Department of Psychiatry, Muhimbili University College of Health Sciences of the University of Dar-es-Salaam, Tanzania
Section of Epidemiology, Institute of Psychiatry, London, UK
Correspondence: Mdimu C. Ngoma, 187 Parrswooodd Road, Didsbury, Manchester M20 4RR, UK
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To determine and compare the prevalence of common mental disorder among, and the characteristics of, those attending primary health care clinics (PHCs) and traditional healer centres (THCs) in Dar-es-Salaam.
Method The Clinical Interview Schedule Revised was used to determine the prevalence of mental disorders in 178 patients from PHCs and 176 from THCs, aged 1665 years.
Results The prevalence of common mental disorders among THC patients (48%) was double that of PHC patients (24%). Being older, Christian, better educated, and divorced, separated or widowed were independently associated with THC attendance. None of these factors explained the excess of mental disorder amongTHC attenders.
Conclusions The high prevalence of mental disorders among THC attenders may reflect the failure of primary health care services adequately to detect and treat these common and disabling disorders. Traditional healers should be involved in planning comprehensive mental health care.
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INTRODUCTION |
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METHOD |
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Setting
The study was conducted in Ilala district of Dar-es-Salaam, in Tanzania.
Two types of health care providers were involved: primary health clinics and
traditional healer centres.
Primary health clinics
Mnazi Mmoja health centre and Amana district hospital were selected. These
were the only local biomedical providers, where medical assistants and nurses
manage patients. Patients can choose freely which of the two to attend.
Traditional healer centres
In traditional healer centres patients are managed by herbalists, diviners,
herbalist-ritualists and faith healers. Traditional healers in modern Tanzania
are known as fundi (engineers or technicians), but were formerly
known as waganga wa kienyeji or waganga wa jadi (traditional
practitioners or doctors). They can be grouped into four categories, but with
some overlap.
Traditional healers in Tanzania are typically inducted through one of four routes (Gessler et al, 1995): inheritance within a family kinship; ancestor-spirits (midzimu) contacted through dreams; the experience of having an illness cured by traditional medicine; a personal decision, followed by a period of apprenticeship.
Normally there is no special procedure to see traditional healers. Patients refer themselves. Some are referred by one healer to another, or transfer themselves. Tanzanians commonly seek biomedical and traditional treatments simultaneously or alternately, when one or the other fails to produce quick results.
In 1995 Tanzanian traditional healers formed an association called Chama cha Waganga na Wakunga wa Tiba Asilia Tanzania (CHAWATIATA), the Tanzania Traditional Health Practitioners Association. The work of registering healers has begun through CHAWATIATA but no comprehensive, formal register exists to date. For the purposes of this study, eight healers (two herbalists, two herbalist-ritualists, two diviners and two faith healers) were selected randomly from a sampling frame of traditional healer centres drawn up by the district CHAWATIATA chairman. This was constructed to include only those (the majority of healers) who had affordable consultation fees and a sufficient number attending daily to allow the study to be completed quickly. Fees for treatment depend on the illness or problem; for AIDS, cancer, diabetes and other illnesses that involve the control or removal of evil spirits, the fee is normally high. Njenga (2002) reported a growth of traditional healer practice in Dar-es-Salaam, mainly less well apprenticed healers. Conversely, traditional healers seemed to be becoming less common in rural areas. The rural phenomenon of payment in kind is not common in urban areas, as the healers operate in a cash economy and need to generate income. Patients usually pay for diagnosis and treatment separately.
Participants
Sample size was estimated to give 80% power to detect a hypothesised
difference in the prevalence of common mental disorder of 15% or greater
between attenders at primary health clinics (among whom we predicted a
prevalence of 35%, after Gureje et
al, 1992) and traditional healer centres (a predicted
prevalence of 50%, although two-sided tests were used throughout). Under these
assumptions, a sample of 182 participants in each setting was required. The
aim was to achieve a representative sample of clients for each service, by
sampling from consecutive attenders. Sampling ratios at the two settings
differed owing to variation in the number of people attending each day. A
sampling ratio of 1:4 was used at the primary health clinics. The daily
case-load at the traditional healer centres was lighter so all those attending
were invited to participate. All those aged 1665 years, who were
resident in the defined area of study and who spoke Swahili were considered
eligible. Only those who suffered from an acute medical illness of a severity
that rendered interview impractical were excluded.
Measures
Socio-demographic questionnaire
Gender, age, religious affiliation, marital status, educational attainment,
number of children, occupational status (employed or unemployed) and
socio-economic status (accommodation type, whether cash saving or in debt, and
ability to buy food in the past month) were recorded through completion of a
questionnaire.
Explanatory model interview
The Short Explanatory Model Interview (SEMI;
Lloyd et al, 1998)
was used to elicit patients attributions regarding their presenting
complaints, their previous help-seeking behaviour and their expectations
regarding the index consultation. The SEMI, which combines open-ended
questions with a structured coding frame, has been used successfully in a
variety of countries and cultures, including southern Africa
(Patel et al,
1995).
Standardised psychiatric interview
A fully structured clinical interview, the Clinical Interview Schedule
Revised (CISR; Lewis et
al, 1992), was used to elicit information on symptoms of
common mental disorder during the week preceding interview. A previously
validated cut-off score of 12 or more was used to identify those with a common
mental disorder (Lewis et al,
1992). At the end of the assessment ICD10 diagnoses
(World Health Organization,
1992) were generated from CISR data using the Programmable
Questionnaire System (PROQSY; Lewis,
1992). The CISR was designed for use in primary care in the
UK and has not been used before in Tanzania. However, it has proved to be a
feasible and valid instrument for the detection of common mental disorders in
Zimbabwe (Patel & Mann,
1997) and Sri Lanka
(Wickramasinghe et al,
2002), and has also been used successfully in India
(Patel et al, 1998),
Taiwan (Liu et al,
2002), Chile (Lewis et
al, 1992) and Thailand
(Silpakit, 1997). It was
translated into Swahili by M.C.N.; three bilingual professionals unacquainted
with the original English version completed its back-translation. On the basis
of the back-translated text and the original version, M.C.N. then developed a
consensus version in Swahili with advice from an independent Tanzanian
psychiatrist. Content and technical equivalence were examined during the
process of translation to ensure that the original content had not been
significantly distorted. The interrater reliability of the Swahili CISR
was estimated before data collection by observer co-ratings of 20 patients
(M.C.N. and research assistant), one interviewer interviewing the patient and
scoring the CISR, the other independently rating. The mean kappa value
across all CISR items was 0.76 (range 0.591.00).
Data analysis
Data were analysed with the Statistical Package for the Social Sciences,
version 10.0 (1999). We compared the prevalence of common mental disorder
(CISR score 12 or more) between primary health clinic and traditional
healer patients, and compared the characteristics of the two groups.
Pearsons chi-squared test was used to compare categorical variables,
and a chisquared test for trend was used to compare ordered categorical
variables. All significance tests were two-tailed. We sought to identify
independent predictors of use of one service or the other using logistic
regression with the type of service as the dependent variable. In a further
logistic regression model, with common mental disorder as the outcome, we then
adjusted the association between attendance at a traditional healer centre and
common mental disorder for any independent predictors of traditional healer
attendance. Finally, we compared participants in the two settings for
attributions regarding the presenting problem, for its chronicity, for the
extent of previous consultations with biomedical providers for the same
problem, and for ICD10 diagnoses and symptom profiles.
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RESULTS |
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Prevalence of mental disorder and patient characteristics
Forty-two of 178 primary health clinic patients (24%) and 85 of 176
traditional healer patients (48%) scored 12 or more on the CISR, and
were thus classified as having a common mental disorder. The 95% confidence
intervals around the observed difference in prevalence of 25% were 15% to 34%
(2=22.408, d.f.=1, P<0.001). Women outnumbered men
in both settings (Table 1).
Attenders at the traditional healer centres were older and better educated
than the primary health clinic patients. They were more likely to be employed,
to be saving money and also to be in debt. They were more likely to be
Christian, to be divorced or separated and to have children. In a logistic
regression analysis, being older, Christian, better educated and divorced,
separated or widowed were all independently associated with traditional healer
centre attendance. After adjusting for these patient characteristics the
association between attendance at a traditional healer centre and common
mental disorder (crude odds ratio 3.03, 95% CI 1.924.76) was little
changed (adjusted odds ratio 2.99, 95% CI 1.775.05).
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Further exploratory analysis revealed large differences in the pathways to care and attributions at presentation among patients in the two settings (Table 2). Those attending traditional healers were twice as likely to be unable to say what was wrong with them, and proportionately less likely to present with a distinct physical illness or specific physical symptoms. In around 10% of those attending traditional healers there was a supernatural attribution, but no attenders at primary care made such an attribution. For attenders of traditional healers their main complaint was more likely to have been chronic, and they were more likely to have previously consulted several biomedical care providers for the same complaint. These last two effects were more prominent among those without common mental disorders compared with those with such disorders; the interaction term was not, however, statistically significant in either instance.
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Associations with common mental disorder
Neither gender, age, education nor any of the indicators of socio-economic
status was substantially or statistically significantly associated with common
mental disorder in either setting. An exploratory multivariable analysis also
did not identify any independent associations with potential risk factors.
Those identified as cases by the CISR assessment were more likely to
have had presenting complaints of more than 1 years duration (90.0%
v. 59.6% for non-cases, 2=11.4, P=0.001) and
to have consulted previously with four or more practitioners for the same
complaint (35.0% v. 13.2% for non-cases,
2=17.3,
P<0.001).
Phenomenology and diagnoses
Table 3 shows the proportion
of patients in each setting reporting clinically significant symptoms (two or
more symptoms) in each of the 14 domains of the CISR. Symptom profiles
were quite similar in the two groups. Overall, the most common symptoms were
fatigue, obsessions and depression among primary health clinic attenders, and
obsessions, worries regarding physical health and depression among traditonal
healer centre attenders. A similar pattern was seen among cases. Panic and
compulsions were rarely reported in either setting. Forty-seven participants
(26%) in the primary health clinic group and 87 participants (49%) in the
traditional healer group were allocated an ICD10 diagnosis by the
PROQSY computer program. In both settings mixed anxietydepressive
disorder accounted for slightly over half of all ICD10 cases.
Depression and obsessivecompulsive disorder were relatively more common
in the traditional healer group, and phobias were more common in the primary
health clinic group.
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DISCUSSION |
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Study strengths
The main objective of the study was to determine the prevalence of common
mental disorders among users of traditional healers and primary health
clinics. Traditional healers are frequently ignored in studies of help-seeking
and care provision although they cover the health needs of a substantial
proportion of the African population
(Gessler et al, 1995).
The selection strategy for the traditional healers was critical to the
avoidance of bias. Purposive sampling would have led us to well-known and more
expensive traditional healers, who were also likely to be familiar with
biomedicine. Wealthy, better-educated clients might have been overrepresented
with respect to the clientele of the less prominent healers providing the bulk
of the service in this sector. An attempt was made to reduce this bias by
asking the district chairman of CHAWATIATA to provide a complete list of
healers with affordable (middle-range) consultation fees and at least three
patients attending per day. The healer sample was then selected at random from
this list.
The CISR was used for the first time in Tanzania in this study.
However, as noted earlier, this instrument has proved to be a feasible and
valid assessment of common mental disorders in a variety of other developing
country settings, including Zimbabwe. Efforts were made to reduce
ascertainment bias arising from cultural and clinical invalidity through
scrupulous translation and back-translation procedures. The advice of an
independent local psychiatrist at the final stage of translation should have
increased the local validity of the Swahili version. Previous research has
shown that if careful attention is given to translation and conceptual
validity, etic instruments can be used with reasonable confidence across
cultures.
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Study limitations
The study was conducted in the capital city, Dar-es-Salaam, and its
findings may not be generalisable to the mainly rural and agrarian population
of Tanzania. Moreover, only two primary health care centres and eight
traditional healers (two from each of the four main categories of healer) were
included. Despite the random selection we cannot claim that this is a truly
representative sample of all healers in Dar-es-Salaam, nor by extension that
the participants necessarily represent all those who use such services. Biases
might have resulted that could explain the differences in prevalence of common
mental disorders between the two settings. Nevertheless, we believe that the
study provides reasonably valid and reliable data on the extent and
distribution of common mental disorders among patients in these settings,
which may be used as a starting point for guiding the development of mental
health care and for further research on common mental disorders.
Patterns of use of traditional and biomedical services
In the developed world, common mental disorders are costly and disabling
disorders, which present often in primary care but are rarely recognised or
treated (Ormel et al,
1994; World Health
Organization, 1995). In Africa, traditional healers are generally
more accessible than biomedical practitioners; in rural Tanzania the ratio of
doctors to population is 1:20 000 whereas that of the traditional healers is
1:25 (Swantz, 1990). The
quality of biomedical health services in Africa (including Tanzania) has been
criticised (Van der Geest et al,
1990; Gilson et al,
1994). In contrast to traditional healers, staff in primary care
clinics are often found to show little concern or respect for their patients.
Formal community mental health services are yet to be realised in Tanzania and
there are only ten psychiatrists in the whole country, four of whom work in
the main hospital in the capital city.
Traditional medicine and biomedicine differ in their concept of the nature and causes of illness. In Africa, mental disorders are often perceived as a source of misfortune; ancestors and witches are believed to have a crucial role in bringing them about. Such disorders may be viewed in terms of magical, social, physical and religious causes, but rarely as diseases within the Western biomedical paradigm (Ndetei & Muhangi, 1979). Traditional healers rituals are linked to the maintenance or restoration of well-being in the whole community. Treatment and prevention focus upon the quality of human relationships and social interaction; healers provide their patients with moral and social guidelines to prevent them from catching the same illness again.
For the Tanzanian centres included in this study, the traditional healer and primary health clinic patient populations were strikingly different. This was particularly true as regards their pathways to care and their presenting complaint. The traditional healers patients had long-standing complaints, and were multiple and frequent consulters prior to the index consultation. The primary care patients had more acute complaints, and for two-thirds (compared with only 7% for the patients of traditional healers) the index consultation was their first for this complaint (Table 2). Although caution is needed when making dynamic inferences from cross-sectional data, traditional healers would seem often to be a last resort for patients with persistent problems who were presumably dissatisfied with the outcome of previous consultations with biomedical providers. It would be tempting, although incorrect, to seek to explain the excess of common mental disorder among the patients of traditional healers on this basis. Chronicity and multiple help-seeking are as evident in traditional healer centres for those without as for those with common mental disorder. Rather, it seems that intractable conditions in general may cluster in these centres, among them a substantial proportion of persistent common mental disorders. Other observed differences in patient characteristics also did not explain the high rates of common mental disorders in those attending traditional healer centres. A multivariate analysis indicated that being older, better educated, widowed or separated and avowing a Christian faith were each independently associated with attending a traditional healer. In Zimbabwe, a contradictory pattern was observed, in that clients of traditional healers were more likely to be female and also to be unemployed, with less education (Patel et al, 1997). In Tanzania, people who are educated, older and in employment are probably better placed to afford to pay for consultations and treatment at traditional healer centres. Primary health clinic consultations are free, but consultation time is short (approximately 3 min), with little opportunity to discuss symptoms or receive explanations about health problems. The association between Christian faith and attending traditional healers indicates that traditional explanatory models continue to exert a strong influence upon help-seeking behaviour, notwithstanding the efforts of missionaries to devalue traditional medicine. The Church in Tanzania officially rejects traditional medicine, which has its roots in animistic religion. However, in the face of hardship many believe that ancestral spirits or evil spirits have been used by jealous persons to inflict illness, misfortune or to generate conflict. The solution is thought to be to consult traditional healers. In Tanzania, modernisation, formal education and economic development seem to have had little impact upon these traditional ways, even among those who are most exposed to modern influences.
Risk factors for common mental disorder
In Harare, female gender, unemployment and poverty were each associated
with common mental disorder (Patel et
al, 1997). Strikingly, none of these factors was associated
with common mental disorder in our study. In Tanzanian society, women have a
status that is perhaps unusual in sub-Saharan Africa. The Government, through
the Ministry of Women and Children, together with non-governmental
organisations, provides women with microcredit by means of grants and
interest-free loans, education on running small businesses, and free legal
advice. Most women live in large extended families in which child care and
household tasks are shared. Any suggestion that these factors might explain
the lack of a female excess of common mental disorders is speculative, and the
findings themselves need to be treated with caution. In particular, the
potential biasing effect of help-seeking needs to be considered; factors such
as gender or poverty may influence help-seeking differently in those with and
those without common mental disorder. Associations present in the general
population may not be evident among those accessing care, and vice versa. In
short, studies of this kind are not suitable for the identification of risk
factors for common mental disorders; only population-based epidemiological
studies provide information about aetiology.
Implications
Our research suggests that patients with common mental disorder constitute
a large part of the workload of both primary health care clinics and
traditional healers in Dar-es-Salaam. We cannot infer from this that most
people with common mental disorder necessarily present to primary health care
clinics and traditional healers. The first filter between onset of common
mental disorder in the community and effective care is presentation to a
primary care provider. Potential barriers are failure to seek help and
inaccessibility of services. In the developed world this first filter is
relatively permeable, but we cannot assume that the same will hold true for
other cultures and health care systems. Population-based epidemiological
studies are needed to improve our understanding of help-seeking behaviour and
barriers to care at this level. We also provide indirect evidence that people
seen by traditional healers may have particularly chronic conditions following
the failure of primary health care, after multiple contacts, to resolve their
problems. Problems may arise at the levels of both recognition and management.
As in previous studies, most patients presented with somatic symptoms and a
somatic attribution. There is little time, particularly in primary health
clinics, to explore the possible psychological basis of these complaints, or
to investigate the wider family and social context of the disorder.
Traditional healers may be better placed in this respect; it would certainly
be interesting to know more of their approach to these cases in terms of their
formulation, their management and the treated outcome. Naturalistic
prospective studies are indicated. These may suggest opportunities for
productive alliances between Western and traditional medicine
(Green, 1988). With the support
of the formal health system, indigenous practitioners might become important
agents in organising efforts to improve the mental health of the community.
Better understanding of the prevailing indigenous models and idioms of
expression for common mental disorder should aid diagnosis and treatment.
Traditional healers may have much to offer, and could usefully participate in
joint training programmes in medical schools and with primary health care
workers.
In Tanzania the Colonial Witchcraft Ordinance 1928, which was used to suppress the practices of traditional healers, is still in force. The Ministry of Health plans to establish a Traditional Health Care Practitioners Act with the objectives of registering, controlling and regulating the use of traditional healers, their practice and the medicine they utilise. In the meantime, traditional healers have taken the initiative. The work of registering healers has begun in coordination with CHAWATIATA. A main objective, stated in their constitution, is to encourage collaboration between Western-trained doctors and traditional healers, and to increase communication between these two sectors through meetings and seminars. Tanzanian biomedical practitioners tend to view this communication as a one-way street, aiming only to train poorly educated traditional healers and recruit their support in the pursuit of public health goals. True collaboration will occur when each is ready and willing to learn from the best of the others practices.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication January 27, 2003. Revision received June 9, 2003. Accepted for publication June 19, 2003.
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