed. If my child survivies, I will have one more." It is unclear if the same fate would have befallen infant boys; regardless, here, it seems mobilizing networks of Nepal's renowned Female Community Health Volunteers (FCHVs) to ensure continuous population surveillance can provide much needed contacts during busy harvest times. To be sure, FCHVs will be just as busy during these harvest times, but attention to these determinants of healthcare seeking can help shape interventions that can respond to the seasonality of eating, and the gendered dynamics of healthcare seeking.
This just begins to scratch the surface of these complex issues; but, these examples hopefully highlight how knowledge of local context and culture should undergird interventions and research design.