Sponsored by Ministry of Health & Presbyterian Health Services
A. DESCRIPTION OF PROJECT
The lives of most village families in Ghana are difficult. The majority of villagers are farmers who barely make a living growing crops such as maize, cassava, yam, and plantain. And most Ghanaians still have poor or inadequate housing, sanitation, water supply and nutrition.
The health status of Ghanaians is among the poorest in the world and the life expectancy at birth is 53 for males, 57 for females. The infant mortality rate is high, 86 per 1 000 live births, as is the incidence of diarrhoea, malaria, and respiratory infections. Hospital and clinic health services, often located far from villages, are oriented more toward the treatment of diseases than preventing illness and promoting health. These conditions represent those common to many people in other regions of Africa as well.
Recently, however, in the District of Dormaa, these poor health conditions began to improve as a result of an innovative project begun in 1985 with the cooperation of the Dormaa District Hospital, which is administered by the Ghana Presbyterian Health Services, and the Primary Health Care programme of the Ministry of Health (MOH). During that time, an anthropological study was being conducted to understand the connection between Dormaa Traditional Religion and Medicine, particularly with regard to the role traditional practitioners could play within the primary health care system. From the results of this research, the MOH Primary Health Care Project and the Ghana Presbyterian Health services obtained a grant from “Bread for the World” to conduct a pilot project to train traditional practitioners in primary health care skills.
The government health staff believed that local traditional practitioners, if well trained, could be effective in promoting health and preventing disease through health education as well as by treating traditional illnesses. When healers were asked what were the most serious health problems in the communities, they replied; marasmus and convulsions in children, fractures, malaria, diarrhoea, guinea worm, gonorrhoea, infertility, whooping cough, stomach disorders, tuberculosis, headache, dizziness, rheumatism, yaws, osteomyelitis, measles, spiritual diseases and madness.
Because traditional practitioners recognized these diseases, it was felt that they could be taught to identify serious cases and refer patients to the hospital. They could also serve as a referral centre in the community, and learn to treat those patients unable to get to a clinic. Since smaller communities had no clinics, trained traditional practitioners could provide services for those who were unable to obtain Western medical care.
The principal aim of the Dormaa Project was to develop a non-institutionalized form of cooperation between all practitioners engaged in providing basic health care. This aim was broken down into the following specific objectives:
1. To establish and maintain relationships between all health care workers in the district, including traditional practitioners.
2. To assist TPs in improving their skills, knowledge and attitudes toward community-based PHC and other development programmes in order to contribute effectively and efficiently to a better economic and culturally acceptable health delivery system in the district.
3. To encourage a dialogue and cooperation among the traditional practitioners and biomedical workers in order to:
a. reduce suspicion and prejudice;
b. encourage mutual respect between TPs and biomedical workers c. strengthen the positive aspects of both medical systems;
d. establish a prompt referral system between the traditional practitioner and the nearby Hospital/Health Centre;
e. carry out preventive health and health promotive activities in their communities.
C. RECRUITMENT AND SELECTION OF TRADITIONAL PRACTITIONERS
The process for recruiting and selecting traditional practitioners for training began in the communities to be served. The project staff visited the Chief and elders of each village to obtain their recommendations of traditional practitioners whom the community respected and trusted, and to obtain information about what health problems these traditional practitioners treated.
These candidates were then interviewed separately by the project staff using a questionnaire to obtain more detailed information. This information was then compared to what the elders had said and two traditional practitioners from each village were selected. The final selection was confirmed by the village elders and ten to fifteen traditional practitioners were then chosen for each regional training programme.
D. TRAINING CONTENT
Two training programmes were developed, one for the group of herbalists, bone setters and spiritual traditional practitioners, and another for TBAs. The content of these two programmes was created after a survey was conducted with the traditional practitioners to find out what they wanted to learn. In addition to these suggestions, the Project staff added the basic elements of Primary Health Care.
The training content for the first group of healers included the following blocks of information:
Block I: Hygienic preparation and storage of herbal medicines.
Block II: Causes, diagnosis, and treatments of traditional and modern diseases.
Block III: Nutritional value of local foods and substitutes for food taboos.
Block IV: Environmental sanitation and health.
Block V: Direct and indirect prevention of diseases, ie, immunizations.
In addition to health content, a related project was started at the request of a group of traditional practitioners who wanted to learn how to keep bees. They used honey in the production of some medicines and wax to preserve them. Honey was also used for public consumption, could be sold in the market, and was useful in pollinating crops. For these reasons the project staff also agreed to teach this group of traditional practitioners beekeeping.
The training content for TBAs included the following:
• Preparation for delivery;
• Basic anatomy of the female and male reproductive organs;
• Signs and symptoms of pregnancy and common complaints;
• Care of the woman during pregnancy, ie. nutrition, rest, sanitation, relationship with husband;
• History taking and record keeping;
• High risks of pregnancy and how to refer;
• Stages of labour and care of woman during this period;
• Care of mother 6 weeks after delivery;
• Weaning and treatment of diarrhoea;
• Family planning and AIDS.
The training course was held in half-day workshop sessions two times per week for five months. This averaged eight sessions per month for a total of approximately 120 hours. These sessions were held in a village in each target zone and scheduled on non-farming days so all could attend. Before training was begun, the staff organized a two day workshop to train the trainers, ie, PHC and hospital staff.
The major content of this training included:
• Understanding of traditional practitioners and their medicines;
• Adult teaching methods, ie, the use of pictures, dialogue, and other non-formal methods;
• Communication skills and interpersonal relationships, ie, building trust and respect, use of eyes and body language, etc.
E. TRAINING METHODS
The meetings were held in a village under a tree, and participants came from the surrounding four to six communities. Ten to fifteen traditional practitioners were chosen for each training programme. One block consisted of two to four workshops, each lasting two to three hours. In every workshop one topic was covered by:
• discussing problems coming out of their work;
• exchanging experiences and ideas;
• story telling;
• role play;
• songs and dances with Nwomdoro musical instruments;
• use of audio-visual aids.
Different methods of instruction were used to make the sessions lively and keep up the interest of the group. In addition to the workshop sessions, the TBAs were given 7 days of clinical practice in the hospital and health centres near where they lived.
F. FOLLOW-UP SUPPORT
At the three regional centres, half-day refresher courses were offered every three months during which all workshop topics were reviewed. During these courses, questions were prepared for the traditional practitioners on all the topics presented in the initial training programme. The traditional practitioners were also encouraged to ask questions and to give suggestions on how the refresher courses could be improved.
Two-day workshops were also offered for the trainers and project staff to discuss past experiences and any improvements needed. This course also served to motivate the trainers to improve their skills.
After completion of the basic course, the project staff made supportive visits at least once a month to the traditional practitioners who graduated from the project. These visits had three purposes:
• to identify problems;
• to monitor activities;
• to provide support and assistance.
During the visits, the staff found out how the traditional practitioners were doing, whether they were encountering any difficulties in their work, and if so, suggested solutions to problems. The traditional practitioners were also informed of the importance of keeping records and were taught good record-keeping methods.
G. CHARACTERISTICS OF PERSONS INTERVIEWED
1. Health Agency Staff
Eleven representatives of the health agency staff were interviewed about their relationship with and views on traditional practitioners. There were five females and six males, and the average age was 36 with a range of 24 to 45. Their occupations included: medical officer, hospital doctor, nurse midwife, nurse, medical assistant, community health worker, nutrition officer, and health educator. The average amount of time worked in their current position was 6.7 years, with a range of 1 to 12 years.
2. Traditional Practitioners
Twenty-three traditional practitioners from ten different villages were interviewed for information. These were eleven herbalists and spiritual practitioners, ten traditional midwives, and two bone-setters. Twelve were males with ages ranging from 41 to 80 and 13 were females aged 40 to 80. The average number of years the traditional practitioners had worked was 25.3, with a range of 8 to 60. Most had little or no education and few could read or write.
3. Community Members
Seventeen members of seven villages were interviewed to determine their satisfaction with the services of the traditional practitioners. Ten were men and seven were women ages 18 to 92 years and had occupations of farmer, labourer, or mother.