Our findings suggest that local understandings about who gets sick, why, when, how illness spreads and how it can be prevented are varied, and therefore could contribute to the transmission of respiratory infections. Responses from our participants highlighted a contrast in people's minds between contracting a respiratory illness and its transmission and prevention. We have linked local interpretations of disease transmission to both the cultural model of hot-cold imbalance and the bio-medical understanding of transmission of respiratory infections. Understanding communities' perception of how an individual's behaviors can be linked to infectious disease transmission can help us engage in meaningful communication regarding behavior change. Well-designed and targeted communication interventions are more likely to be effective if they are theory-based or if they can be linked to a theoretical underpinning of established determinants of behavior and behavior change . We could use these findings to develop culturally compelling behavior change interventions to interrupt respiratory disease transmission .
Informants related their individual experience of catching a cold with the hot-cold imbalance concept where health is maintained through equilibrium, or not having an internal imbalance in the body caused by an excess of either hot or cold. For example, keeping the body warm or avoiding cold elements can maintain internal equilibrium . Our findings related to catching cold are similar to other anthropological and qualitative studies conducted on childhood acute respiratory infection during the 1990s. These studies suggested that people related the occurrence of acute respiratory infection to imbalances of hot and cold in the body, rather than to an infectious agent that can be transmitted from person to person [10, 11, 17–21]. For example, Bangladeshi mothers avoid feeding cold foods to prevent child from catching pneumonia , and Filipino mothers withhold breast milk from their infants after they have been exposed to cold weather, to prevent the child from catching a cold . Identifying and understanding examples of these cultural perceptions could help in the development of communication messages to develop positive social norms related to respiratory hygiene behavior.
For transmission and prevention, most of the informants' responses aligned more closely to the bio-medical understandings of transmission that originated in the germ theory . For example, although informants may not know that Streptococcus pneumonae and Influenza virus are some of the organisms responsible for pneumonia and influenza, and that this is where the common names of the illnesses were derived from, our informants were aware that respiratory infections were contagious and mentioned avoiding the cough, breath, spit and blood from an infected person. Communication messages could build on our informants' understanding of effective prevention measures.
About the prevention of respiratory infections, the community members had some perceptions that matched with the cultural model of hot-cold imbalance. Nevertheless, community members also had perceptions that aligned with the bio-medical concept as well. Though they perceived some 'good behaviors' were related to respiratory hygiene that could prevent respiratory infections, we observed that they did not translate those into practice. Informants told us that covering nose and mouth or turning the face away was a way to prevent the spread of infection. Nevertheless, almost all shopkeepers and customers we observed in the markets coughed into the air. In another study, where school children's respiratory hygiene behavior was observed, 956 (85%) of 1126 events, children coughed or sneezed into the air . We speculate that the people we observed were not aware or did not value how their behavior could affect their health and that of others. Also many adults and young people do not have the habit of practicing respiratory hygiene, perhaps due to long-term exposure to an unhygienic physical and social environment. Communication messages that remind people to practice these 'good behaviors' on a daily basis could make positive changes in the overall environment.
A limitation of this study is that we collected data from only one urban site and one rural site. Nevertheless, the sites were typical of Bangladeshi communities, and we enrolled a heterogeneous mixture of informants from a variety of social groups. As our groups of informants had similar perceptions related to prevention and transmission, our findings from this formative study provide a foundation to design communication materials promoting respiratory hygiene practices that might be applicable for both rural and urban settings. Although we could not recruit informants from all geographic areas in the study sites for in-depth interviews and focus group discussions with adult males and females, we systematically selected participants from every 10th household in order to select them to diminish the bias of sample selection. Focus group discussions were limited in scope to fully explore complex beliefs. Nevertheless, we also conducted numbers of in-depth interviews, which were more appropriate to explore community beliefs. In focus group discussions, some participants were not vocal, and while the group facilitator tried to encourage them, this may have led to bias. Nonetheless, we triangulated our findings from in-depth interviews, focus group discussions and observations.
Our understanding regarding the perceptions about why a person catches a cold and how respiratory infections are transmitted can be used to frame communication messages. Health professionals could use local terms to explain transmission of respiratory infections from the bio-medical perspective to highlight how changes in behavior could prevent transmission. These messages could make people more conscious about respiratory hygiene and then motivate them to follow their identified 'good behaviors' on a regular basis. Since the informants indicated that it is not feasible or practical to wash hands after every event of coughing and sneezing, our communication message could be to ask people to cough and sneeze into their upper arm or sleeve. We suggest piloting these messages with a variety of communication approaches and channels with all community members to reduce respiratory infections.