Acute respiratory infections in rural Bangladesh: cultural understandings,

practices and the role of mothers and community health volunteers

1. Sabina Faiz Rashid,

2. Abdullah Hadi,

3. Kaosar Afsana,

4. Shameem Ara Begum

Article first published online: 21 DEC 2001

DOI: 10.1046/j.1365-3156.2001.00702.x

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Tropical Medicine & International Health

Volume 6, Issue 4, pages 249–255, April 2001

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Rashid, S. F. , Hadi, A. , Afsana, K. and Begum, S. A. (2001), Acute respiratory infections in rural
Bangladesh: cultural understandings, practices and the role of mothers and community health volunteers.
Tropical Medicine & International Health, 6: 249–255. doi: 10.1046/j.1365-3156.2001.00702.x

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1. Research and Evaluation Division, Bangladesh Rural Advancement Committee, Dhaka,

Bangladesh

*Correspondence: Sabina Faiz Rashid A 23 Century Estate, Bara Maghbazar, Dhaka 1217, Bangladesh. E-
mail: sabina.rashid@anu.edu.au

Publication History

1. Issue published online: 21 DEC 2001

2. Article first published online: 21 DEC 2001

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Keywords:

• ARI;

• rural mothers;

• cultural practices;

• Bangladesh;

• community intervention

Abstract
Qualitative data collected from 63 older and younger mothers revealed that almost all recognized

pneumonia and all described mild and severe signs and symptoms to explain incidences of pneumonia.

Respiratory illnesses were attributed to humoral imbalances, supernatural causes and ‘negligent’ mothers.

Home care practices involved drinking specially prepared juices, massaging the child with oil and avoiding

‘cooling’ foods. Traditional and allopathic care was sought depending on the perceived severity of the

illness. The role of the family was important in decision-making. Rural mothers were relieved and satisfied to

be able to quickly access low-cost medicines from Bangladesh Rural Advancement Committee (BRAC)

health volunteers, who clearly influence health care practices. In-depth interviews and focus group

discussions with 23 health volunteers showed that 22 were able to correctly identify breathing rates and their

association with pneumonia. All had knowledge of acute respiratory infections (ARI) and were able to list a

range of signs and symptoms. Some health volunteers complained of operational constraints with monitoring

and technical equipment. Nevertheless, the programme has strong links with grassroots volunteers and

community people, making it a successful intervention.

Introduction
Acute respiratory infections (ARI) are a major cause of morbidity and mortality among young children in

developing countries. Each year an estimated 2.2 million children die from infections of the respiratory tract,

principally pneumonia, worldwide. ARI, particularly acute lower respiratory infections (ALRI), account for

nearly a third of all deaths of children under five in many countries. Inadequate or delayed medical care

results in an estimated 400 children dying each day from ARI in Bangladesh (Denno et al. 1994; Zaman

et al. 1997). For cases of severe ALRI, such as pneumonia, quick and appropriate treatment is essential for

survival (Mull et al. 1994).

In terms of health outcome parameters, research findings indicate the success of approaches in educating
communities and creating awareness of ARI. An effective control programme involves three main parts:

early detection and case management, vaccinations, and health education. Effective case management,

therefore, depends upon informing and involving community members, which in turn influences people

towards using health care facilities (WHO 1981; Denno et al. 1994). Cultural understanding and practices of

communities need to be considered when designing measures and programmes for improving community

health (Feysitan et al. 1997). Very little is known regarding the perception and case management of major

community health problems, and many families may prefer traditional methods of treatment (Iyun & Tomson

1996). People may neglect or ignore health advice and child care instructions if their own notions of illness

causation conflict with the biomedical explanations given in interventions (Iyun & Tomson 1996; Feysitan

et al. 1997).
Background and objectives
The Bangladesh Rural Advancement Committee (BRAC), a local non-governmental organization, has been

working in the field of socio-economic development since 1972. In mid-1992, following World Health

Organization guidelines, BRAC launched an intervention programme to reduce the number of ARI-related

deaths in rural Bangladesh. The ARI programme works through a system of community-based education,

detection and control programmes. After implementation, a large-scale quantitative and qualitative research

study was undertaken to identify programmatic barriers and to improve the overall running of the

programme. This paper reports the qualitative data from that assessment, which was conducted in three

districts of Bangladesh.

The objectives of the qualitative research were to: (i) explore mothers’ knowledge of ARI and their home

care practices and behaviour, (ii) examine health volunteers’ knowledge of ARI and (iii) explore health

volunteers’ perceptions of the programme as well as of the rural communities they serve.

Methods
Data were obtained in the districts of Mymensingh, Bogra and Dinajpur covering 10 areas: Trisal, Boilor,

Kashigonj, Muktagacha, Dapunia, Gobindagonj, Kahaloo, Naruli, Parbotipur and Ranigonj. Data collection

took place over a two-and-a-half month period from December 1998 to March 15, 1999. In-depth interviews

and focus group discussions (FGDs) were the two main qualitative research tools used for eliciting

information. We randomly selected and interviewed 63 rural mothers, 23 health volunteers and five BRAC

staff. Mothers were categorized into two age groups: young (16–25 years) and older (26–40 years). Nine

FGDs were held with 31 young mothers and 20 mothers. Separate discussions took place with 23 BRAC

health volunteers and five BRAC staff members.

The BRAC Acute Respiratory Infections (ARI) programme

The main focus of the BRAC ARI programme is to improve the early detection of pneumonia and thereby

preventing its progression to severe or fatal stages. Following WHO guidelines, BRAC treats ARI at the

primary health care level, by first detecting cases through community and first-level health care workers,

assessing the severity and providing antibiotic treatment at home or referring severely affected children to a

nearby health centre (Fauveau et al. 1990).

The ARI programme currently covers a population of 2.4 million in 10 thanas, government administrative

areas with a population of approximately 50 000 each. BRAC works in conjunction with the government,

which provides drugs and logistics, hospital-based clinical case management and supervisory skills training.

In the field, the programme is implemented through, and very much depends upon, BRAC’s health
volunteers. Community health volunteers are selected from BRAC’s village organizations. They are females

with generally a minimum education level of grade three and reside in the villages where they work.

Volunteers receive 3 months training on health and population issues and on illnesses such as diarrhoeal

diseases, tuberculosis and pneumonia. They also attend continual monthly refresher training courses

conducted by programme organizers of BRAC’s Health, Nutrition and Population Programme. Each

volunteer covers 150–200 households, provides information and services on family planning including the

supply of contraceptives, sanitation and hygiene, immunization, tuberculosis, ARI, nutrition, reproductive

health and treatment of common diseases (BRAC 1998).

In ARI training, volunteers are taught to detect and differentiate between cases of mild and severe

pneumonia through the assessment of respiratory rate and presence or absence of chest retractions. Their

duties include providing and disseminating information to mothers of children under the age of 5, detecting

cases, and treating both non-pneumonia and pneumonia infections while referring severe or complicated

cases to BRAC Health Centres or to hospital. Newborns aged 0–2 months are immediately referred to a

clinic. BRAC staff are technically supported by medical officers who supervise the work of health volunteers.

To promote WHO-standard case management and rational drug use, ARI orientation is provided to both

formal and informal service sectors – private practitioners, traditional healers and village doctors. Since early

1997, BRAC has been working in the 10 thanas in collaboration with the government (BRAC 1998).

Results
The study indicated that mothers were aware of ARI and familiar with its signs and symptoms. As causes

they named humoral imbalances of ‘hot’ and ‘cold’ in the body, supernatural factors and ‘negligent’ mothers.

Mothers care for ill children at home or seek medical care depending on the interpretation of the illness.

Health volunteers were knowledgeable about ARI. Despite limitations in supervision and technical support,
the programme has strong links with the community with volunteers positively influencing rural women’s

health care practices.

Mother’s understandings and practices

Both younger and older mothers were aware of ARI (Table 1). Of the 63 mothers, 24% from both age groups

referred to ARI as ‘pneumonia or double pneumonia’, along with a number of local terms. Eighty-eight

percent of mothers were able to list a range of mild and severe signs and symptoms related to pneumonia

such as ‘The child has a cold, becomes restless, has difficulty breathing, and there are sounds in the throat.’

They were able to distinguish between a number of mild and severe symptoms of pneumonia. Fifty-nine

percent of the mothers mentioned severe symptoms of chest in-drawing, wheezing in the chest and rapid

breathing. They were also able to identify the progressive worsening of the illness, such as from a mild
cough to a more congested one and fever. A mother explained, ‘When a child catches a cold they get

pneumonia. Fever happens, cold happens, coughing occurs and there is difficult breathing. We then take the

child to the health volunteer…’.

Table 1. Local perceptions of signs and symptoms of ARI 

Mothers assessed the severity of their child’s illness according to symptoms of loss of appetite, sleepiness,

restlessness and crying. Some of the mothers commented that a serious stage of pneumonia was when the

‘eyes rolled backwards’ or ‘the child did not want to wake up, was restless, not drinking milk or eating.’ In

explaining symptoms, mothers grouped both mild and severe stages of pneumonia. As one mother

explained, ‘When one gets pneumonia, then the child’s stomach shrinks downwards, there is some fever

and cough happens. Looking at the eyes and mouth, one can tell if the child has pneumonia – the child

starts having difficulty breathing.’ This may indicate a gap in recognizing earlier symptoms of pneumonia.

Eight percent of the older and five percent of the younger mothers perceived these symptoms as signs of an

evil spirit illness (churra chunni dhorsey) or caused by a ‘wind-carrying disease’ (alga batash).

Causes of ARI
Beliefs in the body’s humoral balance, such as between hot and cold, underlie most of the assumptions

regarding the causes of ARI as well as related preventive health practices. Cross-cultural qualitative studies

in Malaysia, the Philippines and India reveal similar understandings of the body, where hot and cold

reasoning underlies perceptions of illnesses, causality and prevention. Respiratory conditions are primarily

thought to be caused by the child’s exposure to ‘cold’ (thanda), such as cold air, cold water and a cold mud-

floor; or from a nursing mother’s exposure to cold. The disease is understood to begin as a cold with a build-

up of mucus. Twenty-seven percent of the mothers thought the child’s exposure to cold air, wind, water or

food had caused pneumonia. They believed that ‘cold’ foods, i.e. stale or leftover foods and cold water

aggravate or in some cases, cause pneumonia. Hence most mothers avoid such foods, among them rice

and bananas which are understood to be intrinsically ‘cold’, as well as oranges, eggs, beans, pigeon meat,

hilsa fish, gourd, tomatoes and fat. One mother said that if children ate sugar cane or lentils (mash kolai),

they would catch pneumonia.

Fifteen percent mothers blamed ‘negligent’ mothers who allowed their children to eat ‘cold’ foods and did not

cover them properly as the cause of illness. Several women suggested that ‘obviously when a child was left

to sit around on the cold mud ground or left in urine-stained clothes for a long time, then the child would fall

ill’. Other negligent behaviours include mothers eating ‘cooling’ or prohibited foods, bathing at the wrong

time and washing with cold water. Another 16% attributed ARI to supernatural causes such as ‘pregnant

mothers who were up to no good were attacked by evil spirits’ and ‘evil winds.’ One woman stated: ‘A
pregnant mother should be careful; if she is not then her child will be born with illnesses such as these…

[referring to pneumonia].’ None of the mothers mentioned germs as one of the causes for ARI illness.

Home care practices

Home care practices usually involved avoiding particular ‘cooling’ foods, and rubbing the child’s chest with

mixtures of garlic and oil to ‘expel mucus.’ Forty percent of the mothers used home care remedies such as

‘warming a mixture of garlic and oil or black cumin seeds and massaging it on the child’s chest to soothe

chest congestion’ or feeding the child basil leaf juice. A few less common home care practices were also

mentioned: ‘We take a duck’s rib and mash it with milk and rub it all over the body and head. In the past

elders and in-laws would say – mash a deer’s horn and rub it on the body.’ Another stated, ‘We heat iron

(lohah) and warm the juice from the leaves and then dip the iron in the juice and feed the juice to the child.’

Some mothers frequently breastfed their child. Quantitative findings showed that a large number of mothers

resort to frequent breastfeeding of their child as well as giving lemon juice, honey, and warm fluids for minor

ARI episodes (BRAC 2000). For this quantitative study, a sample of 2938 women from both the intervention

and comparison areas were selected and 120 of 200 health volunteers were selected at random from the

defined geographical regions. A test instrument focusing on maternal knowledge was developed, the unit of

analysis being a woman with at least one child under 5 years of age. None of the mothers mentioned any

harmful practices, although home care remedies may inadvertently lead to delay in seeking medical care.

The role of the family

In some cases, the attitudes of in-laws and other family members delayed mothers in seeking care from

clinics. One woman commented, ‘When my mother-in-law was alive I could not go to any of the doctors but

now she is no longer alive and I can get care from a doctor.’ Narratives imply that older family members or

males may object to women’s choice of treatment. Other external constraints that delay seeking care are

problems with transportation, distance to the nearest clinic, availability of health workers and the family’s

financial circumstances. Internal constraints discouraging some mothers from accessing care outside the

home are related to socio-cultural norms of purdah (Stewart et al. 1994). Purdah has varying meanings

contextually and historically. Here it refers to the seclusion of women. Although norms can be flexible

depending on the class and economic situation of the women and their family, women in public spaces can

be victimized or harassed.

Perceived severity of the illness

The timing of the mother’s decision to seek medical care depends on her and the family’s understanding of

the severity of the child’s condition. If the respiratory illnesses was perceived to be mild, i.e. when the child

was thought to have been affected by cold, mothers resorted to home remedies and care from an

indigenous healer (kabiraj). One mother said: ‘When my child had a cold then we went to a kabiraj and got
some herbal leaves oil which we massaged it onto my child’s body. The healer gave some medicine for the

child to eat as well. The medicine was taken for 15 days and now I am giving homeopathy.’ If, however, the

infant was thought to be suffering from an ‘evil wind-carrying disease’, mothers were most likely to take their

children to a kabiraj or a religious healer. In the case of spirit attacks, religious healers such as fakirs or

huzurs were more likely to be approached for infants over 40 days old (Department of International Health,

John Hopkins University 1996). A woman recounted about her neighbour: ‘She took the child and had jhar

puk done’, a ceremony where the healer recites incantations and prayers and blows on the child. Another

woman narrated, ‘Each one resorts to care in their own way. When my child had a cold and then fever, I had

jhar puk done from a religious healer (fakir). Then I took garlic and oil, over which the religious healer said a

prayer.’ If the child’s condition did not improve, a large number of women appeared to seek allopathic

treatment and/or advice from a BRAC health volunteer or went directly to a hospital.

Mothers’ perceptions of quality of services

Eighty-two percent of mothers expressed satisfaction with the treatment and services provided by BRAC

health volunteers. Most mothers were relieved to be able to get antibiotics quickly and cheaply from the

volunteers. They felt that the 5 taka (US$0.09) charged by BRAC workers was a small sum of money, and

the payment system to be quite flexible. A mother commented, ‘We don’t go anywhere else because the

health volunteer only charges 5 taka. For outside doctors it costs so much and we have to pay immediately.

Whereas with the health volunteer we can take our time.’ Some women also spoke about receiving medicine

on credit, ‘with the option to pay later.’ All health workers live in the community they serve and come from

similar socio-economic and cultural backgrounds as the villagers. When rural women visit them, or when

they conduct their household visits, the interaction is familiar and relaxed. A large number of the volunteers

have no formal education and thus rural women may feel less inhibited to speak freely about their child’s

illness than when meeting with doctors. The health volunteers are perceived as more understanding and

sympathetic to their complaints.

BRAC health volunteers’ knowledge

During the in-depth interviews and group discussions, all 23 health volunteers identified four categories of

ARI: (1) cough and cold (shordi kashi); (2) pneumonia; (3) severe (marathok) pneumonia and (4) very

severe (khub marathok) pneumonia. Ninety-six percent of health volunteers were able to identify breathing

rates and their association with pneumonia correctly: ‘If the age of the child is 0–2 months and the breathing

is more than 60 then we know the child has pneumonia. If the child is from 2 months to 1 years of age and

the breathing rate is 50 or more, and if the child is 1–5 years and the breathing is 40 or more, then all this

indicates the child has pneumonia.’ Health volunteers are given a timer to assess breathing rates. Similar to

mothers, 51% of health volunteers considered pneumonia primarily to be caused by the child’s exposure to

the cold – air, wind, food and water. They also mentioned a number of other reasons such as ‘stale food,
child not immunized, baby remaining unclean, and malnourished child’. Interestingly, health volunteers did

not link germs to ARI, which may explain some of the mothers’ beliefs.

All of the volunteers were aware of the need to refer children aged 0–2 months suffering from symptoms of

pneumonia to a hospital. In 5% of cases, volunteers attempted to treat the illness instead of immediately

referring the child: ‘My child had pneumonia. He had a cold and then fever. Later he had chest in-drawing

and started crying. He had very high fever. The volunteer gave me 20 tablets.’ Quantitative data of 120

volunteers from 10 subdistricts who diagnosed and treated 1166 children aged 3–60 months showed that

67.7% were able to recognize the signs and symptoms of pneumonia at the household level, whereas only

12.5% were able to correctly diagnose the very severe cases (BRAC 2000). BRAC offers health volunteers

3 days of basic training on ARI, including discussion in the classroom, practice in the field diagnosing

children and disseminating information to mothers and families. However, not all volunteers receive basic

training, because of turnover and replacement by new recruits. New recruits usually end up receiving 1 day

in-service training. The greater the exposure of volunteers to BRAC’s basic training, the better are their

chances of correctly diagnosing pneumonia.

During in-depth interviews, more than half of volunteers complained of the lack of supervision by BRAC field

staff: ‘Now there are less apas (female field programme officers) working and they cannot come any more. If

the apas came more often to the village then it would be good.’ They felt that if there were regular contact

between BRAC staff and the villagers, the community would be more motivated to listen to them. Some of

the rural mothers mentioned that they hardly saw any BRAC doctors or health volunteers in their village. A

health volunteer stated, ‘If more BRAC people came to mobilise in the village then there would more interest

in these programmes. This would be good for BRAC.’

Fifty-seven percent of volunteers lacked functional timers to count the breathing rates of their patients. Many

were annoyed that their complaints and requests for timers had gone unheeded, and some used their

watches. Several volunteers had requested flipcharts for explaining ARI to rural mothers.

Communities in transition
Because of the exposure to electronic media, non-governmental organizations and BRAC health volunteers,

perceptions are changing within the community, with women incorporating new understandings of illness

and health care practices. Sixteen percent of the mothers related how previously elders restricted them from

giving their children certain foods during illness and dissuaded them from going to medical facilities: ‘We

were told one should not eat cold food, oranges, eggs, beans, pigeon meat, hilsa fish … but we eat all of

this. We do not follow these old food restrictions. In the past, for 3–4 days we would not allow the child to eat

rice and vegetables, only salt and rice occasionally. Now we eat all of this and fresh foods. The health

volunteer is good and gives us good medicine.’ A few of the older women, however, were unhappy with the
marginalization of their old beliefs. One woman stated ‘If pneumonia happens we don’t allow the child to eat

cold rice, sweet pumpkin, gourd and goat’s meat. You see goat’s meat has oil and fat in it which children

should avoid, but nowadays people don’t follow this. They don’t listen …’

A number of mothers indicated the influence of the health workers in making them aware of the dangers of

withholding breast-milk when a child was ill: ‘In the past, only once a day, the child would eat only rice and

dry bread. We now know that the child needs to drink mother’s breast-milk and eat. Elders also said to eat

fruits but to avoid vegetables. The BRAC health volunteers help us now. What happened before – let’s

forget it. Now we eat a lot of vitamins and potatoes.’ Elders in the community were once considered the

main authoritative knowledge on care for the sick. The above narrative, however, reveals changing

perceptions and the role of BRAC health volunteers in influencing health care practices. This also applies

vice-versa: many volunteers felt that, now there was more acceptance of their work. They confessed that in

the past they had been subjected to harassment and degrading comments, whereas they were now

respected and often looked up to as the big apa (sister) or ‘little doctor’ in the villages. A volunteer narrated,

‘Now people say shaheb (a term of respect) and listen to us. People give us respect and they like us. Our

work is good and now the village people see there are so many changes. What we do is to help the village

people. We like our work and we enjoy it. Even if the child has fever or headaches they come to us. If we

have medicine we give it to them, and if we don’t, we send them elsewhere.’‘Elders now tell their daughter-

in-laws to bring the child to us.’‘In the past so many people would say so many things and now I don’t have

any problems as they call me all the time for assistance.’

Women volunteers are required to go on household visits against the norms of pardah. As a result,

comments such as ‘How can be-pardah (immodest, shameless) women go house to house and roam

around?’ and ‘What work do these type of women do?’ were commonly expressed by religious leaders and

other elders in the village. Simmons (1996) explains in her study on female family planning workers that

when women were recruited as health workers to the family planning programme in Bangladesh on a vast

scale, they gradually ingratiated themselves into the community by following traditional definitions of gender

while redefining pardah as a state of mind, thus shifting the importance from the external and physical rules

of seclusion to an internalized moral code of conduct. It is this ideology of ‘inner pardah’ that has prevailed in

most places, despite occasional opposition. Health volunteers link their acceptance in the villages to a

number of factors, such as the efficacy of the medicines provided, cheaper prices of medicines when given

by BRAC, timely treatment by volunteers and fewer pneumonia cases in the villages. As one worker

explained, ‘Pneumonia has really decreased, and mothers have become very aware. Before they would go

to the traditional healer but now they come to us for their health problems. They like us and trust us.’

Discussion
Recognition of the term ‘pneumonia’ was almost universal amongst rural mothers. A large number of

mothers in the qualitative study described mild and severe signs and symptoms of severe pneumonia. One

concern is that mothers may be unable to recognize the early symptoms, which may delay seeking

appropriate care. Beliefs in hot and cold humoral balances underlie their perceptions of respiratory

conditions. Other studies on ARI in Bangladesh, such as by Stewart et al. (1994), reached similar findings.

Reviewing ethnographic data on ARI understandings, Pieche (1998) pointed out that the local understanding

of hot and cold needs to be taken into account and is cause for some concern, as some children may

simultaneously suffer from cough (a ‘cold’ illness) and diarrhoea (a ‘hot’ illness), which may mislead mothers

into linking signs of ARI to gastrointestinal illnesses. As a result, they may remove both ‘hot’ and ‘cold’ foods

from the child’s diet, jeopardising the intake of nutritious food at a time when it is particularly needed.

ARI was also attributed to supernatural causes and ‘negligent’ mothers. In rural Bangladesh, the belief is

widespread that careless or inappropriate behaviour of the mother makes her vulnerable to spirit attacks,

thus ‘cooling’ her breast-milk and affecting the child. This is related to the notion that mother’s and child’s

health are closely linked, particularly when nursing (Zaman et al. 1997). Children in the first few weeks of

their life are believed to be vulnerable to spirit attacks, which may cause mothers to seek the wrong kind of

care. A study by the Department of International Health, Johns Hopkins University (1996) found that most

mothers believed that a ‘wind-carrying disease’ (alga batash) can kill their child, whereas pneumonia is

considered to be more manageable. Thus the interpretation of an illness and its causes determine the

choice of types of care, be it medical, traditional or spiritual.

The opinions of in-laws or other family members may delay seeking care from clinics. Ethnographic and

qualitative data from other ARI studies found that decisions were usually taken depending on the advice of

family members, particularly grandmothers and neighbours. The co-operation of the entire family was often

necessary if a child needed to be taken to a hospital or a clinic (Stewart et al. 1994; Pieche 1998; Parker

1990). This underscores the importance of including family members when educating rural women about the

possible dangers of severe pneumonia. Mothers sought different types of care, simultaneously or

sequentially, depending on the perceived severity of the disease. Numerous studies documenting health-

seeking behaviour in rural areas have found that the more serious the illness, the more frequent become

visits by mothers to various healers and doctors. Depending on the deteriorating condition of the child,

referrals or availability of hospital beds, mothers often switch from a kabiraj to a market doctor to a ‘big’

doctor (Stewart et al. 1994; Department of International Health, Johns Hopkins University 1996; Pieche

1998). Unless the child’s condition deteriorates dangerously, mothers rarely take young infants (less than

2 months) out for care, even if they have fever or breathing problems. For very severe cases of pneumonia,

the treatment of choice appears to be clinics or hospital care. Data on ARI suggest that mothers often wait

for 3 or more days before seeking care (Department of International Health, Johns Hopkins University 1996;
Zaman et al. 1997; Pieche 1998; Parker year?). We were able to determine whether care was sought for

children with breathing problems, but not on how early or late, nor in what relation to the child’s age. It is

crucial to know the duration of time before care is sought, as this will shed light on whether mothers are

paying attention to the earlier signs of pneumonia and promptly seeking care.

Health volunteers appeared to have knowledge on ARI; 96% were able to correctly identify breathing rates

and their association with pneumonia. With the intervention of BRAC’s ARI programme and other influences,

mothers are changing their health care practices. Finally, the programme strategy of creating strong links

among volunteers and the community ensures the successful dissemination of information, thus creating

awareness of ARI in rural areas.

Acknowledgements
We are grateful to AMR Chowdhury, Deputy Executive Director and Director of Research and Evaluation

Division, BRAC, for his continual guidance and support. We thank Fazlul Karim, Health Group supervisor,

Research and Evaluation Division, BRAC for his invaluable comments on this paper; and the Health and

Nutrition, Population Programme staff for their earlier critical comments on the draft. Safi Rahman Khan

carefully edited the paper. Finally we are very grateful to the rural mothers, health volunteers and BRAC

staff for bearing our questions with patience and humour – this study could not have been conducted without

their input.

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