Factors Associated With the Use of Traditional Medicine in Wolaita Zone,Southern Ethiopia

Study Design

A cross-sectional study was undertaken to explore the factors associated with the use of traditional medicine in Wolaita Zone, Southern Ethiopia. For the purpose of data collection, the study entirely relied on the qualitative research method, which helps to get rich information from research participants through in-depth exploration of their attitudes, behavior, and experiences (Dawson, 2007). The in-depth interview method was the qualitative method employed in the study to collect data from the target groups, which include traditional practitioners, patients, and caregivers. This method was used because it enables the researcher to gather thorough and richer information by letting the subject narrate his/her experiences in relation to the topic at hand (Kvale, 2009). The data have been analyzed thematically by identifying patterns and coding them from the data and reporting them appropriately.

Setting

Wolaita Zone is one of the different Zonal administrations found in Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS), Ethiopia. Wolaita is one of the most densely populated areas in Ethiopia with an estimated total population of 1.7 million in 2007(FDRE (Federal Democratic Republic of Ethiopia) Population Census Commission (2008). Wolaita Sodo town, the capital of Wolaita Zone, is located 385 km from Addis Ababa, the capital of Ethiopia.

The study was particularly undertaken in three Woredas (districts) in Wolaita Zone where traditional medicine was commonly practiced: Damot Woyde Woreda, Damot Gale Woreda & Sodo Zuria Woreda. Kebeles (the lowest administrative unit in Ethiopia) were purposively selected from each of these Woredas as final targets of the study. Accordingly, three Kebeles (Bilbo Bedesa, Mayo Kote &Tora Sedebo) were selected from Damot Woyde Woreda; two Kebeles (Gedo Bodity & Ode Choroke) were selected from Damot Gale Woreda; and one Kebele(Gununu)was selected from Sodo Zuria Woreda. The selection of these Kebeles was made in consultation with staff members at Woreda health bureaus and the selection criteria considered were availability of known traditional healers in the Kebeles and accessibility of the Kebeles to transportation.

Sample and Recruitment

Traditional practitioners who participated in this study were selected based on the Purposive sampling technique: Well-known traditional practitioners were selected with the help of community members as it was thought that they could provide reliable and rich data pertaining to the objectives of the study. On the other hand, patients (clients) and caregivers who took part in this study were selected based on the convenient (availability) sampling technique: clients and caregivers who attended treatment at the moment the researchers visited traditional healers were interviewed to generate the relevant data. A total of 45 informants—15 traditional practitioners, 20 patients and 10 caregivers—were recruited into the in-depth interview, in which semi-structured interview guide was used to delve into the very details of the factors associated with the use of traditional medicine in the study area. This sample size was determined based on the principle of data saturation; the researchers kept interviewing informants until data was saturated and no further information was emerging

Procedure and Instruments

Data gathering was conducted from March to April 2016. Two male researchers (authors of this article and assistant professors of sociology) were involved in the primary data collection, which took almost 2 months. Traditional practitioners who participated in the study were approached with the help of villagers who identified practitioners practicing in their neighborhood and showed the researchers the way to their residence. Some villagers were even eager to accompany the researchers to the compound of the traditional practitioners. Series of in-depth interviews, which took 30 min. on average, were conducted with selected traditional practitioners in a setting they arranged in their compound. Patients and caregivers who took part in the study were approached at the moment they come to traditional practitioners seeking treatment. Traditional practitioners were helpful in convincing patients and caregivers to participate in the study and arranging the setting where in-depth interview was conducted with them. The interview with patients and caregivers took 30 min. on average. Semi-structured interview guides, which were developed in English and then translated to Amharic and Wolaitigna (local languages), were used to conduct in-depth interviews. The researchers relied on note-taking as well as audio recording while conducting the in-depth interview.

Analysis

Data was analyzed using thematic analysis, “a method for identifying, analyzing, and reporting patterns (themes) within the data” (Braun & Clarke, 2006, p. 79). Field notes and audio files of interviews were transcribed in the local languages (Amharic and Wolaitigna) and transcripts were translated to English after they were checked for accuracy through repeated reading and revision of field notes and replay of audio files. The translated transcripts were repeatedly read to go through the coding process. Manual coding technique was used to organize the data by identifying themes and categories containing similar ideas. Coding of data continued until key themes were saturated and no further information was emerging. Two coders were involved in coding and organizing the qualitative data. The coders resolved overlapping themes and inconsistencies through regular meetings and discussions to reach common understanding. The analysis was based on themes of interview guides and emergent themes derived from the data itself.

Ethical Consideration

Study participants were recruited into the study after they were informed about the aim of the study and method of data collection. The researchers presented an official letter from Wolaita Sodo University to study participants indicating the appropriateness and authenticity of the research. Participation in the study was voluntary and participants were required to offer informed consent. Participants were clearly informed that they had the right to decline and withdraw from the interview at any time and to skip questions they did not want to answer. Participants were also assured confidentiality; they were informed that the data would be used only for the research purpose and that their name would be anonymous. Voice recording was made based on the consent of participants, and the researchers relied on note taking in cases consent was not obtained.

Perceived Inefficacy of Biomedicine

Patients’ perception of inefficacy of biomedicine to treat their particular condition was reported as a major factor in their decision to use traditional medicine. It was discovered that traditional medicine was not viewed as a top priority but rather as a backup plan in case modern biomedicine was deemed inadequate. Traditional practitioners reported that, in most occasions, patients resorted to traditional medicine when they perceived the failure of biomedicine in the cure of ailments.

Most patients come for treatment after they exhaust remedies in health care facilities. They seek solution here when they see no improvement in their health status after being prescribed hospital medicine. This mostly occurs in case of some medical conditions, such as intestinal parasites, where relapse is common after initial sign of recovery. Patients often complain about lack of effectiveness of the medicine prescribed by physicians and they request me to give them a long lasting solution. (Female practitioner interviewee, 45 years old)

In most instances, patients do not come here without attending health facilities. Most clients come to me after visiting pharmacies and hospitals. They come here when they fail to get remedies there. For example, patients diagnosed with hemorrhoid visit me frequently claiming that hospital medicine is not effective in treating their condition. Because relapse is common after they undergo surgery assisted by a physician, they want me to give them a medicine that can heal the disease once and for all. (Female practitioner interviewee, 25 years old)

Testimonies from patients also confirmed the above views. They argued that they transitioned to traditional medicine when they realized that there was no improvement in health condition after they were admitted to healthcare facilities.

I was diagnosed with intestinal parasite. I took the medicine but the condition relapsed after initial improvement. Thus, I decided to switch to traditional practitioners. The first time I come, the practitioner prescribed herbal medicine and appointed me to come after two weeks. I come now for the second time and I hope I will be completely cured after I take the medicine. (Male patient interviewee, 40 years old)

I’m diagnosed with menstrual problem. I attended treatment at different hospitals. They prescribed medicine but there was no cure or improvement in health status. Thus, I decided to come here wishing that I would be cured. Someone who got treatment here informed me of the effectiveness of the treatment. (Female patient interviewee, 37 years old).

Caregivers do also have similar views regarding the issue:

My son was injured while playing with friends. His right hand was broken and I took him to hospital. They told me that the problem was so serious that it couldn’t be cured. They said that amputation was the last resort. I rejected that and took my son to a bone-setter. I told her everything and plead her to get my son cured with the help of God. The condition of my son improved after he got the first treatment and there have been series of follow-ups since then. We are here for the fourth time and my son is almost cured thanks to God. (Female caregiver interviewee, 50 years old).

Perceived Incurability of Diseases With Biomedicine

The use of traditional medicine was influenced by the belief that biomedicine could not cure some medical conditions. It was reported that patients avoided healthcare facilities and visited traditional practitioners when biomedicine was believed to be incapable of healing their illnesses. Traditional practitioners identified common medical conditions for which patients sought their services conceiving that they could not get cure in healthcare facilities. One of such conditions is Sergeta (which literally mean rainbow), which, according to traditional belief, is caused when a person urinates facing the rainbow. According to traditional practitioners, a person suffering from Sergeta mainly presents with the symptom of change in the color of an eye and urine into the colors of rainbow. It was said that eye color was turned to red and green while urine color was altered to yellow. Patients preferred traditional medication for Sergeta mainly because it was believed that the condition was not known to biomedicine.

There is a commonly held belief that traditional medicine is the best source of treatment for Sergeta. Most often, patients with Sergeta visit me seeking treatment as they believe that hospital medicine cannot cure the condition. The most common medicine I prescribe is a chopped herb which is taken with Xawwa (a watery residue left after cheese is made) used as the liquid component. (Female practitioner interviewee, 48 years old)

Goromotte Ayanna (Evil Eye) stood out to be the other common medical condition for the treatment of which people preferred traditional medicine to biomedicine. It was noted that patients who suffered from Goromotte Ayanna frequently visited traditional practitioners believing in the effectiveness of traditional medicine to cure their condition.

Traditional medicine is well accepted source of treatment for some condition like Goromotte Ayanna, which isn’t believed to be cured by hospital treatment. Patients keep on visiting me seeking treatment for Goromotte Ayanna and I prescribe different types of medicine admitted through different routes. One of these medicines is a chopped herb with coffee used as the liquid additive and the other one is a stem bark which is burned to inhale the smoke. I also conduct prayer to get the evil spirit out of the patient suffering from Goromotte Ayanna. (Female practitioner interviewee, 50 years old).

Testimonies of Effectiveness of Traditional Medicine

The utilization of traditional medicine was also determined by witness testimonials which spread through different arrays of social networks. Exhortation of close acquaintances who gave testimonies of effective cure received from traditional practitioners led patients to access traditional medicine to get remedy for their condition. Successful treatment obtained from traditional practitioner was often witnessed by peers, neighbors, family members and community members.

I think one of the reason why clients decide to come to us is the influence of other clients who previously got cured receiving treatment here. There are plenty of occasions when I get clients through referral from other clients who give testimonies of the improvement of their health condition after receiving treatment from me. Old clients send new clients saying that “her medicine is effective. Get the treatment there. Don’t go to hospital or other healthcare facilities.” (Female practitioner interviewee, 30 years old)

I was seriously injured falling from a tree. People in my neighborhood who saw my mother worrying about my condition referred us to this woman saying that she is a well-qualified bone-setter who has previously cured plenty of similar cases. I’m here now hoping that I will be cured. (Male patient interviewee, 20 years old)

In some cases, rhetorical evidences of healing efficacy of traditional medicine initiated patients to utilize services located in remote and distant places. Patients who were lured by stories of effective treatment were compelled to travel long distance to visit the famous traditional practitioner that they were referred to.

Clients often make use of witness testimonials of other clients in their decision to visit me. One tells the other about the effectiveness of the medicine, and in such way of circulation of information people come to me. Some people even come from far places like Addis Ababa, Hawassa and Oromia sent by people who previously suffered similar illnesses and got successful treatment here. (Female practitioner interviewee, 40 years old)

Affordability of Traditional Medicine

Affordability of traditional medicine appeared to be one of the factors associated with patients’ decision regarding its use. The availability of traditional medicine at minimal cost as opposed to the unaffordable cost of biomedicine was reported as an important factor influencing patients to visit traditional practitioners rather than biomedical health units.

The rich people do not often prefer our service. It is in some rare cases that they come here. It’s poor people like me who commonly come here. The poor don’t have the money to visit different hospitals. They come here seeking treatment with least cost and hoping to be cured with the help of God. The maximum I ask them is 40 birr (1.5 $) for hemorrhoid and the least is 5 birr (0.2 $) for skin disease. (Female practitioner interviewee, 47 years old)

Traditional practitioners’ strong sense of belongingness to the community, which puts individual wellbeing rather than financial matters at the forefront of social relationship, was also found to influence patients’ choice of traditional medicine at the expense of biomedicine. As traditional practitioners give primacy for long established friendship and companionship rather than money, community members are more encouraged to access traditional medicine without worrying much about financial constraints. Traditional practitioners insisted that they had been willing to assist clients with their knowledge and skills at different occasions when clients did not afford to pay for the service they were rendered.

I believe that I should give much concern for the wellbeing of my fellows with whom I have lived for long sharing occasions of sadness and happiness. I am not as such concerned about money and I never hesitate to assist villagers who may not afford cost of treatment or don’t have anything to pay. I don’t feel disappointed for not receiving payment as the satisfaction I get when I see them cured is much more than everything that money could give. (Female practitioner interviewee, 55 years old)

Embarrassment to Present Medical Conditions to Biomedicine Practitioners

It was reported that people preferred traditional medicine for some medical conditions which they considered were embarrassing to present to biomedicine practitioner. Especially, patients with sexually transmitted diseases and hemorrhoids were reported to frequently visit traditional practitioners because of the fear to disclose such conditions appearing before a health worker.

It is common that people come here when they have some cases that they don’t want to tell physicians. For example, patients with hemorrhoid often visit me for treatment mainly because they don’t want to undergo surgery assisted by physicians at hospitals. (Female practitioner interviewee, 52 years old)

It was also asserted that female patients with gynecological problems often avoided healthcare facilities and visited traditional practitioners because they were frightened of revealing such conditions to a male practitioner in the healthcare facilities.

Elderly women with gynecological problems are among those clients who commonly visit me seeking treatment. They seem to feel embarrassed about telling their case and undressing in front of male physicians and I think that’s the reason why they often come to me. They say that they feel free to tell me everything about their condition and they choose to pay whatever I ask than going to hospital. (Female practitioner interviewee, 56 years old)

Traditional Medicine Instead of Biomedicine

It was found that study participants visited traditional practitioners when they perceived that biomedicine was ineffective in treating their condition. This was particularly evident in the case of some medical conditions, such as intestinal problems and hemorrhoid, where relapse was common after initial treatment in healthcare facilities. A Similar finding is apparent in studies conducted in Ethiopia and elsewhere in Africa, in which the majority of study participants were reported to transition to traditional medicine because of an initial treatment failure in healthcare facilities (Getnet, 2017; Sorsdahl et al., 2009; Wenzel, 2011). In a study conducted in Tanzania, exaggerated expectations of cure, greater perceptions of treatment failure by biomedicine and increased medical non-compliance was reported to lead many participants with chronic condition to resort to traditional medicine (Stanifer et al., 2015). However, some other studies have reported a contrasting finding that traditional medicine was a primary source of healthcare for the majority of participants, with biomedicine being the last resort to rely on in cases of traditional medicine inefficacy (Birhanu et al., 2012; Ondicho, 2015).

Cultural Belief as a Factor Influencing the use of Traditional Medicine

We found in this study that patients’ decision to use traditional medicine was influenced by the belief that some medical conditions could not be helped by biomedicine. It was reported that patients would not seek biomedical treatment for certain medical conditions, such as evil eye, which were assumed to be the domains of traditional medicine because of the deep -rooted traditional beliefs surrounding their etiology. The association between such kind of perception and the decision to use traditional medicine has been well established in previous studies conducted in Africa. In a study in Tanzania, preference to use traditional medicine for cervical cancer was reported to be a function of the belief that it could not be cured by biomedicine (Mwaka et al., 2015). In another study in Tanzania, it was reported that the belief that epilepsy and mental health conditions were caused by “evil spirits” led to a nearly ubiquitous use of traditional medicine for these conditions (Stanifer et al., 2015). In a study of cervical cancer in Ethiopia, the belief that biomedicine would not cure the condition- as it was believed to be caused by supernatural powers, the devil, and/or punishment for violating normal sexual behaviors-led affected women to seek treatment from traditional practitioners and use holy water(Birhanu et al., 2012). In a study in Kenya, it was reported that illnesses which were assumed to have arisen from the breaking of taboos, witchcraft, evil eye and spirit possession were seen to be best treated by traditional practitioners (Abubakar et al., 2013)

Locals’ Confidence in Traditional Practitioners as a Motivating Factor for Seeking Traditional Medicine

The findings from this study showed that feeling of embarrassment to present some medical conditions to healthcare facilities was an important factor influencing people’s decision to use traditional medicine. Patients with particular conditions, such as sexually transmitted illnesses and gynecological problems, were reported to be ashamed of presenting their condition to health workers, which pulled them into traditional medicine use. This compares with a finding from a study conducted in Tanzania which reported that people tended to avoid biomedicine and prefer traditional medicine for diseases associated with sexual transmission or other forbidden actions because of the privacy and confidentiality in traditional medical practices (Mwaka et al., 2015). In what seems to be similar with this, it was reported in a Bangladesh study that pregnant adolescent girls preferred to deliver at home because “they felt uncomfortable at the thought of being seen by male doctors in the hospital”( Shahabuddin et al., 2017, p.7). This situation hints the importance of re-emphasizing and assessing the service delivery system in biomedicine as it has to consider cultural appropriateness and acceptability.

Interpersonal Factors Influencing the Decision to Use Traditional Medicine

The impact of social factors on health seeking behavior has been well established in the literature. For instance, the social ecological model holds that interpersonal level factors- which refer to social influence from friends and family and norms within social networks- have major influence on health seeking behavior (Kumar et al., 2012). In line with this, the impact of interpersonal relations on individual’s decisions to use traditional medicine appeared to be evident in this study. In seeking treatment from traditional healers, individuals were reported to be influenced by people in their immediate social circle, such as friends, neighbors and family members, who claimed to have been cured by traditional medicine, and this finding is similar with what has been reported by previous studies from Ethiopia and elsewhere in Africa (Aderibigbe et al., 2013; Habte et al., 2017; Liwa et al., 2017; Ondicho, 2015; Oreagba et al., 2011). Ethiopian society has a well-developed collectivist sentiment, and social groups and networks are indispensable elements of social life. The scale and intensity of interpersonal relationship is very high, giving wide opportunity for information sharing and consultation on different matters of daily life, which has its own effect on decision making. Thus, the influence of significant others on individuals’ decision to use traditional medicine in the study area can be understood in light of this broader cultural pattern.

Income as an Important Factor Affecting the Utilization of Traditional Medicine

It is well documented in the health seeking behavior literature that economic factors have significant impact on utilization of health care services. Andersen’s well known behavioral model of health care utilization posits that individual and family income level is one of the different enabling factors determining health care utilization (Kuuire et al., 2015; Tolera et al., 2020). Similarly, the health belief model underscores that cost of health care services is one of the different perceived barriers affecting health seeking behavior: if a given mode of treatment is perceived to be costly, it is less likely that a decision for health seeking behavior will be made (Chandrika & Kanbarkar, 2017; Metta, 2016; Sheeran & Abraham, 2015). In the current study, cost of treatment was found to have its own impact on participants’ decision to seek health care from traditional practitioners. Traditional medicine was reported to be relatively cheaper, making it preferable by people who could not afford biomedicine. The relationship between affordability and traditional medicine use has also been consistently reported in a large number of studies conducted in Ethiopia and other African countries (Aderibigbe et al., 2013; Getnet, 2017; Gyasi et al., 2016; Liwa et al., 2017; Melesse et al., 2015; Mwaka et al., 2015; Ondicho, 2015; Sato, 2012; Stanifer et al., 2015; Tamuno et al., 2010).

Existing evidence suggests that several developing countries have introduced community based health insurance schemes as a way of financing healthcare and enhancing health service utilization (Mebratie, 2015). In 2011, the government of Ethiopia launched community-based health insurance (CBHI) schemes in 13 pilot Woredas in Amhara, Oromia, Southern Nations, Nationalities, and Peoples (SNNP), and Tigray regions (Yilma et al., 2014). The CBHI scheme, which target the very large rural agricultural sector and small and informal sector in urban settings (Feleke et al., 2015), aims to reduce financial barriers and improve access to health services by reducing the burden of out-of-pocket (OOP) expenditure (Badacho et al., 2016). Studies conducted to assess the impact of the pilot CBHI scheme reported that the implementation of the program has resulted in the reduction of health care costs and increase in the utilization of health care services from public facilities (Ethiopian Health Insurance Agency, 2015; Mebratie, 2015). Triggered by the pilot’s early successes, the government of Ethiopia has decided to scale-up the pilot to 161 Woredas (districts) all over the country in July 2013 (Feleke et al., 2015). Therefore, ensuring more affordable healthcare services in the way of CBHI scheme may lead to increased utilization of these services and reduced reliance on traditional medicine in the study area. However, given the fact that the use of traditional medicine is affected by multidimensional factors as discussed in earlier sections, it can be argued that affordability of modern healthcare services may not lead to reduced utilization of traditional medicine in a significant way and at greater scale.

In general, this study has managed to identify diverse factors affecting peoples’ use of traditional medicine despite the accessibility of modern healthcare system in the study area. In terms of conceptual boundary, the study is only limited to examine the factors that made traditional medicine as persistent and strong option to the community. And also methodologically, it entirely relied on qualitative approach with the aim to bring detailed description of the factors. The researchers suggest that future research endeavor has to accentuate on integrating both quantitative and qualitative approaches in order to identify patterns and make generalizations to have a better picture of the issue at hand. Besides, it will be worthwhile to look at the policy context within which traditional medicine is currently operating in order to identify the gaps and inadequacies in practice.