Perceptions and practices of modern and traditional health practitioners about traditional medicine in Shirka District, Arsi Zone, Ethiopia

Background: Traditional medicine is an ancient medical practice that is still widely used in prevention and treatment of various health problems in Ethiopia. Objective: To evaluate perceptions and practices of modern and traditional health practitioners about traditional medicine in Shirka District of Arsi Zone, Ethiopia. Methods : A cross-sectional study pertaining to the perceptions and practices of modern and traditional health practitioners was carried out in February 1999 in four peasant associations of Shirka District. Two types of questionnaires (with closed and open-ended questions) were prepared to assess the respective practitioners. Fourteen modern practitioners and 80 traditional healers were interviewed. Results : Most of the practitioners in both systems had used traditional medicine at least once in their lifetime. The indigenous knowledge surrounding traditional medicine is mainly conveyed verbally and to some extent still employs superstitious beliefs and harmful practices. To substantially reduce the drawbacks and promote its positive elements, both types of practitioners expressed their willingness to collaborate among each other and believe in the need for government support. Conclusion: The knowledge surrounding traditional medicine incorporates a number of harmful practices. To make matters worse, this knowledge is mostly conveyed verbally which may result in the inevitable distortion of original information leading to the expansion of more and more harmful practices. Therefore, the need for more effort of recording the knowledge is stressed. Government support and coordinated effort among the various institutions are emphasized for promotion and development of traditional medicine. [Ethiop. J. Health Dev. 2002;16(1):19-29] Introduction The term traditional medicine is used to explain the traditional medical practice that has been in existence even before the advent of modern medicine. It is still widely accepted and used in prevention and treatment of physical and mental disorders as well as social imbalance. Due to its intrinsic qualities, unique and holistic approaches as well as its accessibility and affordability, it continues to be the best alternative care available for the majority of the global population, particularly for those in the rural areas of developing Experience from many countries such as those in South East Asia suggest that integration of traditional and modern health care systems can solve much of the problems by providing basic health care services for the people in developing countries particularly the under served majority (2,3). In these countries, both systems are equally developed and supplement each other in the endeavor of achieving optimal health care coverage (4). Many of the traditionally used medicinal plants contain pharmacologically active compounds and are used in the preparation of both countries (1). _______________________________________ Ethiopian Health and Nutrition Research Institute, P.O.Box 1242, Addis Ababa, Ethiopia Perceptions and practices about traditional medicine 2 -----------------------------------------------------------traditional and modern medicines (5). Well over 25% of the pharmaceutical preparations in the world and more than 50% in the U.S.A. contain plant derived active principles (6,7,8). In Africa, traditional medicine is still widely practiced because of its socio-cultural appeal, accessibility, affordability, and effectiveness against some health problems (2,3,9). In contemporary health care delivery system, traditional medicine is found firmly established closing the gap in modern medical care (10). Ethiopian traditional medical system is characterized by variation and is shaped by the ecological diversities of the country, socio-cultural background of the different ethnic groups as well as historical developments which are related to migration, introduction of foreign culture and religion. Previous studies showed the existence of traditional medical pluralism in the country (1114). Based on historical data, Slikkerveer (14) identified three medical sub-systems in the highland of Eastern Hararge Zone (Babile area), namely, Cushitic Folk Medicine, Arabic Medicine and Amahara Medicine, which constitute the present indi-genous health care system in the area. These health care sub-systems have their own historical background, perceptions about health and illness, practices and types of healers. Even if there are differences, ethnomedicine of a country is an amalgamation of beliefs (religion and magic) and empirical practices (12-15). Based on the varied and extensive range of their practices, some authors have attempted to classify traditional healers as herbalists, surgeons, traditional birth attendants, spiritual healers etc. at local or even at country level. However, they found it difficult to clearly put them into distinct categories on the basis of their specialization and methods of treatment (12-16). Generally, knowledge of Ethiopian traditional healing methods is based on oral tradition or medico-magical and/or medico-spiritual manuscripts (11-13). Though the country has a long history of written language, at least in the Northern part, the first known traditional pharmacopoeia dates back to the 15 century (12,13). The vast knowledge surrounding traditional medicine is not fully documented and is conveyed from one generation to the next through word of mouth (11). Because of this and the aging of the healers (custodians of the information) as well as the persisting negative attitudes of traditional and modern medical practitioners for collaboration, ethno-therapy of the country faces uncertain future (11). In Ethiopia, traditional medicine still remains to be the only available health service system for the majority of the population (17-19). However, it is often postulated that modern health professionals consider it as a practice that serves no purpose and in their view its continued existence is merely because of lack of access to modern health care service (1,11). Such negative attitudes may possibly stem from misgivings about its biomedical values and probably from many other factors. The present study was therefore undertaken to explore the knowledge, attitudes and practices (KAP) of traditional and modern health practitioners with regard to traditional medicine in the contemporary health care delivery system in Shirka District. It is hoped that this will help in promoting positive elements of traditional medicine and its integration with modern health care practices as well as in formulating a policy that includes both practices for optimum health care coverage. Methods A cross-sectional study of perceptione and practices of modern and traditional health practioners was carried out in February 1999 in Shirka District of Arsi Zone. The altitude of the district ranges from 1200m to over 2500m above sea level. According to the 1997 census, the rural and urban population of Shirka was 114,879 (20). The ratio of males to females was equal and about 35% of Perceptions and practices about traditional medicine 3 -----------------------------------------------------------the rural households are considered poor (20). There is strictly limited supply of clean water in the rural areas of the district. Shirka has a health center and a clinic that are located in Gobessa and in one of the peasant associations (Hela Tereta), respectively. Both health facilities have serious shortage of medical facilities and medicines. Four peasant associations (PAs), viz., Hela Gelebe Goro, Hela Mekana Kersa, Hela Tereta, and Limu fi Tijo representing all the three agroclimatic zones (Kolla, Woyna Dega and Dega) which were involved in the present KAP study were selected in consultation with Shirka District Agricultural Office, Pilot Agricultural Development Scheme (PADS) and Istituto per la Cooperazione Universitaria (ICU). A total of 14 modern health professionals (all of whom were available in the district during the time of the investigation) as well as 80 traditional heath practitioners (all the prominent healers in the four PAs) were involved in the study. Social and demographic characteristics of the study subjects are shown in Table 1. The modern health practitioners were contacted at their respective working places, while the traditional healers were approached through the concerned peasant association officials in their respective PA offices. There was no any document indicating the number and type of traditional health practitioners in the district health office and the selected PAs. Two types of questionnaires, one for the modern and another for the traditional health care practitioners were used. The study questionnaire for the traditional healers contained the following main components: a) Personal data including name, address, age, gender, religion, educational status and ethnicity, b) Their knowledge and practice about traditional medicine which included source of knowledge, year of service, type of traditional medical practices (eg. herbalism, bone setting, and traditional birth attendance, etc.), main health problems for which they provide medicament, documentation of the history of their clientele, collaboration with traditional and modern health practitioners, their advice to their clientele to maintain health (such as personal and environmental hygiene, balanced diet, vaccination, etc.) as well as their belief and practice about harmful traditional health practices, c) Their attitudes such as preference for modern to traditional health care practice or willingness to convey their knowledge, co-operation with modern health practitioners (researchers) and integration of the two systems, reason for the acceptance of traditional medicine by the community, their views to improve and promote traditional medicine. The questionnaire for the modern health practitioners comprised of the following components: a) Socio-demographic characteristics of the study subjects such as age, gender, qualification and facility of assignment (clinic vs. health center). b) Knowledge, practice and attitude towards traditional medicine such as acceptance of traditional medical system by the practitioner and the community, current collaboration and future willingness to collaborate with healers, importance of training of the healers for promotion and development of the system, recommendations for promotion and integration of traditional medicine with the conventional system. Both questionnaires were semi-structured with closed and openended questions. Prior to filling the questionnaire, informed consent was obtained. The first and second authors conducted the in-depth interviews. The questionnaires were prepared in Amharic and most of the traditional healers responded in Oromifa. Limitations posed by language barriers between the interviewers and the traditional healers were solved by translators from Gobessa Health Center and Shirka District Perceptions and practices about traditional medicine 4 -----------------------------------------------------------Agricultural Office. Data were classified into categories and the results were presented in absolute figures and percentages. Results Socio-demographic characteristics: Table 1 shows selected socio-demographic characteristics of the study subjects. The gender distribution of modern health professionals was 12(85.7%) and 2(14.3%) for males and females, respectively. Of these, 64.2% were 20-30 years of age, 85.7% served > 10 years, and 78.6% were health assistants, 14.3% nurses and 7.1% druggist. The distribution of traditional healers by age category of >31 years accounted for 72(90%), males 70(85%), those who served >10 years were 55(69%); 58(73%) were herbalists and 22(27%) were bone setters, traditional birth attendants or those who exercise two or more of the practices (no spiritual healer was reported to be prominent in any one of the PAs). Moreover, 75% were Oromo, 23% Amhara; 57.5% Muslims and 42.5% were Christians. Illiterates, those who can read and write, and those who have had modern education at elementary or senior high school levels accounted for 47.5%, 27.5% and 25%, respectively. Perceptions and practices about traditional medicine 5 -----------------------------------------------------------Table 1: Socio -demographic characteristics of modern and traditional health practitioners, Shirka, 1999 Variables Modern health practitioners (N=14) Traditional healers (N=80) Gender Male Female 12(85.7) 2(14.3) 68(85.0) 12(15.0) Age in years 20-30 >31 9(64.2) 5(35.8) 8(10.0) 72(90.0) Years of service 0 9 >10 2(14.3) 12(85.7) 25(31.3) 55(68.7) Modern health practitioners by qualification Health Assistant Nurse Druggist 11(78.6) 2(14.3) 1(7.1) ------Traditional health practitioners by type of practice Herbalists Bone-setters Traditional birth attendants Two or more of the practices --------58(72.5) 10(12.5) 5(6.3) 7(8.7) Ethnicity Oromo Amahara Others ------60(75.0) 18(22.5) 2(2.5) Religion Muslim Christian ----46(57.5) 34(42.5) Educational status Illiterate Read and write Primary school Secondary school --------38(47.5) 22(27.5) 14(17.5) 6(7.5) Note: Numbers within parenthesis are percentages Practices and perceptions of modern health practitioners: About 79% of the modern health practitioners have visited traditional healer(s) at least once in their lifetime to seek treatment. Majority of them (71.4%) believed in the importance of traditional medicine for maintaining health. Among the practitioners, 28.6% came across patients who were advised (referred) by traditional healers to take medication in the clinic or health center, and 85.7% of them encountered patients who first visited traditional healers for the same illness episode. It was demonstrated that 78.6% of the modern health practitioners prefer modern health care services compared to the traditional. 86% of them were in favor of collaboration of modern and traditional practitioners, integration of the two systems, and the importance of scientific research into traditional medicine for its promotion and development. The majority (92.9%) indicated that the government should support traditional healers. Training of healers was strongly felt to be important for the improvement of the service and should focus on dosage determination and side effects, while 50% Perceptions and practices about traditional medicine 6 -----------------------------------------------------------stated hygienic preparation and administration of traditional medical preparations as equally important (Table 2). Practices and perceptions of traditional healers: Among the traditional healers, those who obtained their knowledge from their relatives, expressed willingness to convey their knowledge, and preferred modern medicine accounted for 56.2%, 78.7% and 77.5%, respectively. Furthermore, those who believe in the acceptance of traditional medicine by the community for a mere cultural or other reasons accounted for 98.7%, whereas 65% of them indicated efficacy of the preparations as the main reason behind its acceptance. About 97% of the healers stressed the need for training, 98% were willing to collaborate and 84% supported integration of modern and traditional medical systems to improve health care coverage of the country (Table 3). As depicted in Table 4, only 7.5% of the traditional healers collaborated with other Perceptions and practices about traditional medicine 7 -----------------------------------------------------------Table 2: Modern health practitioners perception and practice about traditional medic ine, Shirka, 1999 Questions Response (N=14) Do you accept traditional health care practice?