Academic journal article Journal of Health Population and Nutrition

Cultural and Social Context of Dysentery: Implications for the Introduction of a New Vaccine

Academic journal article Journal of Health Population and Nutrition

Cultural and Social Context of Dysentery: Implications for the Introduction of a New Vaccine

Article excerpt

INTRODUCTION

Over the past four decades, extensive research has been carried out in Bangladesh on the epidemiological and clinical aspects of diarrhoeal disease, particularly as they relate to cholera. Although research and resultant interventions have significantly reduced the rates of diarrhoeal illness, diarrhoea still accounts for over 10% of childhood deaths annually (1), contributing to an even greater share of morbidity (2) with rates highest among the poorest populations (3). While the political and economic environment clearly contributes to the continuation of high rates of diarrhoeal illnesses, another explanation relates to the appropriateness of medical and public-health interventions that have been developed to prevent diarrhoeal illnesses and their availability and relevance, particularly to high-risk populations. Shigellosis, one of the most severe forms of diarrhoeal disease, is a major cause of morbidity and mortality, accounting for an estimated 1.1 million deaths annually (4). In addition to the death and suffering which occur with acute illness, shigellosis can lead to complications that may persist and cause serious health problems long after the episode has passed. The vast majority of cases occurs in developing countries and tends to attack and be most severe among populations living in impoverished settings (4,5). In Bangladesh, the disease is believed to be endemic. Dysentery, the clinical term to describe bloody diarrhoea, is often coupled with fever and abdominal pain and contributes to 12% of diarrhoeal cases; an estimated 80-90% of dysentery is caused by Shigella species (6). In areas where dysentery is more prevalent, rates are even higher, accounting for 39% of all diarrhoeal episodes (7). While the use of oral rehydration solution (ORS) allows most watery diarrhoeal illnesses to be successfully managed at home, it provides little benefit to patients suffering from shigellosis (4). Furthermore, treatment of shigellosis requires laboratory confirmation for accurate diagnosis and antimicrobial drugs for treatment, many of which have become ineffective over time due to the spread of drug-resistant strains (8,9). Because of the severity of the disease, its highly infectious nature, and the inherent difficulties associated with prevention, particularly in overcrowded areas with poor populations, together with the problems involved in diagnosis and treatment, a vaccine offers a viable alternative for the control of shigellosis.

Remarkably little research has been conducted in Bangladesh on the interactions of cultural dimensions and social circumstances influencing the management of diarrhoeal illnesses. Much of the in-depth research has failed adequately to distinguish between culturally-constructed classifications of diarrhoeal illnesses and the extent to which beliefs relating to specific illnesses guide treatment practices. While researchers working in the South Asian region have demonstrated that such data are essential for the development of successful interventions (10-14), most ethnographic data have focused on watery diarrhoea used for designing strategies promoting ORS (15). Presently, there are no ethnographic data examining the linkages of cultural beliefs and the social conditions and behaviours associated with dysentery in Bangladesh. As a result, there are few community-based efforts that differentiate between dysentery and secretory diarrhoea.

Epidemiological, sociobehavioural and costing studies were undertaken to identify relevant information for policy-makers involved in the implementation of a Shigella vaccine. This paper presents results from the sociocultural and behavioural study which was designed to provide a contextual framework for understanding local interpretations and accompanying health practices that may affect community acceptability of a future Shigella vaccine programme. The theoretical approach used is built on the concept of 'explanatory models' introduced by Kleinman (16), which provides a valuable conceptual and analytic tool for the investigation of local belief systems and care-seeking behaviours. …

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