Public Health in Ghana :

Traditional Medicine, Illness Perceptions, and the Health-Seeking Behaviors of Rural Women

Field of Interest

            There is a great disparity in the quality of health care available to the world’s rich and poor populations. While the developed world has curbed most infectious diseases, they are still widespread in impoverished countries. Health inequity is particularly evident in Sub-Saharan Africa. Nineteen of the twenty countries with the highest child mortality rates are in Africa [1]. Public health organizations are working hard to alleviate morbidity throughout Africa, however they face setbacks from poverty, the lack of basic infrastructure, political instability, and cultural beliefs that can inhibit implementation of Western health management protocols. Public health progress has also been impeded by the human immunodeficiency virus (HIV) epidemic.

            Over the past few years, I have developed a strong interest in Sub-Saharan African public health issues. My passion for Africa led me to Kenya for two months during 2004, where I worked in a rural hospital, assisted with medical clinics, and collaborated with a women’s community development program to promote HIV awareness.  This experience helped to clarify my educational and career goals. I have decided to complement my major in Molecular and Cell Biology (MCB) with a minor in African studies. After graduation, I plan to pursue a combined MD/MPH degree, with the long-term goal of working with public health projects in Africa.

I have already completed the requirements for my major in Molecular and Cell Biology and I have been doing research with Dr. David Knecht for more than a year. I enjoy laboratory research, and I will write my honors thesis for MCB on this work. However, I would also like to learn about the public health applications of science. With my University Scholar project I will pursue these public health interests.

Project Proposal

Introduction

            Traditional beliefs and practices shape health-seeking behaviors throughout much of the developing world. The World Health Organization (WHO) reports that 80% of African populations rely on traditional medicine for their primary health care needs [2].  For many people, clinics and hospitals are inaccessible and unaffordable. A study in Uganda found that the ratio of traditional practitioners to the overall population was as little as 1:200, compared to 1:20,000 for allopathic practitioners [2]. As a result, populations often rely on local healers, traditional birth attendants, and herbal treatments. People also self-prescribe pharmaceuticals available at local chemists for malaria, infections, and other common illnesses. Misuse of these drugs is common and poses a significant health risk [3].

In addition to issues of affordability and accessibility, the way people think about illness and its causes plays a role in health-seeking behaviors. Local perceptions may be obstacles to the curing process, especially when they influence illness recognition. A recent study in Ghana found that serious danger signs for child dehydration, fever, and respiratory infection were classified as ‘not-for-hospital’.  The study found that these illnesses were “considered untreatable using modern medicines” [4]. Such beliefs reflect the fact that Western care often overlooks cultural sensitivities. For this reason, even when biomedical care is an option, traditional medical practitioners and herbal remedies may seem more appropriate. In fact, a study in rural Ghana found that biomedical care was sought for only 50% of illnesses that were considered life- threatening [4].  From this and similar research, it is clear that the recognition and perception of illness on a community level must be examined in order to promote widespread usage of available Western care.

Health-seeking behaviors often employ both Western and traditional medical strategies, a practice referred to as medical pluralism. While many people feel there is a dichotomy between Western and traditional medicine, it is clear that both practices have some benefit. Vaccination campaigns against tuberculosis, measles, polio, yellow fever, diphtheria, whooping cough, tetanus, and hepatitis B have dramatically reduced the prevalence of these diseases in Ghana [5]. Some traditional practices also have proven medical validity. In a review of current research, the WHO Traditional Medicine Strategy found that 34% of studies on herbal medicine showed increased health benefits post-treatment when compared to placebos [2]. This and similar data point to a need for collaboration between national health organizations and traditional medicine practitioners, in order to increase access to effective affordable health care in resource-poor communities.

The complex relationships between biomedical health initiatives and traditional medicine, cultural standards, and other local practices have become evident in efforts to promote maternal and child health in Ghana . Women’s health-seeking behaviors deserve significant study. Empowering women has been recognized as an important means to combat child poverty and disease [6].  In Ghana , traditional medical knowledge is spread orally between women in rural illiterate communities [7]. Much research needs to be done in regard to the accuracy and efficacy of common health-seeking practices. The results of such research are important for public health officials to consider, especially as they develop new national health policies [8].

            One of the goals of a project called RIING (Research to Improve Infant Nutrition in Ghana ) is to elucidate the factors that influence infant-feeding practices in Ghana [9]. Through this research, RIING hopes to gain knowledge about how the health and growth of Ghanaian children can be improved. They also investigate factors involved with mother-to-child HIV transmission. RIING is funded by the United States National Institute of Health. Researchers involved with RIING come from Iowa State University, the University of Ghana, Emory University and The Noguchi Memorial Institute for Medical Research, as well as the University of Connecticut. RIING also works with a variety of local hospitals and health organizations in Ghana .

Specific Aims

            The aims of this project are: (1) To investigate local illness perception and traditional healing practices in rural Ghana; (2) To determine the implications of these cultural beliefs for biomedical health care efficacy; and (3) To conduct primary field research on the use of traditional medicine in Ghana, by working with RIING.

Methods

First of all, literature-based research on the prevalence of traditional medicine and its usage in Ghana will be completed. The impact of medical pluralism on overall health status will be investigated. There is significant literature available on this topic, especially within the disciplines of critical medical anthropology and health policy. Dr. Luci Fernandes, in the Department of Anthropology, has offered her expertise in finding appropriate resources on ethnomedicine. This research portion of the project will be carried out under the guidance of Dr. Josef Gugler, in the Department of Sociology. Dr. Gugler has extensive experience living and working in Sub-Saharan Africa and has focused much of his research on development in poor African countries.

Secondly, the above thesis will be complemented by fieldwork in Ghana . This research will be advised by Dr. Rafael Pérez-Escamilla in the Department of Nutritional Sciences, and will be carried out with RIING. Dr. Pérez-Escamilla has shared this proposal with his colleagues in Ghana , and they are willing to facilitate my research. My first semester as a University Scholar will involve intense preparatory research and planning for this fieldwork. I will then work with RIING during July and August of 2006. Hopefully, funding will be available through a UCONN Summer Undergraduate Research Fund grant. Otherwise, the project will be self-funded. Institutional Review Board approval has been secured for all of RIING’s current projects. However, my research will need to be approved by Human Subjects Review. Dr. Pérez-Escamilla has agreed to help me secure approval. There is adequate time to obtain this consent before my fieldwork in Ghana is carried out this summer.

In Ghana , qualitative research on the prevalence of traditional medicine and its implications for health will be completed. Specifically, this study will focus on the health-seeking behaviors of women of childbearing age in the rural Manya Krobo district. A series of in-depth interviews will be completed, with the help of a local interpreter.  Women will be asked about their knowledge of and use of traditional medicine. Specifically, interviews will address the use of traditional healers and herbal medicines. Questions will be aimed at determining which illness symptoms are thought to require traditional care as opposed to Western care.  The outcome of health-seeking episodes will also be investigated, in order to qualitatively examine the efficacy of traditional treatments. Additionally, two focus groups will be held, so that larger groups of women can be reached. Other interviews will be completed with key informers, including an herbalist, a traditional birth attendant, a village chief, a local chemist, and a Western-trained health care provider. Current studies have shown that each of these community members have roles in rural health-seeking behaviors for a wide range of illnesses, including malaria, malnutrition, respiratory infection, infertility, and HIV [4, 10].

The above two projects will be combined into a thesis paper that presents and analyzes my results. This thesis will enhance current knowledge about the use of traditional medicine in Ghana . The results will be submitted for publication in a peer-reviewed medical anthropology journal. Lastly, both my independent research and my on-the-ground experience in Ghana will be supplemented by a plan of study that deviates significantly from a standard MCB major. For a complete description of coursework please see the “Plan of Study” section.

Rationale and Justification

A thorough appreciation of local health perceptions and the prevalence of traditional medicine in Ghana is crucial for the delivery of effective medical care. The results of this research may be pertinent to humanitarian service and public health initiatives in Ghana .

Plan of Study

My plan of study includes courses spanning a wide range of disciplines relevant to Africa and public health. As some of these are graduate classes outside of my major, it may be difficult to enroll if I am not selected as a University Scholar.

First of all, I will take classes that complete my African Studies minor. These include courses on modern African history (HIST 223) and economic development (ECON 247). These subjects will provide an introduction to the current political and economic environment in Africa. I will take Intermediate French II (FREN 164), which fulfills the language requirement for the minor. During both semesters of my senior year I will take independent study credits in African Studies. This will enable me to devote significant time toward researching and writing my University Scholar thesis.

In addition, I will take Humanitarian Services Administration (HSA) courses offered by the College of Continuing Studies. These courses are offered in the Masters of Professional Studies Program and prepare graduates to work in humanitarian and medical fields related to development, refugee aid, and disaster relief. I will take HSA 305, which investigates economic, social, and environmental sustainability. I will also take HSA 303, a course that examines the relationship between poverty and public health, which is clearly pertinent to both my research project and career plans. Furthermore, in Humanitarian Issues (HSA 312) I will learn about the role of national, international, and non-governmental organizations in global human development.

My plan of study also includes courses within my major (MCB) relevant to public health. A course in virology will provide a detailed introduction to the pathology of HIV and other viral diseases. I will also take pathogenic microbiology (MCB 233), which is particularly pertinent to health initiatives in developing countries.

I have finished all of my general education requirements except for a computing course, which will be fulfilled by MCB 221C, Introduction to Molecular Evolution and Bioinformatics. In this class, I will learn how to analyze data with a wide range of scientific computer software. This knowledge is also important to public health research, which involves significant statistical data analysis. The course will also enable me to complete a minor in Bioinformatics.

Furthermore, I will complete my current independent research project with Dr. David Knecht. I will write a thesis on this work, which will be in addition to my University Scholar thesis. This will be carried out through independent study and senior research thesis courses in the MCB department.

Proposed Schedule of Classes                                 

Spring 2006                                                                 Fall 2006

PNB 275 Enh. Human Phys. & Anat. (4)                      MCB 211C Int. to Mol. Evol. and Bioin. (3)    

MCB 246 Virology (3)                                     MCB 299 Independent Study (3)                    

HIST 223 History of Modern Africa (3)                        MCB 322 Human Disease (3) 

HSA 305 Principles of Sustainability (3)                        MCB 233 Pathogenic Microbiology (4)

ECON 247 Economic Development (3)                        AFRI 299 Independent Study (3)

                                    HSA 303 Poverty and Public Health (3)

Summer 2006                                                               Spring 2007

AFRI 293 Foreign Study (3)                                         MCB 292W Sr. Research Thesis (3)

                                                                                    MCB 219, Developmental Biology (3) 

                                                                            SOCI 258W  The Developing World (3)

                                                                        FREN 164 Intermediate French II (4)

                                                                                    AFRI 299 Independent Study (3)

                                                                                    HSA 312 Humanitarian Issues (3)        

Conclusions

            If I am selected as a University Scholar I will be able to invest the remainder of my time at UCONN studying public health in Africa. This is a topic that I feel very strongly about. In Kenya , I saw first hand the need for improved health care. I witnessed men, women, and children suffer and die from preventable diseases. I have found that there are few structured opportunities for a UCONN undergraduate student to study public health. In this University Scholar proposal I attempt to bring together these few opportunities and supplement them with independent research.

References

1.      World Health Organization. “World Health Report.”(2003) WHO, Geneva, Switzerland .

2.  World Health Organization. “Traditional Medicine Strategy 2002-2005.” (2002) WHO,                         Geneva, Switzerland .

      3. Wolf-Gould, C., Taylor, N., Horwitz, S., and M. Barry. “Misinformation about                                       medications in rural Ghana .” Social Science and Medicine. 33.1 (1991):83-9.

4.  Hill, Z., Kendall, C., Paul, A., Betty, K., and E. Adjei. “Recognizing childhood illnesses                          and their traditional explanations: exploring options for care-seeking interventions                               in the context of the IMCI strategy in rural Ghana .” Tropical Medicine and                                           International Health 8.7 (2003): 668-676.

5. Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Research                                 (NMIMR), and ORC Macro. 2004. Ghana Demographic and Health                                               Survey 2003. Calverton, Maryland: GSS, NMIMR, and ORC Macro.

 6. United Nations Children’s Fund. “State of the World’s Children 2005.” (2005) UNICEF,                            New York.

 7. Yeboah, T. “Improving the provision of traditional health knowledge for rural communities in Ghana .” Health Libraries Review 17 (2000): 203-208.

8.      Tsey, K. “Traditional medicine in contemporary Ghana : a public policy analysis.” Social            Science and Medicine. 45.7 (1997):1065-1074.

 9.  The RIING Project, Research to Improve Infant Nutrition in Ghana . 2005. Iowa State University. 26 Oct. 2005. <http://www.fshn.hs.iastate.edu/riing/>

 10.  Dzator, J. and J. Asafu-Adjaye. “A study of malaria care provider choice in Ghana .” Health Policy. 69 (2004): 389-401.