UNIVERSITY OF GHANA INTEGRATING TRADITIONAL AND ORTHODOX MEDICINES IN HEALTHCARE DELIVERY IN GHANA: A STUDY OF WENCHI MUNICIPALITY BY OPOKU-MENSAH, FOSTER ABRAMPA (10204970) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL HEALTH SERVICES MANAGEMENT JULY, 2015 University of Ghana http://ugspace.ug.edu.gh I DECLARATION I hereby declare that, this work is the original work of Opoku-Mensah Foster Abrampa under the supervision of Dr Albert Ahenkan and that it has not been submitted in part or in full to this university or any other institution across the world for the award of a degree. I further declare that reference and due acknowledgment has been given to all scholarly works used. ……………………………… ……………………………… OPOKU-MENSAH, FOSTER ABRAMPA DATE (STUDENT) University of Ghana http://ugspace.ug.edu.gh II CERTIFICATION I hereby declare that this thesis was supervised in accordance with procedures laid down by the University of Ghana. …………………………….... …………………………… DR ALBERT AHENKAN (PH.D.) DATE (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh III DEDICATION I dedicate this work to my father, Obour-Manu Jones, (may his soul rest in perfect peace), my mother, Mpra Kuma Margaret and my siblings Agyenim Boateng Benson and Amankwaa Afriyie Regina. University of Ghana http://ugspace.ug.edu.gh IV ACKNOWLEDGEMENT There are people whose direct and indirect contributions helped in the writing of this thesis and their efforts therefore need to be acknowledged. I first of all express my sincerest gratitude to Dr Albert Ahenkan, (my supervisor) for patiently and painstakingly given me the needed attention, guidance, assessment and the input needed from the start to the end of this work. Special thanks to Dr Thomas Buabeng, Dr Theophilus Maloreh-Nyamekye and Dr Justice Bawole (head of department, Department of Public Administration and Health Services Management), I say may God bless you for inspiring my life. I thank the administrator of Wenchi Methodist Hospital for giving me permission and opportunity to interview their workers. The contributions of Mr. Yussif Iddrisu, Mr. Daniel Danso, Mr. Obour Andrews, Mr Paul Kwabena Manu, Mr E. K. N. Asiedu and Mr. Affum Micheal in my life need to be mentioned. I thank the immediate past and current headmasters (Mr. Konadu Adams and Mr Francis Adjei), the staff and students of Sankore L/A ‘A’ JHS. I thank 2015 batch of MPhil students of Health Services Management for being cooperative throughout my period of study. High and above all is the divine protection that has been given to me by the almighty God and placing all the right people there for me at the right time. University of Ghana http://ugspace.ug.edu.gh V TABLE OF CONTENTS Content Page DECLARATION............................................................................................................................ i CERTIFICATION ........................................................................................................................ ii DEDICATION.............................................................................................................................. iii ACKNOWLEDGEMENT ........................................................................................................... iv TABLE OF CONTENTS ............................................................................................................. v LIST OF TABLES ..................................................................................................................... viii LIST OF FIGURES ..................................................................................................................... ix LIST OF ABBREVIATIONS ...................................................................................................... x ABSTRACT ................................................................................................................................ xiii CHAPTER ONE: INTRODUCTION ......................................................................................... 1 1.1 Background to the study ................................................................................................... 1 1.2 Statement of the problem ................................................................................................. 5 1.3 Objectives of the study ..................................................................................................... 7 1.4 Research question ............................................................................................................. 8 1.5 Research hypotheses ........................................................................................................ 8 1.6 Significance of the Study ................................................................................................. 8 1.7 Scope of the study .......................................................................................................... 10 1.8 Operational definitions ................................................................................................... 10 1.9 Organisation of the study ............................................................................................... 11 1.10 Conclusion ...................................................................................................................... 12 CHAPTER TWO: LITERATURE REVIEW .......................................................................... 13 2.1 Introduction .................................................................................................................... 13 2.2 Theoretical framework ................................................................................................... 13 2.2.1 Parsons Sick Role Theory ....................................................................................... 14 2.2.2 Stages of illness and medical care .......................................................................... 15 2.2.3 Observational Learning Theory (OLT) ................................................................... 16 2.3.1 Medical systems and medical pluralism ................................................................. 17 2.3.2 Orthodox Medical System (OMS) .......................................................................... 19 University of Ghana http://ugspace.ug.edu.gh VI 2.3.3 History of OMS in Ghana ....................................................................................... 19 2.3.4 Traditional Medical System (TMS) ........................................................................ 22 2.3.5 Socio-economic variables and the use of medical systems .................................... 34 2.3.6 Integrating traditional and orthodox medical systems ............................................ 38 2.4 Conceptual framework ................................................................................................... 42 2.5 Conclusion ...................................................................................................................... 43 CHAPTER THREE: METHODOLOGY ................................................................................ 44 3.1 Introduction .................................................................................................................... 44 3.2 Study area ....................................................................................................................... 44 3.2.1 Site selection ........................................................................................................... 44 3.2.2 Age and sex structure .............................................................................................. 47 3.2.3 Economic activities ................................................................................................. 47 3.2.4 Labour and dependency .......................................................................................... 47 3.2.5 Ethnicity .................................................................................................................. 48 3.2.6 Income distribution pattern in Wenchi Municipality .............................................. 48 3.2.7 Pattern of household expenditure in the municipality ............................................ 49 3.2.8 Health facilities and accessibility............................................................................ 49 3.2.9 Top diseases in the municipality ............................................................................. 51 3.2.10 Childhood killer diseases ........................................................................................ 52 3.2.11 General health and demographic trends .................................................................. 52 3.3 Research approach.......................................................................................................... 52 3.4 Study design ................................................................................................................... 54 3.5 Target population ........................................................................................................... 55 3.6 Sources of data ............................................................................................................... 55 3.7 Sampling technique and size .......................................................................................... 55 3.8 Data collection instruments ............................................................................................ 58 3.9 Pre-testing of data collection instruments ...................................................................... 59 3.10 Ethical consideration ...................................................................................................... 60 3.11 Data management and analysis ...................................................................................... 61 3.12 Conclusion ...................................................................................................................... 62 University of Ghana http://ugspace.ug.edu.gh VII CHAPTER FOUR: DATA ANALYSIS AND INTERPRETATION ..................................... 63 4.1 Introduction .................................................................................................................... 63 4.2 Recap of the objectives .................................................................................................. 63 4.3 Hypothesis one ............................................................................................................... 64 4.4 Hypothesis two ............................................................................................................... 65 4.5 Results on research Question ......................................................................................... 66 4.6 Challenges of integrating traditional and orthodox medicine ........................................ 66 4.6.1 Challenges relating to traditional medicine and practice ........................................ 67 4.6.2 Challenges relating to orthodox medicine and practice .......................................... 74 4.7 Conclusion ...................................................................................................................... 76 CHAPTER FIVE: DISCUSSION .............................................................................................. 78 5.1 Introduction .................................................................................................................... 78 5.2 Education and use of medical systems ........................................................................... 78 5.3 Area of residence and use of medical systems ............................................................... 81 5.4 Challenges of integrating TM and OM .......................................................................... 85 5.5 Conclusion ...................................................................................................................... 92 CHAPTER SIX: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS .............. 93 6.1 Introduction .................................................................................................................... 93 6.2 Summary ........................................................................................................................ 93 6.3 Conclusions .................................................................................................................... 96 6.4 Recommendations .......................................................................................................... 97 6.4.1 Implications for Policy Making .............................................................................. 97 6.4.2 Directions for future research ................................................................................. 98 REFERENCE ............................................................................................................................ 100 APPENDIXES ........................................................................................................................... 116 University of Ghana http://ugspace.ug.edu.gh VIII LIST OF TABLES Table Title Page 3.1 Distribution of Respondents and their communities 58 4.1 Group statistics on use of medical systems 65 4.2 ANOVA results on the effects of education on medical systems use 66 4.3 Results of a multiple comparison using the LSD 67 4.4 Group statistics and results of t-test on residence and medical systems use 68 University of Ghana http://ugspace.ug.edu.gh IX LIST OF FIGURES Figure Title Page 2.1 Conceptual framework 45 3.1 Location of Wenchi Municipality at the national and regional levels 46 3.2 Map of Wenchi Municipality showing accessibility to health facilities 51 University of Ghana http://ugspace.ug.edu.gh X LIST OF ABBREVIATIONS ANOVA One Way Analysis of Variance BE Basic Education CAM Complementary and Alternative Medicine DANIDA Danish Development Agency df Degree of Freedom F F-value GHS Ghana Health Service GSS Ghana Statistical Service HA Alternative Hypothesis HIV Human Immune Virus HM Herbal Medicine HO Null hypothesis HP Herbal Practitioners LSD Least Significant Difference M Mean MA Municipal Assembly MOH Ministry of Health MP Medical Pluralism MS Medical System NFE No Formal Education NHIDL National Health Insurance Drug List NHIS National Health Insurance Scheme University of Ghana http://ugspace.ug.edu.gh XI NHP National Health Policy OL Observational Learning OLT Observational Learning Theory OM Orthodox Medicine OMPs Orthodox Medical Practitioner(s) OMS Orthodox Medical System P P-value PE Primary Education PM Plant Medicine PNDCL Provisional National Defence Council Law PPS Probability Proportionate in Size PTD Professional Traditional Doctor SCT Social Cognitive Theory SD Standard Deviation SDM Socio-Demographic Model SE Secondary Education Sig Significant Value SLT Social Learning Theory STDs Sexually Transmitted Disease(s) TAMU Traditional and Alternative Medicine Unit TBAs Traditional Birth Attendant(s) TDs Traditional Doctor(s) TE Tertiary Education University of Ghana http://ugspace.ug.edu.gh XII TM Traditional Medicine TMC Traditional Medical Care TMD Traditional Medical Doctor TMPs Traditional Medical Practitioner(s) TMS Traditional Medical System UN United Nations UNICEF United Nation International Children Emergency Fund WHO World Health Organization WMA Wenchi Municipal Assembly WMH Wenchi Methodist Hospital University of Ghana http://ugspace.ug.edu.gh XIII ABSTRACT Over the years, different societies combine traditional and orthodox medicines in different proportions in the treatment of ailments. While some societies have well developed combination of the two, others are not. This study examines the integration of traditional and orthodox medicines in WM. The purpose was to examine; the relationship between educational level and place of residence and medical systems use and as well the challenges of integrating traditional and orthodox medicines. Based on the objectives, two hypotheses were tested and one research question answered. A mixed approach based on a comparative design was used. Multistage and purposive sampling techniques were adopted to select 104 participants with 6 of them being key informants for interviews and the rest answering questionnaires. An analysis of variance shows; the effect of education was significant on the use of medical systems but that of residential status was not. The challenges found to affect integration of TM and OM were multi-dimensional and range from legal-attitudinal-policy issues. Among other things, it is recommended that; traditional medicine and healthcare providers should be placed on the NHIS and more value added to the branding of traditional medicines. Besides, it is recommended that a research be conducted to examine; the effectiveness of existing national policies on integrating traditional and orthodox medicines, to look at how people use traditional medicine for self-treatment; specific herbs that are used to treat particular diseases and how the activities of traditional medicine practitioners help in the promotion of culture. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background to the study Different societies in the world have different institutions of medicine to deal with the problem of risk and uncertainties created by illness both philosophically and pragmatically. The issue of medicine has strong ties with philosophy, religion and the entire belief system of every individual society. Each society around the world has a unique medical system. However to the larger extent, each of these medical systems in these societies is influenced by cultural, political and economic forces (WHO, 2000). Medical pluralism is therefore a global phenomenon. Wade et al., (2008) in trying to explain Medical Pluralism (MP) said it the employment of more than one medical system for the treatment of diseases and illnesses. Specifically, they mentioned that it involves the use of Conventional medicine as well as Complementary and Alternative Medicine (CAM) to treat diseases. According to Islam (2005), most contemporary societies practice medical pluralism. This practice arises from the existence of different cultures that are co-existing, complementary or competing. Medical care systems around the world can generally be classified into Modern/Orthodox medicine and Alternative/Traditional medicine (WHO, 2002; Sato, 2012). Orthodox/Modern medicine is based on sound biomedical research and it has been known to be in use in developed countries for a bit of more than a century. University of Ghana http://ugspace.ug.edu.gh 2 Traditional medicine on the other hand includes all the known healing practices that have been compiled over centuries through trial and error or merely by cultural and religious beliefs (Sato, 2012). Traditional medicine and herbal medicine have been defined by the Traditional Medicine Practice Act (2000) as the; “practice based on beliefs and ideas recognized by the community to provide healthcare by using herbs and other naturally occurring substances”, and “any finished labelled medicinal product that contain as active ingredients aerial or underground parts of plants or other plant materials or the combination of them whether in crude state or plant preparation” (p.31). Traditional alternative medicine uses plant, animal, and mineral substances. It may be prepared from bark, root, seed, tuber, whole plant, fruit, leaf or any combination of the list and/or vegetable, animal, and mineral substances (Stewart and Cole, 2005; Semenya et al., 2012; Delvaux et al., 2013). It also includes remedies like herbal medicines, folk knowledge, rituals and spiritual elements (Tabi et al., 2006). Practitioners of traditional medicine ranges from a wide range of professionals and may include fetish priests, herbalists (non-spiritual and spiritual), spiritual diviners, traditional birth attendants, bonesetters, ‘circumcisioners’ (Sato, 2012) etc. The practice of traditional may be based on sources that are social, cultural, and religious. It also includes knowledge and attitudes, as well as prevalent beliefs in communities regarding the wellbeing of people. This wellbeing includes physical, mental and social. Traditional medicine also includes the believed causes of disease and disability (Mshana et al., 2008). It has been estimated that globally about 80 per cent of people depend on CAM for their healthcare needs (WHO, 2010). As a result, countries are finding ways to integrate TM into their healthcare systems. For instance In China and India, there are well developed CAM systems for decades now. This systems have even been adopted by some western countries. They are even included in the school curricular from up to tertiary levels. These systems are the ‘acupuncture’ and ‘ayurvedic’ University of Ghana http://ugspace.ug.edu.gh 3 respectively (Vlachogianni et al., 2014). In 2000 and 2001, regional meetings were held in the Americas. The aim was how efficacious and safe CAM is. The meeting also came out with requirements needed for registration of herbal products and ways of facilitating integration of TM into national healthcare systems in the Americas. Today there are clearer Regulations for registration and use of herbal medicines in some American countries like Bolivia, USA, Chile, Colombia, Ecuador, Guatemala, Mexico, Peru, Venezuela etc. (WHO, 2002). Europe is not an exception on the adoption and use of traditional medicine. For instance, 12 European countries have since the year 2000 established or revised their regulation on herbal medicines in accordance with the WHO Guidelines for Assessment of Herbal Medicines (WHO, 2002). Traditional Medicine is also said to be occupying greater part of primary healthcare of individuals, institutions and communities in Ghana and other developing countries worldwide (WHO, 2002). In Africa, majority of people use traditional medicine for treating ailments and illness. It is said that traditional healers play an important role in the health of between 60 and 95% of the people in the continent (Anyinam, 1995; WHO, 2000; Cunningham, 2001). Against this background, the WHO is particularly focusing on how to support development of Traditional Medicine in Africa (WHO, 2002). For instance in the year 2000, the WHO set up a Regional Committee for Africa. In a resolution, this committee adopted a strategy for the African region to promote traditional medicine in health system (WHO, 2000). This resolution recognized CAM has the potential to help achieve ‘Health for All in Africa’. It also recommended accelerated development of local production of traditional medicines. University of Ghana http://ugspace.ug.edu.gh 4 Ghana is a medical pluralistic society practising both traditional and orthodox medicine (Twumasi, 1979; Mwabu, 1986; Tsey, 1997; Tabi, et al., 2006). The two medical systems have co-existed in the country over period of time providing a wide range of medical services for the health needs of Ghanaians (Sato, 2012). Following the WHO Regional Resolution (WHO, 2000), Ghana has promoted the integration of orthodox and traditional medicine through its Ministries, Departments and Agencies with the aim of facilitating its integration into the national healthcare delivery system. Several policy initiatives have therefore been pursued by the government over the years. Examples are; technological support for research and development, formulation and implementation of regulations and legislations and promoting acceptance of traditional medicine among key stakeholders (MOH, 2004). Base on World Health Organization’s recommendation, in the year 2000 the Traditional Medicine Practice Act was passed as the government’s commitment to integrating traditional medicine and orthodox medicine. Further commitments include recognizing the role of CAM and its practitioners in improving health. There was the establishment of the Traditional and Alternate Medicines Directorate of the Ghana Health Service in the National Health Policy (NHP) (MOH, 2004). The policy seeks to bring all CAM practitioners under one unbralla and preparing guidelines, ethics, and training manual for traditional medicine. Section 5 of the policy stressed the need to build the capacity to ensure that traditional medicines are safe, efficacious and of good quality. University of Ghana http://ugspace.ug.edu.gh 5 However, development and production of herbal products has been slow in Ghana (MOH, 2004). Perhaps that is why there is lack of integration of TM into the national healthcare delivery system by the Ministry of Health (MOH) and Ghana Health Service (GHS) (Asante, 2010). In the existence of these competing and distinct medical orientations coupled with the efforts of the WHO and MOH in integrating TM and OM, a research is needed to find out people’s perceptions about them and the extent to which socio-economic variables play a role in their utilization as well as the challenges of integrating traditional medicine and orthodox medicine. 1.2 Statement of the problem All over the world, individuals with medical needs have the potential to seek healthcare from different providers (Sato, 2012) who generally practice as modern/western/orthodox healthcare professionals or traditional/alternative medical practitioners. In some cases, traditional and orthodox medicines are used as compliments while in other cases they are used to substitute each other (van Andel, et al., 2012). Extensive work has been done on these types of medical practices (Falconer, 1994; Anyinam, 1995; WHO, 2000; Cunningham, 2001; Williams et al, 2013). However, most of these studies usually compare numbers. For instance, it is not difficult comparing the percentage of individuals who use the services of these practitioners. In percentage wise, 80% rural and 72% urban have at least used traditional and/or orthodox medicine before (Falconer, 1994; Williams et al., 2013). Some of these studies have also focused on factors that influence health seeking behavior. Examples of the factors identified by these studies are poverty, cultural values, religious background, availability and/or perceived quality of medical care, location, generation, age, gender, kind and form of the health problem (Aday and Andersen, 1974; Mwabu, 1986; Anyinam, University of Ghana http://ugspace.ug.edu.gh 6 1987; WHO, 2000; Cunningham, 2001; UN Millennium Project, 2005; Williams, 2007; William et al, 2013). Others include efficacy, perceived side effects, level of education, employment, population growth, accessibility, acceptability and urbanization (Lewu, et al., 2007; van Andel, et al., 2012). These studies do not mostly focus on these factors vis-a-vis modern or orthodox medicine and traditional medicine. While it is known that most people in the rural areas use traditional medicine because of lack of accessibility to orthodox medicine (Sato, 2012), it is also a common practice by even people in urban areas to subscribe to traditional healthcare despite the availability and accessibility of western medicine in this 21st century (Williams et al., 2013). Besides, the studies that examine factors influencing a person’s choice to use either traditional or orthodox medicine seem to be exploratory in nature (Twumasi, 1975; Sena, 2001). They do not test how significantly these factors can influence a person’s decision to use either traditional and/or orthodox medicine. Owing to the scarcity of health-seeking comparative behavioral studies which empirically test reasons for usage of these multiple recourses and tangible outcome measurements, researchers and policy makers’ are usually left with the option of guessing. Often times, they are for instance tempted to guess that traditional medicine and its related practices are only popular especially amongst more rural populations who are poor and have impeded access to formal healthcare (Sato, 2012). In the existence of these two distinct, competing and viable medical practices in Ghana (Tsey, 1997), what is the extent to which these socio-demographic variables play significant role in the use of either modern or traditional medicine or sometimes both at a point in time? Critically University of Ghana http://ugspace.ug.edu.gh 7 examining most of these studies, it has been observed that enough has not been done on the quantitative and qualitative accounts of these demographic variables in the use of medical systems in Ghana. In the context of the Wenchi Municipality for instance, the extent to which people’s educational attainments, economic status, area of residence, religious background, etc. affect their medical preferences seems to have not received much attention (if any) in studies and policy implementation in Ghana (if any). Most of these studies have also not accounted for the challenges faced in integrating TM and Orthodox Medicine (OM). Therefore, given Ghana’s quest to incorporate both traditional and orthodox medical systems into the main stream of healthcare delivery to provide comprehensive medical care, further studies into medical preference would be significant to both research and health policy formulation. Against this background, this study seeks to empirically examine the factors affecting the use of traditional and modern medicines in the Wenchi Municipality of the Brong Ahafo region of Ghana. 1.3 Objectives of the study The general objective of this study is to examine the utilization of traditional and orthodox medical systems and the challenges of integrating them in the Wenchi Municipality. Specifically, the study seeks to: 1. Examine the relationship between educational attainment and utilization of medical systems in the Wenchi Municipality. 2. Compare rural and urban population’s preference for medical systems in the Municipality 3. Examine the challenges of integrating traditional and orthodox medicines in healthcare delivery (from the perspective of service providers) in the Municipality. University of Ghana http://ugspace.ug.edu.gh 8 1.4 Research question Base on the third objective, the following research question was formulated to guide the study:  What are the challenges of integrating traditional and orthodox medicines in healthcare delivery (from the perspective of service providers) in Wenchi Municipality? 1.5 Research hypotheses In line with objectives one and two respectively, the following are the hypotheses that the study tested: 1. H0: Educational attainment has no significant effect on the use of medical systems in Wenchi Municipality. H1: There is significant difference among people with various levels of education in the use of medical systems in Wenchi Municipality. 2. H0: There is no significant difference between rural and urban areas in health seeking behaviour in Wenchi Municipality. H1: There is a significant difference between rural and urban areas in the use of medical systems in Wenchi Municipality. 1.6 Significance of the Study This study was designed to examine the use of traditional and orthodox medical systems in Wenchi Municipality. Specifically, the study helps determined the factors which account for people’s medical preferences. This in turn can help enhance the design of medical systems. It can also help identify problems associated with the use of medical systems as well as the pragmatic means of University of Ghana http://ugspace.ug.edu.gh 9 incorporating both medical systems in providing a comprehensive healthcare delivery in the country. On the academic front, the study broadens the already existing knowledge on the preferences of people between orthodox and traditional medicines for further research and medical care planning. The study brings a fore insight into the importance of integrating traditional healthcare and modern healthcare in Ghana. It is very useful to grow knowledge on the social, economic and cultural benefits of traditional medicine and care in the Ghanaian healthcare system. Increased in the knowledge of this traditional healthcare can foster the quality and quantity of healthcare delivery in Ghana in general and in especially rural areas. Also, the information that is provided from the analysis of this study is vital and useful to government’s policy concerns. Results of the study are also useful for the current debate on how to achieve integration as the information provided is a vital source of reference. Particularly, results from this research is very important to the Ministry of Health (MOH), because it is the MOH that directly provides all services concerning public health delivery. For instance the ministry is in charge of policy formulation, monitoring and evaluation and mobilization of resources. The ministry also regulates health services delivery in general (MOH, 2007). The study is also a valuable source of information to the Traditional and Alternative Medicines unit, who have it as a duty to closely monitor and evaluate the delivery of all forms of traditional and alternative healthcare in Ghana (MOH, 2007). For this same reason, it is very useful for the pharmaceutical companies. Other organizations and countries that are currently trying to integrate traditional and orthodox healthcare systems may also draw some lessons from the findings of this study. University of Ghana http://ugspace.ug.edu.gh 10 As if this is not enough, the findings are useful to the general public, who are concern about the current healthcare system in the country or their own health status. 1.7 Scope of the study The study was limited to the Wenchi Municipality of the Brong Ahafo region of Ghana. This is as a result of the limited resources and time frame within which the work has to be submitted for appraisal. Another reason is that the municipality have both rural and urban populations that made the comparison possible. 1.8 Operational definitions Orthodox/Modern medicine: It is any medical system that is based on sound biomedical research and are considered foreign to Ghanaian culture. Traditional Medicine: Practices based on beliefs and ideas recognized by local communities to provide healthcare. It uses herbs and other naturally occurring substances, may include finished products that are labelled and contain aerial and underground parts of plants, plant materials or the combination of them as active ingredients which may be in crude or processed state. Traditional Medical Practitioners TMPs: Medical practitioners whose healings are based on beliefs, ideas, herbs, or naturally occurring substances that are local to the people. In this study, TMPs does not include medical herbalists. Integration: The process that involve the combination of orthodox and traditional medicines in the provision of healthcare services. Rural areas: Settlements with population below 5000. University of Ghana http://ugspace.ug.edu.gh 11 Urban areas: Settlements with population over 5000. Improved healthcare delivery: Improved healthcare coverage is used in this study to mean wider coverage of healthcare particularly increase in number of providers. 1.9 Organisation of the study The study is structured into six chapters. The first chapter provides an introduction/background to the concept of traditional and orthodox medicines and the problem statement. The objectives as well as the research questions and hypothesis of the study are also included in the chapter. The benefits of the study to stakeholders was also discussed with the scope of the study also covered. Chapter two of the study reviews literature pertaining to the use of traditional and orthodox medicines. It reviews literature both from the empirical and theoretical perspectives by introducing and discussing the theoretical framework for the study, as well as the empirical literature in relation to the study. Chapter three provides an in-depth explanation of the methodology that was used to carry out the study. There is a discussion of the study background, study approach, study population, study design, research instrument, sampling techniques and methods of analysis. The fourth chapter captures the analysis and presentation of data gathered from the field. Chapter five takes care of the discussion of the findings specifically, perceptions and the use of medical systems. Under this chapter, the findings were discussed in relation to the pertinent concepts in the literature and theoretical framework. It also looks at the challenges of accessing and utilizing the medical systems in the municipality. University of Ghana http://ugspace.ug.edu.gh 12 Finally, chapter six focuses on conclusions and recommendations. The chapter summarises the findings of the study and make recommendations that helps to understand the use and integration of traditional and orthodox medicines into the medical mainstream of the country. 1.10 Conclusion In this chapter, effort was made to explain why studying the integration of TM and OM in WM is a research problem. Among other things, the chapter explained that studies on integration are mostly exploratory and do not test hypothesis. Besides, such studies seems to be missing in the context of Wenchi Municipality. The objectives as well as the hypothesis and the research questions are stated in this chapter. The chapter also talked on the scope of the research as well as the practical and the academic importance that this research will serve to the world. University of Ghana http://ugspace.ug.edu.gh 13 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction The health of the individual is one of the fundamental issues in the area of medical research and policy analysis. This chapter reviews various theories, studies and policy documents in the area of medical pluralism and utilization preferences. Included in the chapter is also the theoretical framework under which the study was conducted. 2.2 Theoretical framework On January 25, 2008, a physician in San Diego diagnosed a seven year old boy of measles. The infection was transmitted by the boy to eleven other children in the community. It was realized that all the twelve children did not seek any standard measles immunization (Center for Disease Control and Prevention, 2008). Why didn’t the parents of these children utilize the available treatments and vaccinations? Cases of this nature and even those that are worse are common throughout the world including Ghana. Scholars have tried to identify the factors that affect healthcare utilization. Culture, economic status, access, perceptions, knowledge, belief in efficacy, age, gender roles, social roles etc. (Tabi et al., 2006; Williams, 2007; Dovie et al., 2008) are among the extensive list of factors that are said to influence the choice of health seeking among people. In this section, three theories including Parsons’ sick role, Rebhan Suchman’s stages of illness and medical care and Bandura’s Observational Learning Theory are discussed. In discussing the theories, effort has been made in each occasion to link them with health seeking behavior. University of Ghana http://ugspace.ug.edu.gh 14 2.2.1 Parsons Sick Role Theory Talcott Parsons proposed a health utilization theory known as Sick Role Theory in 1951 (Parsons, 1951). The theory proposed that, when an individual is sick, s/he adopts a role of being ill. According to Parsons, there are four main components of the sick role: the individual is not responsible for the illness. As a result, s/he is not expected to be able to heal without assistance. Parson’s second component is that, there is a general recognition that being sick is an undesirable state; as a result in the third component, he said the individual is excused from performing normal roles and tasks; and that the individual is expected to seek medical assistance and to comply with medical treatment in order to get well. The theory is credited for its attempt to identify typical behaviors that can be seen in people when they are sick. Included in these sick behaviors is health seeking (i.e. the last of the four components of the theory). In this current study, the researcher has done a rigorous work in identifying from the literature the factors that may influence a sick person to access a particular type of healthcare. This means the current study expanded on the fourth component of the sick role theory. Then through hypotheses testing, the strengths of these factors in influencing the choice of healthcare seeking were determined. Since the theory failed to account for variability in illness and behavior of sick people, other scholars have proposed theories that are a bit multifaceted (Wolinsky, 1988). University of Ghana http://ugspace.ug.edu.gh 15 2.2.2 Stages of illness and medical care It has been theorized that an individual go through a five-staged decision when ill (Cockerham, 1982). These stages determine whether or not to utilize healthcare when sick. It also includes the type of care to seek when sick. These stages are: the individual’s symptom experience; the individual’s assumption of a sick role; medical care contact; the assumption of and dependent- patient role and the individual’s recovery from illness. According to the theory, the sick person experiences different symptoms at different stages of the illness process. According to Cockerham, in stage one, the patient experiences such symptoms as; pain, emotion, and recognition of experience as symptomatic of illness. By the time the individual gets to the second stage s/he may go through exploration of his or her lay referrals. The purpose of going through these lay referral systems is for the validation of the sick role. It also enables him to explore treatment options. According to Cockerham, lay referrals are systems that involve non-professional people helping sick people to give meanings to the symptoms of their diseases. They also help them to identify options for treatment. Examples of such persons are family members, friends etc. (Cockerham, 1982). At stage three, the individual sick person may seek help from a professional healthcare system. According to the theory, the pace of entering stage three is a function of the individual’s role and membership within the community and as well dependent on the extent of his/her social networks. This is because, the individual’s social networks may tend to delay medical care contact by extending the first two stages for longer if the networks are parochial than if they are cosmopolitan. A network that is parochial refers to the network with close and traditional relationships. With such network, the individual becomes reluctant to incorporate new information and are likely to University of Ghana http://ugspace.ug.edu.gh 16 utilize lay referrals for treatment. Cosmopolitan networks on the other hand is social relationships that are individualistic in nature, open to new information, and are likely to utilize a scientific approach to medical care (Wolinsky, 1988). The theory further assumes that the assumption of dependent-patient role is done through acceptance of professional healthcare treatment. This forth stage may be disrupted if the individual and the professional healthcare provider have differing/opposing opinions of the illness. At the final stage the patient now recovers after seeking treatment and upon relinquishing their role as patient. However, for the case of chronic diseases, the sick person may assume a chronically ill role (Wolinsky, 1988) for the rest of his life. The current research dwells on stage four (i.e. acceptance of professional treatment) and the special case of chronic illness with stage five. In the current research, the researcher tried to establish a fact that, there are two types of professional treatments (i.e. treatment using traditional medicine and treatment using orthodox medicine). The aim was to test the factors that inform a person’s decision to use either traditional medicinal method or orthodox medicinal method of treatment. Although being able to accurately outline some important stages that sick people go through, the theory fail to incorporate denial that is included in most decision stages people go through in such emergencies as sickness, grieving etc. 2.2.3 Observational Learning Theory (OLT) According to Bandura (2001), when people observe others (models), their behavior change. This change in behavior is as a result of a learning process called Observational Learning (OL). Observational learning is often referred to as Social Learning Theory (SLT) or Social Cognitive University of Ghana http://ugspace.ug.edu.gh 17 Theory (SCT). It is called social learning because it shows the role that observation of people plays in the social behavior of the observers. It is called social cognitive theory because Bandura has focused on some cognitive activities like expectation and self-perception. In this study, it is assumed that observing others health-seeking behavior has some effect on the health-seeking behavior of the observer. This is truer in the case of traditional medicine. It is assumed under the current study that, whether the person being observed used professional treatment when sick, the type of professional treatment and the consequences that followed will go long way to determine whether the observer should seek professional treatment and the type of treatment to seek. Because of the strong link between the type of treatment sought by the model and the observer’s likelihood of repeating the behavior of the model, this study mostly dwell on this theory then the previous ones reviewed. The key processes of SLT are attention, retention, motor ability, and reinforcement and the factors that affect observational learning are status of the model, development of the observer and vicarious consequences. According to Bandura, observational learning leads to acquisition, inhibition, dis-inhibition, facilitation and creativity. 2.3.1 Medical systems and medical pluralism In the view of Fabrega and Manning (1979) medical care system refers to the totality of facilities and resources that structure how members of a socio-cultural group treat their illness. According to them, these facilities and resources include beliefs, knowledge, practices and personnel (Stoner, 1986). Medically pluralistic societies offer a variety of treatment options (physician, spiritualists, University of Ghana http://ugspace.ug.edu.gh 18 pharmacist, and so on) that health seekers may choose to utilize exclusively, successively, or simultaneously (Stoner, 1986). There are only arbitrary relationships in terms of distinguishing modern medicine and traditional medicine when we consider variables like personal, interpersonal and community. These variables go a long way to affect what goes on between practitioners and clients. There are general distinctions between traditional and orthodox medicine. For instance orthodox medicine is considered as modern, biomedical with structurally dominant systems. In contrast, traditional medicine is considered more local, culturally relativistic, and functionally strong and uses traditional healing approaches respectively (Sato, 2012). In another instance, it is argued that the basic distinctions than can be found in orthodox/modern/scientific and traditional/alternative medicine is the fact that while OM is natural in orientation, TM is supernatural in orientation (Tanyanyiwa, and Chikwanha, 2011). According to Verkerk, this distinction is based in view of their historical foundations. This means that, while OM is based on natural science with its empirical traditions, TM is based on traditional religious theories of illness and magic/ritual (Verkerk, 2009). The distinction between traditional and modern denotes the changing and creative nature of modernity as compared to an assumed stagnant and unchanging traditionalism (Stoner, 1986) even though the medical institutions labelled ‘traditional’ have undergone considerable change in the last century. University of Ghana http://ugspace.ug.edu.gh 19 2.3.2 Orthodox Medical System (OMS) Modern medicine is sometimes referred to as Western medicine, biomedicine, scientific medicine, or allopathic medicine (WHO, 2001). Modern medicine is evidence based and practices the use of a discrete, well-defined chemical entity for the treatment of diseases. This type of medicine is often said to be new in origin. Some scholars even argue that it is not more than a century old. Example, Aspirin is perhaps one of the oldest orthodox medicines in the world, but it was not discovered until 1895 (Garodia et al., 2007). 2.3.3 History of OMS in Ghana In Ghana, the beginning of modern medicine has a contested claim because scholars have always argued emotionally on how and when it emerged in the Ghanaian healthcare system. In a study, ‘in sickness and in health: globalization and healthcare delivery in Ghana,’ Senah (2001) has given a lengthy account on how modern healthcare system developed in Ghana during the precolonial, colonial and post-colonial eras of the country. According to Senah, this development is in three phases. An account of these phased development is given below. The first phase consists of the emergence of biomedicine and how it was subsequently established in the Ghanaian healthcare system. This introduction was, however, a sole preserve for the colonial masters. The purpose for its establishment was to protect these colonial masters against the possibility of contracting of diseases that they considered infectious from some conditions of the natives that they consider ‘unhygienic’. This is because they couldn’t cease having interactions with them and their environment (Senah, 2001). During this period, healthcare personnel attended only to the foreign expatiates. This clearly shows that the indigenes were relegated from orthodox healthcare access during this time period. University of Ghana http://ugspace.ug.edu.gh 20 Furthermore, according to Senah the signing of the bond of 1844 begun the second phase of the development of orthodox medicine by the colonial masters in the then Gold Coast. The signing of the bond enhanced activities of the colonial masters in the hinterland. These activities include; commercial, missionary and other activities. It also helped in the promotion and subsequent realization of some dreams of the colonial masters in that they could not have enjoyed good health without ensuring that the natives do same (Twumasi, 1975; Senah, 2001). Because of this, colonial health services including basic sanitary facilities were later extended to domestic servants of the colonial masters. Among these servants were people in the civil service and military service. Their early inclusion was due to the fact that they were considered to have constant contact with their colonial masters and their local indigent’s counterparts (Senah, 2001). That is to say that they were the constant middlemen between the local people and the colonial masters. As time went on, educated Ghanaians who were constantly exposed to western ideas and work in urban and colony areas gradually familiarised themselves with western-biomedicine. As a result, their reception, to modern healthcare services became more positive. For instance, according to Patterson, in the coastal areas, there were many educated people. These people were therefore quick to access orthodox medical care. On other hand, only few people among the northern Dagomba Villagers were educated. As a result, they were restricted from such services and they continue to use traditional medicine. However, with the spread of formal education, and continuous provision of sanitary facilities, living conditions begun to improve. As a result, people’s negative perceptions about orthodox medicine eroded continually but in a gradual process. This helped pave way for orthodox medicine which was able to penetrate through the societies (Patterson, 1981). University of Ghana http://ugspace.ug.edu.gh 21 Base on this, Patterson (1981) had given a remark that national health status dramatically improved, including national health standards. The first hospital in Ghana was built in Cape Coast in 1868. During this same period, several other dispensaries were built in other communities across the country. This was the beginning of the third phase of orthodox medicine in the country (Senah, 2001). From the words of ͼPatterson 1981), many people in Ghana were subsequently employed into British-colonial-modern healthcare setups in the nineteenth century. However, the “rising racism and a desire by Europeans to monopolize higher posts in the empire blocked the careers of educated Africans in all branches of the colonial service” (p.13). As a result of the rising racism, possibilities of hiring more local practitioners were suppressed (Patterson, 1981) although there was an increase in demand for more health personnel. Similarly, other authors such as Delancey (1978) and Ford (1971) acknowledged that the increased modernization efforts altered the pattern of disease contraction and management in the country. Rapid modernization led to steady increase in cross-country interaction. Because of this, diseases like tuberculosis, smallpox, typhoid, heart problems etc., began to become major issues in health in this country although previously they were never prevalent. In Ghana, the current medical system has grown enough to include government-operated financed delivery systems in which medical care is provided at government hospitals. It also includes health centres, clinics, health posts and maternity homes. There are also quasi-government-operated health services like those run by the army, the police, and some large firms and corporations for their employees (Tabi et al., 2006). Besides, there are private hospitals and Traditional Medical Practitioners (TMPs). University of Ghana http://ugspace.ug.edu.gh 22 2.3.4 Traditional Medical System (TMS) Traditional Medicine (TM) and its practitioners are said to be officially recognized in 1978 by the Alma Ata Declaration. It was recognised as a needed resource for achieving health for all (WHO and UNICEF, 1978). Since the declaration, the governing bodies and member states of the world body have adopted a number of resolutions and different other declarations on traditional medicine (WHO, 2010). Traditional medicine is the collection of knowledge, skills, and practices based on beliefs and experiences in indigenous cultures. Put differently, “traditional medicine is the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness” (WHO, 2010 in Muweh, 2011, p. 9). Traditional healthcare systems in general have had to meet the needs of the local communities for many centuries. Traditional medical practices are well developed in few countries. For example for a very long time in China and India, there have been a development of sophisticated systems of TM such as acupuncture and ayurvedic medicine. This development is in the right direction and WHO is calling on other countries to do same. This is because traditional medicine is generally available, affordable, and commonly used in large parts of Africa, Asia, and Latin America (WHO, 2010). In Ghana, the Traditional Medicine Practice Act 595 was passed in 2000. According to the act, TM refers is practiced based on beliefs and ideas of the people that are recognized by the community in healthcare provision. These beliefs and practices use herbs and other naturally University of Ghana http://ugspace.ug.edu.gh 23 occurring substances (WHO, 2011). Traditional medicine is the genesis for all medical treatments because initially all drugs were natural in the form of vegetable, animal, mineral products etc. in their crude forms. Before the emergence of the twentieth century, all medical practices were what we now call the traditional system. Traditional medicine has been defined in another context to be “the sum total of all the knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observations handed down from generation to generation, whether verbally or in writing” (WHO, 1978 in Adachukwu and Yusuf, 2014, p. 675). Looking at the discussion, traditional medicine can said to be used mainly to distinguish the ancient and culture- bound healthcare practices, which existed long before the application of science to health matters in official, modern, scientific or allopathic medicine. Some frequently used synonyms for TM are indigenous, unorthodox, alternative, folk, ethno, fringe, unofficial medicine and healing etc. (Bannerman, 1983). Almost, all traditional medicines have their roots in folk medicines and household remedies. WHO has listed 20,000 medicinal plants used in different parts of the world (Korpenwar, 2011). Other estimates indicate the number to range between 35,000 and 70,000 worldwide (Lewington, 1993; Bhattarai & Karki, 2004). Some of the earliest remedies and prescriptions became widespread and were subjected to certain refinements, revisions and improvements through practices by trained or experienced medicine men and then got incorporated in organized or codified systems of medicines. Since TM is primarily used by a large part of the world’s population, there is a widespread and increasing appreciation in terms of the role that it plays in healthcare delivery. This is even more pronounced among people who consider it affordable (Boon and Ahenkan, 2008) and sees it to be University of Ghana http://ugspace.ug.edu.gh 24 deeply interwoven into the fabric of cultural and spiritual life of especially local communities where there are no health services (Mander, 1998). Efficacy and effectiveness of traditional medicine The efficacy and effectiveness of traditional medicine have a root in the processes involved in the choice of the profession, the training of the professionals, nature and processes involved in treatment etc. (Abel and Busia, 2005). Traditional medical practitioners usually choose their profession with a sense of spiritual vocation. They are likely to be drawn into practice as a consequence of some incidents that suggest they heard a ‘voice’ or felt a calling from the spiritual world – much as nuns and monks do in the Christian tradition. The final decision to allow a person into training is that of the relatives. When this permission is obtained, a person may enter into the apprenticeship of another practitioner who usually practiced under the same influences as the apprentice felt. It is a dual-sex vacation since both men and women are accepted as traditional medical practitioners but they may be trained at different shrines (Twumasi, 1975). In Ghana, the practitioners uses magic, religious acts and concepts etc. They do this to find the cause and course of a disease before applying treatment/medication. While physical medicine may be applied, the real potentiality of the medication is always sought in terms of how spiritually potent the medicine is (Twumasi, 1975). As a result of the above processes, traditional medicine has proven efficacy in a number of important treatment areas in the country. These areas include but not limited to fertility and antifertility regulations (Kharkhov and Mats, 1998; Adams and Garcia, 2006; Lans, 2006; Rodrigues, 2007) mental health, prevention of disease, treatment of non-communicable diseases, treatment of sexually transmitted diseases, psychoactive stimulation and improved quality of life University of Ghana http://ugspace.ug.edu.gh 25 in elderly people and in persons suffering chronic diseases etc. (van Andel et al., 2012; Semenya and Maroyi, 2012; Andel et al., 2012). Characteristics of traditional medicine In most communities in the world, traditional healthcare practitioners practice means of healthcare that is culturally acceptable to the local population, and deals satisfactorily with many health problems. The important things associated with most traditional medicines are animal sacrifices, exorcism and religious ceremonies. Other features are preaching of supernatural powers and evil spirits. It also include psychotherapy, cauterization, and the use of animal and mineral products (Foundation for Medical Research, 2006). It has been said that, occasionally, there may be liberal use of musico-therapy, often associated with tribal dances and with ritually induced trances or hypnotism. Among all the forms of traditional medicine, herbal medicine is, however, the most popular. There are common features for traditional medicines (WHO, 2004) and these include the following: 1. Traditional medicines are different from orthodox medicine in character as well as in medicinal value. 2. Most of them use herbal products (Tabuti, 2006). 3. Traditional medicine may involve multiple drug formulations. These formulations may include; plant, animal and mineral products as their essential components (Che et al, 2013). 4. In therapies that involve traditional medicine, there is usually data on pre-clinical investigations. In most cases, this data is incomplete (Foundation for Medical Research, 2006). University of Ghana http://ugspace.ug.edu.gh 26 5. There are cases that traditional medical practices are based on beliefs which are mistaken, faulty, experimentation or inaccurate. These mistaken beliefs may pose further danger after use (Tanyanyiwa, and Chikwanha, 2011). 6. Though in some cases information on dosage is lacked or insufficient, there are other cases that they include information on empirically defined doses (Semenya et al. 2012). 7. Mostly, traditional medicine uses plants whose identities are controversial. 8. In most cases, traditional medicine poorly adopt safety measures (NCCM, 2011). 9. Traditional medicines usually use additives many of which even have therapeutic properties and in themselves can heal diseases (Spinella, 2002). Development and strength of traditional health care system in Ghana since colonization As a result of colonialism, there has been a slow-down in the development of various African cultures (including traditional healthcare system) because most of the colonial authorities imposed their cultural practices (including the practice of biomedicine and modern healthcare system), upon the people of Africa and of this country Ghana (Sena, 2001). Therefore, it was not surprising that the people who practice traditional medicine in this country developed a negative and hostile attitude towards modern and scientific approaches to the provision of healthcare in the early stages in Ghana. Contrary to orthodox healing, Twumasi (1982) have remarked that, the indigenous healers believed that there is a state of balance between man and the environment and they had immutable supernatural laws to explain disease causation base on this state. These indigenous people of the time saw that the newly introduced biomedical knowledge of germ theories that tries University of Ghana http://ugspace.ug.edu.gh 27 to explain disease causation and consequently comes with it mode of treatment is irrelevant to their traditional cosmology and concepts of disease. However, through the gradual education from colonial masters, as time went on, they became accustomed with OM and saw the power in its healing. Despite the fact that the people of the time viewed modern health personnel as very powerful figures and also despite that the skills in anesthesia and surgery of these modern health personnel won the respect of the local people, they were at the same time puzzled by the behaviour and attitudes that these health workers portrayed. In a remark by Patterson, he said, Ghanaians perceived physicians as “strangers who had to use an interpreter and often asked impolite questions; demand, for unknown reasons, samples of blood, urine, and faeces; and sometimes cut open bodies of the dead. Some were so disagreeable that the people avoided them” (Patterson, 1981, p.15). It is true that the colonial masters attempted to educate Ghanaians. The aim of this education was to create awareness on the causation of diseases and how to prevent these diseases. However, often times many people avoided the services of these Europeans. Instead, they continued to use healthcare system indigenous to them which is the application of herbal medicine (Senah, 2001). These remark by Patterson and Sena support Twumasi (1982) view when he contended that, with the emergence of the new health system, indigenous (referring to traditional) healers monopolized the health market. It was as a result of this that the colonial reforms on healthcare were later directed to threaten at a faster rate the role of traditional healthcare system in the country Ghana. As evidence, an inference that can be drawn throughout the development of traditional healthcare system in Ghana is that the utilization of herbal medicine increased despite the development of modern healthcare. The obvious cause of this was the fact that, it was immediately accessible and University of Ghana http://ugspace.ug.edu.gh 28 available to be used by local people which was not the same with orthodox medicine. The reason was that, the colonial administration had limited the number of hospitals, health equipment’s and workers. In effect, there was limited accessibility and availability of biomedicine in the country. Surely, one other argument is that, the process which involve non-formal acquisition of this form of healthcare provision was very attractive to the majority of the people in the country whose educational level was heavily limited. In addition to all these, it was realised that the use of herbal medicine was inexpensive. This did not only make it attractive and popular to use, but it also made it an inherited tradition. The resulting consequence was that, the colonial masters placed a ban on traditional healing including all other indigenous practices by legally restricting them through the Native Customs Regulation Ordinance which was passed in 1878. The reason was to make direct efforts that will help neutralize the influence of traditional healers and to promote orthodox medicine which was the new health dispensation. Through this the colonial officers did not only impose the idea of science and orthodox medicine on the natives and portrayed it as superior, but they also distorted the local peoples worldview on healthcare seeking in order that they uphold the modernist project (Senah, 2001). In a study ‘the professionalization of indigenous medicine: a comparative study of Ghana and Zambia’ by Twumasi and Warren (1986), they suggested that, institutionalization of orthodox medicine was a means to liquidate the local peoples practices of using herbal medicine for treatment. There is also a work by Sena demonstrating how indigenous healers were denied any official mandate and legitimacy to practice medicine (Sena, 2001). In the view of Twumasi and Warren, through these efforts, TMPs lost their prestige as healers. They also succeeded in discrediting them and later portrayed them as insincere, quack, incompetent and illiterate (Twumasi and Warren, 1986) medical practitioners who were even considered harmful on the University of Ghana http://ugspace.ug.edu.gh 29 health of the people. This conscious attempt to de-legitimatize and stigmatize a whole medical system of the indigenous people which have been developed through hard work and pain over years was fully aided by the ‘church’ (Twumasi, 1982). Although there is limited data on the practice of traditional healthcare in Ghana, there are still studies that have interesting revelations on the subject. Example, studies from (Senah, 2001; Twumasi & Warren, 1986) have provided an explanation to the secret nature of TMPs and why up to date some individuals, churches, etc. still view traditional way of healthcare delivery as indecent. Despite this, many of the Ghanaian population were seeking herbal medicine behind the door. Among these secret traditional health seekers were illiterates and women. This evidence is given by Patterson (1981) when he observed that, women and other Ghanaians with no education and no constant contact with the Whites were not exposed to orthodox medicine. As a result, they continued to use traditional medicine. This was so because as a result of their limited knowledge, they became suspicious of biomedicine and much reluctant to be examined by its practitioners who are mostly males and considered strangers (Patterson, 1981). Use of traditional medicine Traditional medicine has maintained its popularity in all regions of the developing world and its use is rapidly spreading in the industrialized countries also (WHO, 2003). In China, for example, herbal preparations account for 30%- 50% of the total medicinal consumption. In Ghana, Mali, Nigeria and Zambia, the first line of treatment for 60 percent of children with high fever resulting from malaria is the use of herbal medicines at home (WHO, 2003). WHO have estimates that, in several African countries, traditional birth attendants assist in a majority of child births. Traditional medicine which already provides health security to over 80 percent of the population in Africa, if standardized and properly controlled, has the potential to be used in primary healthcare. In most University of Ghana http://ugspace.ug.edu.gh 30 developing countries, ethno medical healing systems constitute primary healthcare for many people (Miller, 1980). Regulatory situation for traditional medicine in Ghana Restrictions contained in the Poisons Order Act of 1952 limits registered medical practitioners on the use of the substances and drugs (WHO, 2001). The Medical and Dental Decree of 1972, the National Drug Policy and the (MOH, 2004) “Nurses and Midwives Decree of 1972 allow indigenous inhabitants of Ghana to practise traditional medicine, provided they do not practice life-endangering procedures” (WHO, 2001, p. 16). According to WHO, “The Centre for Scientific Research into Plant Medicine was established in 1975” (WHO, 2001, p. 16) in Ghana. Apart from its research capacity, the centre operates a hospital. This hospital provides both traditional and allopathic medicine (WHO, 2001). Until the passage of the Traditional Medicine Practice Act, the Government worked with the Ghana Psychic and Traditional Medicine Practitioners' Association to license and register traditional medicine practitioners and to ensure a standard of care. The Traditional Medicine Practice Act 595 was drafted by traditional medical practitioners, placed before Parliament in 1999 and passed on 23rd February, 2000. The Act establishes a council to regulate the practice of traditional medicine practitioners and license them to practice and to regulate the preparation and sale of herbal medicines (WHO, 2001, p. 16-17). According to the Act traditional medicine is all the “means of practices based on beliefs and ideas recognized by the community to provide healthcare by using herbs and any other naturally occurring substances” (MOH, 2004, p. 31). In the same way, the Act define herbal medicines “as any finished labelled medicinal products that contain as active ingredients aerial or underground parts of plants or other plant materials or the combination of them whether in crude state or plant preparation” (p.31). WHO has discussed the four parts of the Act as follows; University of Ghana http://ugspace.ug.edu.gh 31 i. Part I concerns the Traditional Medicine Practice Council, including its establishment; function; membership; tenure of office of members; how meetings are carried out; committees such as Finance, General Purposes, Research, Training, Ethics, and Professional Standards; Allowances; and the establishment of regional and district offices. ii. Part II covers the registration of traditional medical practitioners. Clause 9 states that no person shall operate or own a practice or produce herbal medicines for sale unless registered under this act. The qualifications for registration are given in Clause 10. Clause 11 provides for the temporary registration of foreigners who have a work permit, satisfy the requirements for registration under this act, and have a good working knowledge of English or a Ghanaian language. The rest of Part II deals with matters concerning renewal of the certificate of registration, suspension of registration of practitioners, cancellation of registration, and representation to the Council. In Clause 13, it is provided that the Minister of Health, on the recommendation of the Council in consultation with recognized associations of traditional medicine practitioners, may regulate the titles used by traditional medicine practitioners based on the types of services rendered and the qualifications of the practitioners. iii. Part III covers matters concerning the licensing of practices: mandatory licensing; method of application and conditions for licensing; issuance and renewal of licences; acquisition and display of licences; ownership and operation of a practice by a foreign practitioner; revocation, suspension, and refusal to renew a licence and representations to the Council by aggrieved persons; powers of entry and inspection by an authorized inspector; and notification of death to a coroner. iv. Part IV concerns staff for the Traditional Medicine Practice Council as well as financial and miscellaneous provisions, such as the appointment of a registrar, the provision of the Register of Traditional Medicine Practitioners, offences, and regulations. Clause 41 states categorically that the Act shall not derogate from the provisions of the Food and Drugs Board Law PNDCL 305B (WHO, 2001, p.17). According to WHO (2001), the Traditional Medicine Unit was created in Ghana in 1991 and by 1999 it has reached the status of a directorate. The Ministry of Health in Ghana, the Ghana Federation of Traditional Medicine Practitioners' Association and other stakeholders have come together to develop a five-year strategic plan for the practice of traditional medicine. This plan outlined the activities to be carried out from 2000 to 2004 to help advance the cause of traditional medicine in the country. Among other activities, the act has outlined ways of developing a training programme from basic to tertiary levels in traditional medicine. University of Ghana http://ugspace.ug.edu.gh 32 Volume 1 of the Ghana Herbal Pharmacopoeia contains scientific information on 50 medicinal plants. Efforts are being made to integrate traditional medicine into the official public health system. It was expected that by the year 2004, certified and efficacious herbal medicines will be prescribed and dispensed in hospitals and pharmacies (WHO, 2001, p. 18). However, even as at now, this has not been able to be realised (Asante, 2010) perhaps because the development and manufacture of herbal products have been very slow in the country (MOH, 2004). Local officials are however allowed to authorize the practice of traditional medicine in their administrative subdivisions (WHO, 2001). According to a strategy plan by the WHO (2002) on traditional medicine, there are four areas that must be looked at critically in the process of integrating TM into a healthcare system. These areas are briefly discussed. Policy: Through an act of Parliament, a policy to guide programmes and practice of TM must be instituted in countries. The policy should include a legal framework which sets parameters in which traditional healers and their clients can operate and a code of ethics to guide what is right from wrong. Safety, efficacy and quality of traditional medicine: This can be achieved by expanding the knowledge base of TM. Through research, dosages of traditional remedies ought to be standardized and their efficacy established. Also by providing guidance on regulatory mechanism and quality assurance, issues of safety, efficacy and quality may be addressed. University of Ghana http://ugspace.ug.edu.gh 33 Access and affordability: What makes TM attractive is its easy accessibility and affordability to the majority of its users. In this regard, issues of safety, efficacy, and quality should be established with these fundamental aspects in mind. Rational use: This encompasses sound use of appropriate traditional medicine by traditional healers. The above four areas are crucial components of an ethical framework on which the integration of TM into the Ghanaian health system ought to be based. The argument is that TM, despite its wide use and claims of efficacy, ought to comply primarily with a set of ethical standards. Therefore, any health policy on TM ought to be guided by a moral framework and ethical principles. Problems associated with use of traditional medicine The overall goal in drug development is quality, safety and efficacy. All measures in drug development are directed towards this goal. The requirements of health authorities on quality, safety and efficacy are standardised on a high level based on the development procedure for herbal as well as synthetic drugs. Health authorities are reluctant to accept traditional drug preparations from other cultural areas without well-documented data on quality, safety and efficacy. In many developing countries, appropriate utilization of local resources to cover drug needs is dependent on preliminary scientific study to determine the efficacy and safety of the preparations based on plant drugs that are used on an empirical basis in traditional medicine (The Foundation for Medical Research, 2006). University of Ghana http://ugspace.ug.edu.gh 34 There are a number of health related problems that are caused through the process of practicing TM (Kassaye, et al., 2006). For instance, a number of harmful practices have been traced to traditional healers. Examples of such practices are female genital mutilation, milk tooth extraction etc. (National Committee on Traditional Practices of Ethiopia, 1998), blindness and changes in central nervous system function have been found with dosage of Hagenia abyssinica (Rokos, 1969). Also, it has been fund that traditional healers may cause delays in the treatment of communicable diseases such as TB because in most cases they fail to refer patients to modern health services (Yimer, et al., 2005). It is noted and rightly so, that current TM practices are faced with some ethical, research, professional etc. complications. These include quackery, which remain unchecked because of lack of regulations or their enforcement in especially many developing countries; safety and efficacy of traditional therapies which may be unknown; dosages which may not be standardized; toxicity levels which may be undetermined (Phungwako, 2006) etc. 2.3.5 Socio-economic variables and the use of medical systems Judging from practices such as radio advertisements (Awunyo-Vitor et al., 2013), one will be tempted to believe that everybody in Ghana uses herbal medicine. There is every indication that a very large and growing number of Ghanaians use herbal medicine. This section review literature on the social, economic and cultural variables that influence the choice of health seeking behaviour. It has being argued that the frequency of use made by an individual of traditional or modern medical services is influenced in a large measure of extent by his/her education, socio-economic status, age and locality (Williams, 2007; Dovie et al., 2008). Dovie et al., (2008) further opined University of Ghana http://ugspace.ug.edu.gh 35 that area of residence, employment status, education and age were important factors explaining people’s choice for medical services. While their study suggest that urban residents, the educated and the young are less likely to have knowledge on medicinal plants as compared to the uneducated, rural populations and the aged, other studies have contradicting results. For instance, (Cunningham, 2001) observed that urbanization as a factor tends to increase the demand for plants resources (including use as medicine) rather than reducing the demand for wild plant resources, resulting in a commercial trade. Critically analyzing the statistics of (WHO, 2011), the surest conclusion that can be drawn is that modern health services are underutilized by the population primarily due to the use of more accessible traditional and transitional medical services. Tabi et al. (2006) and Williams (2007) found out that the attainment of formal education, acquisition of new skills, rapid economic development and improved job markets are important factors of explaining the attitude of people towards traditional or modern medical services. When a study was conducted to examine the factors which influence the choice of people in the area of medical system, Tabi et al (2006) found out that education, religion and culture, economic and financial factors, accessibility and affordability of healthcare and personal belief/faith in healing are important factors which make people to choose either modern medicine or otherwise. It was also discovered that the individuals perception of the causes of a given sickness or diseases guide him/her to choose a source of treatment. Most African societies have disease theory systems that they use to identify, classify and explain diseases. These theories can be used to explain the phenomenon of medical systems in Africa. This is because a society’s causation theory of a particular disease is important in determining the type of treatment (medical system) to be administered. Health issues that are considered cultural-bound University of Ghana http://ugspace.ug.edu.gh 36 like witchcraft, convulsion, STDs, aphrodisiacs, infertility etc. are considered to be caused by supernatural forces and can only be treated through herbs or visiting a traditional healer (who buys his medicine at a fetish market) instead of consulting a clinic (Ventevogel, 1996; Myren, 2011). Therefore looking for plants or western medicine to deal with or treat certain physical illnesses should be culturally more appropriate. In a careful review by Asare-Danso (2005), it was identified that three basic theories of disease causation exist. According to him these are the personalistic, naturalistic and emotionalistic diseases theories. Personalistic theories of disease attribute the cause of disease to personalities or personal entities, like witches, sorcerers, ghosts and ancestral spirits. Naturalistic diseases are explained in impersonal, systematic or scientific terms attributing the cause to micro-organisms. An example of a naturalistic theory is the germ theory. The emotionalistic theories attribute the cause of disease to intense emotional experience of the person involve. With this, the individual society’s perception about the cause of disease will therefore inform the choice of medical system. In his thesis, Darimani (2007), cited that reasons for using traditional medicine are usually instigated by belief that certain diseases can only be treated by traditional means. This means that given the type of disease and perception of the individual about the cause of such disease, one may be forced to use traditional medicine or otherwise irrespective of area of residence, economic status or even educational attainment. Asare-Danso (2005) supported this argument in his three basic theories of disease causation and by inference, each society possess its theory of explaining the cause of diseases and illness and that plays a critical role in the choice of medical system. Beside the factors raised, some of the reasons that account for wide use of TM around the world include: acceptability, availability and affordability (Williams et al, 2013; Sadik, et al., 2013). University of Ghana http://ugspace.ug.edu.gh 37 Similarly, Twumasi (1975) has indicated that in Ghana patients visit the traditional healers and also the hospitals and in rural areas where there are no modern health services, patients who cannot for several reasons travel outside has no other choice than to consult traditional healers. Similarly, Mender (1998) also identified that in most contemporary societies, traditional medicine is commonly practiced in rural areas where they lack modern health facilities. As a result, some studies have observed that modernization and technological innovations of modern medical systems may relegate the use of traditional medicine to the background. According to Asare-Danso (2005), the issue of bad environmental management practices is posing a threat to the traditional medical practices as compared to modern medicine which comparatively operates under well- organized and hygienic environments through the use of new technologies. Also, some studies have attributed the use of traditional medicine to area of residence (rural verses urban) indicating that people living in urban centres are likely to utilize modern medicine more than their rural counterparts. Evans-Anfom (1986) and Asare-Danso (2005) indicated that two- thirds of the world population live in rural settings and they rely on traditional medicine because orthodox (modern) medicine predominantly functions in the urban settings. It has also been argued that when people move to new locations they are likely to give up their belief systems which are essential in the use of medicine. In this regard, Tabi et al. (2006) indicated that when people are removed from the influence of the traditional village system by moving to new locations and begin to act independently of traditional values, they change their taste and preference in terms of medical system. Thus, a person begins to adopt values and norms of others within close proximity and leave the village way of life. University of Ghana http://ugspace.ug.edu.gh 38 On the contrary, Barimah and Teijlingen (2008) have observed that a large percentage of Ghanaians living in Toronto (Canada) irrespective of their environment still attach significant importance to TM more especially the Ghanaian Traditional Medicine with specific reference to faith healing as involving their health seeking behaviour. This findings confirm the assertion that when Ghanaians travel to other places (even outside the country) to seek better opportunities, they do not abandon/forget their traditional medicine usage. For instance, The use of traditional medicine from Ghana is rather becoming popular among Ghanaians abroad especially those in UK, Germany, Holland, Belgium, Denmark, Canada, Sweden, Scotland and the USA (F. Amankwaa, personal communication, February 10, 2015). According to Asare-Danso (2005), in this modern and scientific era, one would have expected that the traditional medicine would no longer be patronized in Ghana, and that modern or orthodox medical system would take its place. However, this is not the case, as more people continue to show interest in, and patronize traditional medicine (Asare-Danso, 2005). The use of traditional medicine has also been attributed to poverty. For instance, Twumasi (1975) indicated that most people in the rural areas use traditional medicine due to their inability to travel out to access modern health centres. But the Danish Development Agency (DANIDA, 2005) noted that the cost of using traditional medicine in Ghana ranges from One Dollar ($ 1) to Fifty Dollars ($ 50) depending on the illness treated. Therefore they are challenging the view held by many that, Africans use traditional medicine due to poverty (Abel & Busia, 2005). 2.3.6 Integrating traditional and orthodox medical systems When modern healthcare system and its practitioners emerged in Africa, traditional healers and initiation leaders were not interested in showing any form of distinction between what is modern University of Ghana http://ugspace.ug.edu.gh 39 medicine and what is traditional medicine. They were ready to invite modern medical personnel and all that is involved in their ‘antiseptic regime’. In simple terms, the traditional medical practitioners tried to involve the actors and agents of orthodox medicine in healthcare treatment in their communities (Langwick, 2006). On the contrary, Langwick rightly put it that modern healthcare personnel grew more concerns in these distinctions. They therefore exercised much control on traditional healing practices. This control was done by creating sharp contrast between orthodox and traditional healthcare systems, without any regards to those traditional practices that are even considered effective (Langwick, 2006). In view of this, physicians over the years have set and they continue to set boundaries between orthodox and traditional healthcare systems. They view any treatment that do not have roots in biomedicine as unscientific and impure and try to set orthodox medicine away from it. Different societies around the world have evolved their own distinct ways and methods of dealing with ill health. In many developing countries including Ghana, use of medicinal plants and herbs is inherent part of traditions, beliefs and cultural values of the people. It is considered a corpus of knowledge that has been passed on from generation to generation. However, these indigenous healthcare systems still remain relegated from the official healthcare system in Ghana. Despite the official status accorded to western medicine, it is believed that between 60%-95% of the population in Ghana and other developing countries rely on traditional medicine (TM) for their health security (Anyinam, 1995; WHO, 2000; Cunningham, 2001). Recognizing this, WHO and other African regional bodies have been encouraging countries to officially recognize and integrate traditional medicine into their national health policies (WHO, 2002). University of Ghana http://ugspace.ug.edu.gh 40 In 1978 WHO officially promoted traditional medicine in developing countries (WHO, 1978). In a declaration in 1979 WHO recommended that there should be collaboration between orthodox healthcare and traditional medicine. An example of such collaboration is defined in such fields as maternal care (i.e. usage of traditional birth attendants). This is because, the rise in health related problems such as HIV epidemic, shortage of health workers, rising costs of medicines, non- equitable distribution of health resources and lack of universal access to quality healthcare services have worsened the healthcare delivery system in especially Sub Saharan Africa and Ghana (Hornbay et al, 2003). In this context, traditional healers have been called on to take an active role mainly in primary healthcare delivery. This call was made explicit in a document by WHO in the year 2002. This official document recognizes the importance of TM and spells out strategizes and roles that TM can play in improvising healthcare delivery systems mainly in developing countries (WHO, 2002). Few years ago, TM/CAM was outside the mainstream conventional medicine and there was no hope of integration (Barrett, 2003). Today, there are calls for integration. Meines (1998 in Barrett, 2003) stated that the integration process has already begun and will likely continue. But there are hindrances to this call. Example, there is the issue of efficacy which is captured by Dalen 1998 in Barrett (2003, p. 420) that “promising unconventional therapies must be subjected to the same level of scientific scrutiny that we now require for drug therapies introduced by ‘mainstream’ medicine”. Others include; lack of standards of practice and economics ignorance about CAM. To overcome these and other challenges in the integration process as discussed in section 2.3.4 above, a number of integration models have been suggested. As an example, there is the Workgroup on the Integration of Complementary and Alternative Medicine (CWIC) model (Barrett, 2003). The main aim of the model is to bring order and University of Ghana http://ugspace.ug.edu.gh 41 reconciliation to the divisive process of practicing medicine. The model put emphasis on the value and belief-laden nature of CAM, conventional medicine, and other health care payers. According to Barrett (2003), the model is described with such phrases like: “better understanding of each other’s languages and philosophies,” “building trust and relationships,” “increased awareness,” “mutual respect,” “patience and openness”, “communicating each other’s views and needs,” “attitudes towards healing,” “cross-fertilization,” “mutual interest,” and, of course, “paradigms” (p. 422). There are other views on the integration. Some of these include the functionalist view, the capitalist view, views by the political-economists, the modernization views etc. According to Adefolaju (2014), functionalism assumes society is an organic whole whose various parts work to maintain each other. This perspective liken society to an “organ in the human body, such that an understanding of a part would require same of its relationship to other organs as well as its contribution towards the maintenance of the organism” (p.119). The assumption is that the mere existence of a social structure makes it functional to the survival of the society. The pillars of the theory assumes therefore that both traditional and orthodox health systems have been developed to enable the people meet their health/medical needs. Integration should therefore recognizes the importance of both. Capitalist’s view of integration assumes that the process of integration should be dependent upon acquiring support from people in decision-making bodies who have a major stake in seeking solutions to health problems. In addition, any integration process should relay to a greater extend on patients who demand forms of treatment that are mostly neglected by orthodox medicine (Han, 2002). The political economic theories calls for an analysis of the mutual link between local practices, social, economic, and political factors (Han, 2002). Authors of this theory assume that the University of Ghana http://ugspace.ug.edu.gh 42 dominant medicine system depend on social and economic relations. According to this model, it is individuals who have to take care of their own health needs and not the society at large. Each of these perspective have its own strengths and shortfalls. For example, although, political economic ideas have proven to be fruitful, they at the same time “seem to overlook individual agents' views or hermeneutics or interpretivist views” (Han, 2002). As a result, any attempt to integrate will be more successful if it is eclectic in nature. 2.4 Conceptual framework Base on the extensive literature that has been reviewed, the following conceptual framework (see figure 2.1) has been developed for the study. — — — — — — Figure 2.1: Module of the conceptual framework Integration Medical systems Improved healthcare delivery Integration challenges relating to OMPs Socio- demographic factors Residence Education TM OM Integration challenges relating to TMPs University of Ghana http://ugspace.ug.edu.gh 43 This study is hinged on the Socio-Demographic Model (SDM). The model explains that, there will be differences in levels of preference and/or usage of medical systems by people with different levels of demographic features. In this study, it is only two of these features that ware considered. They include place of residence and education. It is appreciated that there are a number of other socio-demographic features that could be considered by other researchers in future. According to this model, the integration of orthodox medical system and traditional medical system may lead to improved healthcare delivery. Integration as used in this model is the combination of orthodox and traditional medicine in the provision of health. The model further assumes that, the process of integration is affected by certain problems. While some of these problems relate to the practitioners of traditional medicine, others relate to the practitioners of orthodox medicine. 2.5 Conclusion In this chapter, literature was reviewed on some important theories, concepts and studies about medical systems. Three theories including the sick role, stages of illness and observational learning theories were reviewed. Then literature was reviewed on orthodox medical systems, traditional medical systems, socio economic variables and how they affect the choice of medical systems and the integration of traditional and orthodox medicine. Base on the concepts that emanated from the literature review, a conceptual framework known as socio demographic model was derived. University of Ghana http://ugspace.ug.edu.gh 44 CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter describes the methodology that was used for the study and how the research was conducted. It includes brief description of the study area, followed by the approach for the study, study design, target population, sampling techniques, data collection instruments, sources of data as well as how the collected data was analysed. 3.2 Study area 3.2.1 Site selection The research was conducted in the Wenchi Municipality. The Municipality is located in the Western part of Brong Ahafo Region. It is located at the northeast of Sunyani Municipality. Wenchi Municipality is situated within latitudes 7, 30 o and 8, 05 o North and longitudes 2, 15 o West and 1, 55 o East. The total land area covered by the Municipality is 3,494 square kilometres. The following are the adjoining districts or municipalities; Techiman Municipality, Kintampo South District, Tain District and Sunyani Municipality to the West, Northwest, East and South respectively. The population of Wenchi Municipal in 1970 was 98091 (WMA, 2006). According to reports from the assembly, by 1984, the population had increased to 155,857. The 2000 National Housing and Population Census put the population of Wenchi Municipal Assembly at 166,641 (WMA, 2006). The 2000 estimates include that of Tain and Banda districts because they were part of Wenchi Municipality as of that time. With support from Ghana Statistical Service in 2010, the Municipality estimated its population to be 89,739 excluding Tain and Banda districts. University of Ghana http://ugspace.ug.edu.gh 45 The current population of the municipality is estimated to be 113,684 (WMA, 2012). Though the current population of the municipality has been estimated, most of the population characteristics in this section are based on the 2000 and 2010 population and housing censuses base on the information available at the Municipal Assembly (MA). The Municipality is made up of 69.59 percent rural settlements and only 30.41 percent urban. According to population criteria of the district, only Wenchi town is classified as urban settlement. Even Nchiraa which is the next bigger community in the municipality has a population of 3658. The other communities include Awisa, Nkonsia, Beposo, Droboso and Nwoase are even smaller and therefore considered as rural settlements. Figure 1 shows the location of the municipality at the regional and national levels (WMA, 2006). University of Ghana http://ugspace.ug.edu.gh 46 Figure 3:1 Location of Wenchi Municipality at the national and regional levels Source: Wenchi Municipal Assembly, 2006 University of Ghana http://ugspace.ug.edu.gh 47 3.2.2 Age and sex structure From the estimation of the assembly, as at 2006, the population of Wenchi was considered youthful in that 7.24 percent were below 5 years while 35.45 percent were within ages 5 and 18 years with 50.12 percent between 18 and 59 years. At the same time, only 6.69 percent of the population was above 60 years. The indication is that, a large potential labour force exists in the municipality. This is an asset that needs the requisite skills development to push the development agenda in the Municipality. Economically active population in the municipality is 50.12 percent, while at the national and regional levels it is 24.4 percent and 23.9 percent respectively. The current sex ratio in the district is 1:1.03, while it was 1:06 in 1984. This shows a level of decline in the male population over the years (WMA, 2006). 3.2.3 Economic activities The major economic activity in the municipality is agriculture, including animal and forestry. The agriculture sector alone employs about 75 percent of the working population. There are a number of other small-scale industries in the municipality. These range from agro-processing to stone quarrying, beekeeping, soap making etc. 3.2.4 Labour and dependency It has been estimated that 47, 499 of the people of Wenchi Municipality are economically active. This means they are within the age group of 15-64years. Out of this, 22556 are males, and 24943 are females (GSS, 2012). By definition, dependency ratio is the relationship between persons in dependent ages (i.e. persons less than 15 and those above 65) and those in productive ages (i.e. persons aged form 15-64 years) (WMA, 2006). Statistically, the dependency ratio of WM is better University of Ghana http://ugspace.ug.edu.gh 48 than that of the region at large. This is because, while the dependency ratio of the Brong Ahafo Region in the year 2006 was estimated to be 90.5, that of WM was 85.7. Statisticians within the municipality have however accepted that, this figure may be misleading. This is because there are people within age 15 and 64 who are not employed. Example a lot more of such people are students. Others are unpaid family labourers and apprentices (WMA, 2006). According to the Municipal authorities, child labour is not a common practice. However, it is seen in certain pockets such as quarrying communities, where community members organize themselves to embark on illegal quarrying (WMA, 2006). 3.2.5 Ethnicity There are about eight major ethnic groups that are spread across the lengths and breaths of WM. Fifty (50) percent of the people in the municipality are Bono, the dominant ethnic group who doubles as the indigenes. Besides the Bono, the next major ethnic group is the Banda with fifteen (15) percent of the numbers. These two groups are mainly farmers. Others are Mo, Kulango and the Asantis (who are also farmers). There are also the Fantes and Ewes who mainly do carpentry work and fish along the Subin River. There are small numbers of Dagombas who farm in rural areas and Sisalas who are normally charcoal producers (WMA, 2006). 3.2.6 Income distribution pattern in Wenchi Municipality Income distribution in the district is generally skewed. There are only 22.6 percent of the households that earn about 49.5 percent of the total annual income in the district which amount to GH¢2,000 and above per household per year. Below this, another 6.4 percent of the population in the WM earns about 10.44 percent of the remaining total income in the municipality. The University of Ghana http://ugspace.ug.edu.gh 49 remaining 64.51 percent of the population control only 31.7 percent of the total amount earn in the municipality. This large percentage of people in total receive an estimated annual income which is below GH¢1000 a year (WMA, 2006). 3.2.7 Pattern of household expenditure in the municipality Records show that the largest component of household expenditure is on food purchase which occupies 53.5 percent of their total income (WMA, 2006). The statistics further show that households also commit about 9.8 percent of their income on transport and a surprisingly 8.8 percent on clothing compared to 8.1 percent on education (WMA, 2006). The expenditure on health is minute and has not yet been given any respectable position in the rank of household expenditure patterns. 3.2.8 Health facilities and accessibility As of now, there are six public health facilities in the district. All these facilities are poorly staffed. There are also three other health facilities that are owned and managed by private individuals. Only one of these facilities has achieved the status of a hospital (i.e. Wenchi Methodist Hospital) with two being health canters, three clinics and one maternity home. Altogether, the workers in these facilities include six doctors, forty-four nurses and one pharmacist. These limited numbers of orthodox medical practitioners are responsible for the provision of health services for the whole population of the municipality. However, doctors from Cuba are posted to the District occasionally to augment the strength of the medical staff. Besides, there is an unknown number of Traditional Birth Attendants (TBAs) in the municipality. The TBAs are officially recognised to provide support to health delivery in a form of child birth and other maternal health issues. Apart from University of Ghana http://ugspace.ug.edu.gh 50 these, there are also herbalists in the municipality. In terms of healthcare delivery, these herbalists play a very significant role. Put together, these health facilities refer cases to Techiman Holy Family Hospital, Sunyani Regional Hospital etc. occasionally (WMA, 2006). There is steady progress by the Municipal Health Insurance Scheme in the municipality. Statistics show that as of December 2012, there were 13,019 registered members of the NHIS with 6,027 males and 6,992 females. By that same period the scheme had renewed 30,020 members out of which 10,106 were males while 19,914 were females bringing total enrolment to 43,039 (WMA, 2012). The maximum acceptable travel time for reaching a health facility is 30 minutes. Therefore for a health facility to be accessible, communities that are 32km away can meet this maximum time requirement only by a second class road while those that are within 10km from a health facility can achieve this by travelling along a feeder road. Where the only means of transport is by walking, this 30 minutes journey can only be completed if the distance is not more than 2km. In calculating accessibility to health services, hospitals and health canters were chosen. From the map (see figure 3.2), all communities running from Buoku in the South and Branam in the North have access to health facility. This is because there is a second class road connecting these communities (which are not more than 32km from Wenchi) to health centres. Others like Nchiraa, Wurompo and Nwoase are also accessible because they are not more than 10km away from health centres and travel to these health centres by feeder roads (Ministry of Local Government and Rural Development and Maks Publications & Media Services, 2006). The accessibility routes to health facilities in the municipality are shown in figure 3.2 below. University of Ghana http://ugspace.ug.edu.gh 51 Figure 3:2 Map of Wenchi Municipality showing accessibility to health facilities Source: Wenchi Municipality, 2011 3.2.9 Top diseases in the municipality The municipality has been able to compile the list of top 10 diseases. During 2003 and 2004, the figures included those of Tain district and Banda district. Statistics show an increase in the incidence of most of the top diseases over the years except five of them which include upper respiratory tract infection, worms’ that infect the intestines, diseases related to pregnancy, accidents, and pneumonia in which number of cases drop. Malaria recorded the most incidents University of Ghana http://ugspace.ug.edu.gh 52 with 59.3 percent of all illness, followed in a distance by diarrhoea. Pregnancy related diseases have the least incidents of all the top ten diseases. (WMA, 2006; WMA, 2012) 3.2.10 Childhood killer diseases Childhood killer diseases in the Municipality require special attention for the future of the Municipality. Measles is the number one childhood killer disease in the Municipality. The highest infection of measles occurred during the periods running from the year 1997 to the year 2001. During this time, there were over 400 reported cases. To be specific, in 2001, measles topped the list with fifty-five percent followed by tuberculosis and then tetanus. However, polio and diphtheria are under control (WMA, 2006). 3.2.11 General health and demographic trends In general, WM has mixed health indicators. For instance, as of 1997, infant mortality was 50/1000. By 2005 it has reduce to 1/1000 live births. Maternal mortality has also decline from 700/100,000 in 1997 to 400/100,000 in 1999 but rose again to 600/100,000 in 2001. However, there was further decline to 102/100,000 live births in 2005. This is probably due to improved access to health services and increased nutritional value. Teenage pregnancy is very high in WM. As much as 729 cases were reported in 1997, rising to 847 in 1999 and 1239 in 2001 (WMA, 2006). 3.3 Research approach The study used a mixed method approach. This was done through combining both quantitative and qualitative research techniques, methods and concepts in achieving research results. The study employed mixed method in order to draw from their strengths and as well minimize the weaknesses University of Ghana http://ugspace.ug.edu.gh 53 of both qualitative and quantitative approaches. The mixed method was used in other to help bridge the schism between them as Onwuegbuzie and Johnson (2006) indicated. In other words, this allowed the researcher to collect multiple data that have helped the results to complement the strengths and non-overlapping weaknesses of each of the methods. Thus, using mixed method was more than simply collecting and analyzing both kinds of data but it also involved the use of both approaches carefully in such a way that the overall strengths of the study ended up being greater than either qualitative or quantitative research (Creswell & Clark, 2007). According to (Creswell, 2008), quantitative research approach provides rich details on the processes and test objective theories which linked the variables together. The qualitative research method on the other hand serves as a means to explore and understand the meaning individuals or groups ascribe to a social or human problem (Creswell, 2007). Using in-depth interviews allowed the researcher to gather in-depth and new information (Miles & Huberman, 1994) regarding the use and preference for medical systems (i.e. traditional and orthodox medicine). In the same way, Patton (2002) advocated that qualitative research presupposes examination upon processes and meanings that do not gain sufficient description for the investigator by using quantitative methods or where quantitative methods alone are inappropriate. It was therefore more beneficial combining the methods because combining them helped the researcher offset the weaknesses and strengths of approaches under both methods. For instance, quantitative methods tend to be more appropriate than qualitative when theory is well developed and for purposes of theory testing and refinement and the opposite is true. To enhance the richness of the research and validity of the results therefore, a combination of quantitative and qualitative University of Ghana http://ugspace.ug.edu.gh 54 approach was deemed better in this study. In addition, data from many sources enabled the confirmation of each other and provided new ideas and fresh insights (Miles & Huberman, 1994). More so, there is a possibility to rate studies that use multiple sources of evidence high in terms of their overall quality than those that rely only on single sources of information (Cooper and Schindler, 2011). 3.4 Study design Research design refers to the plans and the procedures for research that span the decisions from broad assumptions to detailed methods of data collection and analysis. Decisions on which design to use are influenced by objectives of the study, worldview assumptions of the researcher, data collection method, tools, analysis and interpretation, research problem, audience of the study, source of information, as well as the researchers personal experience (Kothari,1985; Creswell, 2009). This research work is a comparative study. According to May, a comparative analysis is a very old method of doing research. It is widely used in several fields of scientific inquiry. In Broad terms comparison approach is often used to contrast two or more cases and to explore differences that are parallel between or among them (May, 1993). This method was used to compare the use of orthodox and alternative medicines in the current research. The main goal was to arrive at a typology that will be based on the differences and similarities between traditional and orthodox medicine that can be observed. It also helped to explore, understand and explain differences across these health system units and arrive at causal models that transcend the particular cases from which they are derived (May, 1993). University of Ghana http://ugspace.ug.edu.gh 55 3.5 Target population The target population for the study includes the population of Wenchi Municipality who utilise medical systems and age from 18-60 years. This section (which is 50.12%) of the entire population was estimated to be 56,978 in 2014 (WMA, 2012). This section of the population was considered because they are the economically active population. Being the financiers of their families, they take most of the decisions of their families including decisions on healthcare use. Medical service providers including orthodox and traditional health providers were also included in the study. 3.6 Sources of data The study made use of both primary and secondary data. The primary sources were obtained from the field using questionnaires and interview guides with focus on education, residence, perception about the cause of diseases, and their preferences and views about both medical systems. Various books, periodicals, reports, internets, journals, websites and other documents were consulted in obtaining the secondary data. 3.7 Sampling technique and size To sample respondents, both probability and non-probability sampling techniques were employed. Probability sampling was employed using the multi-staged sampling to sample consumers of medical systems in the municipality. This is as a result of the geographical dispersion of the communities within the enumeration area (municipality). The first stage of the sampling process involved identifying the clusters (communities) to be included in the study. The second stage of sampling involved stratified sampling where towns and villages within a community were identified using a sampling frame (list of towns and villages) obtained from the Town and Country University of Ghana http://ugspace.ug.edu.gh 56 Planning Division of Wenchi Municipal Assembly with focus on rural and urban settlements. However, since the population size of each geographical area (stratum) is approximately not the same, Probability Proportionate in Size (PPS) was further used. This implies that highly populated geographical areas had larger number of the sampling units. The third stage involved systematic sampling using a sampling frame of households (list of households) within the selected area. The sampling units (consumers) of medical systems were finally selected randomly from the randomly selected households. Specifically, the multi-stage sampling was used in this study to; 1. Ensure the representation of the divergent socio-economic groupings in the Municipality. 2. Ensure the representation of the town and area councils under the Wenchi Municipality in the study, and to 3. Ensure the representation of urban and rural areas in the study. Purposive sampling on the other hand was used to sample doctors and herbalists to participate in the interview. Thus, purposive sampling was used to select key informants from modern medical system and traditional medical system including traditional leaders, doctors, herbalist, priests and priestess, pastors, and chemists, and other stakeholders deemed relevant for this study. These persons ware considered appropriate for the interviews due to their experiences in their respective jurisdictions so far as medical systems are concern. In all, 104 respondents were used for the study. From the table on sample size determination by (Krejcie and Morgan, 1970), the sample size for a target population of 56978 should have been 381. Adding to this it has been observed that, a larger sample can give an accurate representation of the characteristics of the population from which it was derived (Cronbach, et al, 1972; University of Ghana http://ugspace.ug.edu.gh 57 Marcoulides, 1993). However, practical realities such as time, access to samples, and financial costs restricted the size of the sample (VanVoorhis and Morgan, 2007; Cooper and Schindler, 2011) of this study to 104. Beside these realities, the sample is justified by the rule of thumb that the suitable sample size for most behavioral researches is larger than 30 and less than 500 (Roscoe, 1975; Abranovic, 1997). Adding to this is the argument that where the required larger sample size cannot be achieved, researchers can manipulate the effect size (VanVoorhis and Morgan, 2007) to achieve similar results as in larger sample size. This is done by putting respondents into extreme groupings that allow for the use of parametric test(s) with high power. In the case of this study, the tests are independent t-test and ANOVA. Out of these, 98 were sampled using probability techniques and the remaining 6 sampled using the non-probability (purposive) sampling technique. This was in an attempt to ensure fair representation of the entire study area. Table 1 shows the distribution of the respondents and communities in which they were selected from. Table 3.1: Distribution of Respondents and their communities Community Key informants Consumers Total Women Men Wenchi Township 3 21 21 45 Amponsakrom 1 9 9 19 Awisa 1 9 9 19 Subinso 1 10 10 21 Total 6 49 49 104 University of Ghana http://ugspace.ug.edu.gh 58 As indicated in the table, four communities were selected for the purpose of this study. These included Wenchi Township, Amponsakrom, Subinso, and Awisa. These communities were purposively selected due to the availability or otherwise of modern and traditional medical facilities and also to conform to the main objectives of the study. Wenchi Township was selected due to the availability of both medical systems and to represent an urban area, Amponsakrom does not have any modern medical facility, Awisa has a well-established shrine which depicts a traditional medical centre and Subinso has a health centre and a host of traditional healers. These helped the researcher to do a comparative analysis of the use of medical systems since the availability or otherwise of these medical facilities and treatment are essential to the objectives of the study. 3.8 Data collection instruments The main instruments for the study were: 1. Questionnaire and 2. In-depth interviews guide The individual questionnaire was designed for a cross-section of people within the ages of Eighteen (18) years and above in the municipality. The age 18 and above was chosen because people at this age category take most decisions especially in terms of the choice of medical systems. This was in line with the objectives of this study. The individuals represented consumers and users of the forms of medical practices in the study area. The questionnaire contained only close ended items. University of Ghana http://ugspace.ug.edu.gh 59 The questionnaire was structured in two main parts in relation to the research questions and objectives. The first part focuses on the basic characteristics of the respondents which included key demographic variables like age, educational background, and place of residence. Part two of the questionnaire focuses on the perception local people have about medical systems. This second part was sub-divided into knowledge, attitudes and perceptions people have toward medical systems. In exploring the research questions, areas that were covered included efficacy, safety, affordability, among other key variables. Uses of medical systems were also captured under the second part of the questionnaire. The in-depth interviews on the other hand were conducted using interview guide. This was designed for respondents within traditional medical and modern medical professions in the selected areas. Specifically, traditional herbalist, spiritualists, and medical doctors were the target group. This was designed to capture the challenges of integrating traditional medicine into orthodox medicine. 3.9 Pre-testing of data collection instruments To test the validity of the data collection instrument; questionnaire and interview guide, a pre-test was done. This pre-testing of the instrument for the study was conducted in Wenchi with five respondents. The pre-testing helped the researcher to re-phrase and re-structure unclear and ambiguous questions. Some of the questions were re-arranged to ensure logical ordering of questions and deletion of repeated ones. Additionally, the pre-test made planning for the actual field work less stressful and less difficult. University of Ghana http://ugspace.ug.edu.gh 60 3.10 Ethical consideration The policy of voluntary participation was strictly adhered throughout this research. All participants who participated in the interviews and the survey were well informed about the purpose of the research, how information and data collected would be handled and treated with high confidentiality, and that no individual information would be kept once the data is collated. In the same way, as the participants decide to participate, they were free to withdraw and to discontinue participation at any time. That is to say, respondents were also advised that they could withdraw from the study even after the process has begun. It is therefore very clear that, participants were not forced to participate in the research. Besides, because the study required the participation of human respondents, more other ethical issues that are complicated were further addressed. The consideration of these ethical issues was necessary for the purpose of ensuring the privacy as well as the safety of the participants. Among the significant ethical issues that were considered are consent and confidentiality. In order to secure the consent of the selected participants, the researcher reviled to respondents all the important details of the study, including its aims and purpose. By explaining these important details, the respondents were able to understand the importance of their role in the completion of the research. The confidentiality of the participants was also ensured by not demanding the names or other personal information of the respondents. It must further be stated that an introductory letter was obtained from the Department of Public Administration and Health Services Management, University of Ghana Business School to introduce the researcher as an affiliate of the university, and that the researcher is on an academic assignment who should be accorded the needed assistance. University of Ghana http://ugspace.ug.edu.gh 61 3.11 Data management and analysis The data for the study was analysed both qualitatively and quantitatively. Prior to the data analysis, the data obtained from the field was cleaned for data validation. This was done by checking that every question that was supposed to have only one answer does not have more, and that respondents answered the questions correctly. After that, time was taken to edit the data for completeness and consistency after which actual data analysis was performed. The qualitative data (recordings from the interview sections) was transcribed and analysed. This involved reviving the data line by line in details. The transcribed data was then grouped thematically. Thematic grouping involves taking one piece of data and comparing it with all others that are similar or different from it. In doing this, the researcher was able to develop conceptualizations of relations between the various pieces of data. As a concept became apparent, a code was assigned to that segment of the document (or an entire document). To ascertain whether a code is assigned appropriately, text segments were compared with segments that have been assigned the same code previously to check whether the segments reflect the same concept. The quantitative data was analysed using the Statistical Package for Social Sciences (SPSS), now Statistical Products and Services, version 18. Both descriptive and inferential statistics were employed in answering the research questions and exploring the objectives tor the study. In presenting descriptive statistics such as frequencies, tables were used. Inferential statistics on the other hand were employed in testing the hypotheses and exploring factors that affect people’s choice of medical systems using the independent t-test at a 95 percent confidence level and the One Way Analysis of Variance (ANOVA). University of Ghana http://ugspace.ug.edu.gh 62 The ANOVA was used to test hypothesis one. This is because there is one dependent variable (medical systems use) and one independent variable (education) with the independent variable having 4-levels in the hypothesis. The independent t-test was used to test the mean differences in hypothesis two. This is because there are two variable (i.e. place of residence as independent variable and medical systems consumption as dependent variable). In testing the hypotheses, where the significance value of the test-statistics (p-value) obtained was less than 0.05, the null hypothesis is rejected. In mathematical terms, where; 1. P-value ≤ 0.05 => Reject H0 at 0.05 2. P-value > 0.05 => Fail to Reject H0 at 0.05 3.12 Conclusion This chapter gives an in-depth explanation of all the methods that were employed in the study. First, brief background information of the study area was giving. This was followed by a description of both the study approach and study design. Attention was also given to the target population, sources of data and data collection instruments. After this, a description was given on the sampling techniques used including the sampling size and the justification for the sampling size. Going forward, the chapter gave a description on pretesting of data collection instruments as well as how ethical principles were observed. The chapter ended with how the collected data was managed and analysed including the specific statistical instruments that were employed to analyse each of the hypothesis and the justification for using them. University of Ghana http://ugspace.ug.edu.gh 63 CHAPTER FOUR DATA ANALYSIS AND INTERPRETATION 4.1 Introduction This study examined traditional and orthodox medical systems in the Wenchi Municipality with specific focus on factors (education and place of residence) as well as the challenges of integrating traditional medicine into orthodox medicinal systems in the Wenchi Municipality. The results of the data analysed are presented in this chapter starting with the hypotheses testing (quantitative analyses) and followed later by the qualitative analyses. 4.2 Recap of the objectives The main objective of this study was to examine the utilization of traditional and orthodox medical systems in the Wenchi Municipality and assess the challenges of integrating traditional medicine into orthodox medicine in the Municipality. Base on this, the researcher came out to achieve three specific objectives and these include; 1. Examining the relationship between educational attainment and utilization of medical systems in the Wenchi Municipality, 2. Comparing rural and urban population’s preference for medical systems in the Wenchi Municipality and finally, 3. Examining the challenges of integrating traditional and orthodox medicines in healthcare delivery in the Municipality. Based on these objectives, two hypotheses were formulated and one research question asked. The rest of the chapter is on the presentation of results of the tested hypotheses and the answered research question. University of Ghana http://ugspace.ug.edu.gh 64 4.3 Hypothesis one Hypothesis one states that there is significant difference among people with various levels of education in the use of medical systems in Wenchi Municipality. The one way ANOVA was used to test this hypothesis. This is because the hypothesis has two variables (one dependent i.e. medical system use and one independent i.e. level of education). The independent variable has four levels which include: no formal education, basic education, secondary education and tertiary education. The results of the group statistics are shown in table 4.1 below Table 4.1: Group statistics on use of medical systems Level of Education Number Mean Standard. Deviation No Formal Education 24 4.06 .68 Basic Education 18 3.61 .89 Secondary Education 9 3.28 .65 Tertiary Education 47 2.77 .57 Total 98 3.28 .86 The ANOVA results are also shown in table 4.2 below. Table 4.2: ANOVA results on the effects of education on medical systems use Sum of Squares df Mean Square F Sig Between Groups 29.35 3 9.78 21.72 .000 Within groups 42.32 94 .45 Total 71.67 97 University of Ghana http://ugspace.ug.edu.gh 65 An analysis of variance shows that the effect of education was significant, F (3, 94) = 21.72, p = .000. Table 4.3 shows results of a multiple comparison using the LSD. The Post-hoc analyses using LSD indicated that preferences for traditional medicine (as compared to orthodox medicine) was lower for participants with tertiary education than for participants with no formal education (p = .000), basic education (p=.000) and secondary education (p = .03). Similarly the preference was lower for participants with secondary education than those with no formal education (p=.004) but not than those with basic education (p=.22). In the same way, preferences was lower for participants with basic education than those with no formal education (p=.03). Table 4.3: Results of a multiple comparison using the LSD NFE BE SE TE NFE .03 ⃰ .004 ⃰ .000 ⃰ BE .22n.s .000 ⃰ SE .03 ⃰ TE *. The mean difference is significant at 0.05 level. ns. Mean difference not significant at 0.05 level. 4.4 Hypothesis two Hypothesis two states that, there is a significant difference between rural and urban areas in health seeking behaviour in Wenchi Municipality. The independent t-test was used to test for significance of mean differences. This is because there are two variables (one dependent which is the use of University of Ghana http://ugspace.ug.edu.gh 66 medical systems and an independent variable which is place of residence) that are independent of each other. Results of the t-test together with the group statistics are shown in table 4.4 below. Table 4.4: Group statistics and results of t-test on residence and medical systems use Place of residence N Mean SD t df p Urban 42 3.13 .91 Rural 56 3.40 .80 Total 98 6.52 1.72 -1.56 81.78 .11 Among respondents in Wenchi Municipality on the use of medical systems (N = 98), there was a statistically no significant difference between residents of the two areas, residents in Urban (M = 3.13, SD = .91) and residents in Rural (M = 3.40, SD = .80), t (81.76) = -1.56, p = .11. Therefore, the study rejects the alternative hypothesis that there is a significant difference between rural and urban areas in health seeking behaviour in Wenchi Municipality in favour of the null hypothesis that there is no significant difference between rural and urban areas in health seeking behaviour in Wenchi Municipality. 4.5 Results on research Question This study used a mixed method. Beside the hypothesis, one research question was asked and this question was answered using an in-depth interview guide. The rest of this chapter is devoted to the presentation of results on the research question. 4.6 Challenges of integrating traditional and orthodox medicine This section presents results on the challenges in the integration of traditional and orthodox medicines in Wenchi Municipality. The section is based on the research question, “what are the University of Ghana http://ugspace.ug.edu.gh 67 challenges of integrating traditional and orthodox medicines in healthcare delivery in Wenchi Municipality?” In coming out with these challenges, the researcher made several enquiries from key informants. Some of these enquiries relate to key informants perceptions about other medical systems, their readiness to work hand in hand with each other as well as the general challenges hindering the integration of the two medical systems from their perspective. Concerning the second issue, all the key informants interviewed agreed that they were ready to work hand in hand with each other no matter the method of treatment they used. However, there were issues that were seen as challenges in a situation that these two categories are to work together to provide healthcare to clients. The challenges identified are multi-sectorial and range from legal-attitudinal-policy issues and even beyond. There were also challenges relating to; inadequacy of specialists, dosage, referral of cases etc. These challenges are classified as those that mostly have their roots from orthodox medicine and/or its practitioners and those that have their roots from TM and/or it practitioners. The findings on these challenges come next beginning with those that relate to TM and its practitioners. 4.6.1 Challenges relating to traditional medicine and practice Legal and ethical challenges The interviews revealed a lot of challenges bordering on legal and ethical matters. Practitioners of orthodox medicine are guided by well regulated rules and regulations, codes of conduct as well as ethics. For instance from the Ghana health service Code of Ethics (GHS, 2008), there are generally well defined moral principles and rules of behavior that guide professionals under the GHS. Two doctors accepted that beside these codes that are general codes for all health service providers, there are specific codes for each category of practitioners under the GHS such as those under: “Nurses and Midwives Council, Medical and Dental Council etc.” University of Ghana http://ugspace.ug.edu.gh 68 In the same way, there are rules that regulate the practice of traditional medicine in Ghana in general. For instance, there is a 13-paged policy directive document published by the MOH in 2003 as Code of Ethics as well as Standards of Practice for the TMPs to help raise their standard of practice. However, the implementation of this document seems to have not reached the traditional medical practitioners in the Wenchi Municipality. Except one Traditional Birth Attendant (TBA) who undergone a training and is therefore regulated by the practices of TBAs, all the practitioners of traditional medicine interviewed operate freely under no guidelines whether rules, regulations or ethics. They don’t even know the existence of those documents. A chief traditional healer confirmed this “as for us, we are not regulated by any rules, regulations, ethics or whatever. Everybody does things in his/her own way except during the time that the priest at Nwoase was alive. During that time, we use to meet at his shrine occasionally to discuss issues relating to our practice”. Bringing two practitioners together (those that are guided and those without any guidelines who does things the way they like), the author has a view that it will be at least a little worrisome. However, the practitioners think though this is a challenge, it can be managed easily. In the view of the orthodox medical practitioners, the TMPs can be brought together under one umbrella and rules, regulations or ethics made for them. They think however that both OMPs and TMPs cannot be guided under one code of conduct. A medical doctor in an interview said, “oh my friend, this a simple… all the traditional medical practitioners must be brought together under one umbrella and codes of conducts made to regulate their activities… what we can’t do is that, we the OMPs and the TMPs cannot operate under one codes of conduct… But just as nurses, midwifes, doctors etc. have different codes of conduct, so they can do for the traditional medical practitioners”. University of Ghana http://ugspace.ug.edu.gh 69 The TMPs also have the view that operating under codes will never be a headache for them. Though they are not currently regulated, this does not mean in the near future if things change and there are rules, they will not be comfortable. According to a priest, “we will be very comfortable and will even like it that way. This is because, this will at least help to minimise the number of quacks”. Another TMP reiterated the point. “My son the doctor is the head of all of us. So whatever codes they want me to obey, I will not hesitate. I will obey”. Inadequate trained traditional medical practitioners Though it is known that there are far more TMPs than there are OMPs in the country, an interesting revelation was made during the interview sections. For instance, it has been estimated that the ratio of the Traditional Medicine Practitioner (TMP) to that of the country’s population is 1:400 while of orthodox medical practitioners to the population is 1:12,000 (STEPRI, 2007) in Ghana. The respondents has an opposite view that the “TMPs are very few”. It is not just the TMPs that are few but rather the trained TMPs. For instance, a medical doctor claimed that few and in fact “very few of them are trained”. The scarcity of trained TMPs and the call that more of them should be trained is also reported by another doctor this way “So I can only advise that they train more herbal practitioners and employ them at the hospitals…even we are talking of job creation and all that. Training them will create more jobs. As Ghanaian and having used herbs and knowing their efficacy, I can’t say we should abandon Herbal Medicine (HM), but I will advise that we train more Herbal Practitioners (HP) so that we can even have herbal prescribers at the hospitals. In that case, if a client comes and opts to be treated with traditional medicine, there will be professionals in the traditional way to do that”. University of Ghana http://ugspace.ug.edu.gh 70 Dosage of traditional medicine The issue of dosage is another area that must be looked at. Both OMPs and TMPs agreed that most herbal medicines do not have the right dosage. Dosage in most cases is left to the discretion of the patient or client. A herbalist said “I usually ask them to drink one, two, or three cup full(s) in the morning, afternoon and evening according to the age of clients and type and intensity of sickness”. But when this man was asked to talk about cup specifications, he couldn’t. During a personal discussion with one of the survey respondents it was confirmed that: “at times you know that a particular herb is good, but you take a particular dose and if you are not careful your case worsens”. A medical doctor trying to talk about the unscientific nature of the operations of the TMPs also said: “if a herbalist gave a medicine and said take two cups a day, your cup may be different from mine”. During an encounter with some of the survey participants, they raised some issues that importantly relate to dosage. Example one lamented that, “most of the TMPs doesn’t tell the truth and will let you use one medicine for several diseases. As a result, there are cases people take TM and die”. Another said “if you don’t know how to use it, it can be dangerous”. Perhaps, it is as a result of this that yet another respondent suggested “they must improve information on dosage”. A herbalist however does something different. He said: “I have small calabashes that I give to clients when I have to prepare something for them to drink. And I will usually indicate the level they should drink including the number of times based on age, type and intensity of sickness… However, the problem I face is that, I sell the calabashes and sometimes the people think am cheating them. So now what I do is that, I rather make them bring cups from their houses so that I show them the quantity to be taken. I do this because the issue of the quantity one have to take is important to me. At times some people take wrong University of Ghana http://ugspace.ug.edu.gh 71 quantities and later accuse you that your medicine is not powerful. I must prevent that bad name”. Extinction of certain medicinal plants in the municipality According to traditional medical practitioners, the practice of traditional medicine is now becoming difficult. This is because most of the plants that they use for treatment before does not exist today or are very difficult to find. According to a herbalist: “these days, you have to travel very far, at times outside this village to get some herbs. This was not the case during some time ago. Because I am old and weak, at times I’m not able to go for such herbs”. Adding to this, another herbalist said, “I learned this profession under the apprenticeship of my grandfather in this same village. During that time, the practice of TM was a bit easier than today because the plants needed for preparation of medicines were readily available. But this is not the case today. Many of the plants my grandfather was using I cannot find them today”. Poor conditions of preparation and old tools for manufacture Many complaints were raised about the mode and conditions under which TM is normally prepared. According to the Medical doctors, “most of the herbalists prepare their concoctions under unhygienic conditions”. This is how another medical doctor at the WMH puts it. “Taking herbal concoction at times worsens the plights of sick people. In most cases the reason is not because the medicine itself is not effective but because it is unhygienic. You know hygiene is part of health. The inputs use in herbal preparations or the products themselves may be exposed to germs, and if these medicines are applied to patients (especially if it’s administered through drinking), the germs may be introduced to the person and that will cause further sickness”. In an encounter with a survey respondent and consumer of TM, he accepted that one of the dangers of TM is the “unhygienic nature of the tools they use to prepare and administer their drugs”. University of Ghana http://ugspace.ug.edu.gh 72 Buttressing what the medical doctor said, another respondent said “at times they even dry leaves and tree backs on the ground” exposing them to flies and worms. Lack of proper diagnosis before treatment It was realised that the TMPs do not have proper ways of diagnosing diseases before treatment. As a result, they usually use try and error. This fact is captured in a statement made by a herbalist in the following way. “Because I don’t have machines to diagnose to know what actually causes a disease, usually I advise my clients to go to hospital first to know the cause of the disease. When they come back and the cause of the disease is known, it makes my work easier. This is however not the case when the disease have a spiritual cause.” Another TMP said, “at times you apply a particular herb and it doesn’t work. In that case you will have to try other”. It is not only the TMPs who are aware of their inability to diagnose diseases before applying treatment. The OMPs are also aware of this shortfall and that is why they will not especially “like clients to go to them before coming to the hospital”. A medical doctor puts it differently in the following way, “even if people will first come here and know the cause of their disease before going to a herbalist, it would have been somehow better. But in many cases, for reasons best known to them, they will visit herbal doctor as soon as they are not feeling well. When they go, the herbalist just start administering treatment without any biological examination. This is the reason why sometimes, they end up worsening their cases before coming here”. Even the consumers of the systems (who are assumed to know nothing about the practice of medicine) in some cases have testify this in the comments they gave while answering the survey questions. According to one of them, “a doctor must tell your disease before knowing which TM University of Ghana http://ugspace.ug.edu.gh 73 to use to treat it”. Another respondent said, a person “must first know the root cause of a disease before applying TM”. Challenges relating to health insurance issues There was another challenge that do not directly relate to either practitioners of OM or TM. Instead, is institutional in nature coming from the NHIS sector of the health institution. Despite the quest and the effort to integrate TM into the mainstream healthcare system of the country, it was realised that up to date not even a single herbal product is on the National Health Insurance Drug List (NHIDL) and according to both the OMPs and TMPs, “this is worrying”. Their response is not far from right in the sense that even the OMPs accepted that “the TMPs help in the treatment of diseases” and even some mentioned to have “ever used herbal medicine sometime” and “it was good”. It is therefore expected that at least through research, herbal drugs that are known to be efficacious should be included in the NHIDL. But this is not the case. According to an OMP: “we at the rural areas though we don’t know much about herbal medicine, at least we know its efficacy. However, as of now they haven’t thought of making herbal drugs insurance covered….because not all of us see things the same way….but I hope that will happen in the near future. The problem is that more people will have to be trained to do that”. As stated above, another OMPs think this is neither a problem of the doctors nor those who created the drug list. In the candid opinion of this OMP: “who will prescribe it even if it’s there. In that case they have to add it to what we learn at the medical school. If you don’t teach it, how do I write it? Every drug that am writing today, belief me I learned about it in the medical school. Even if I don’t know all, I studied almost all of them and when I prescribe them, I know what I am doing”. University of Ghana http://ugspace.ug.edu.gh 74 4.6.2 Challenges relating to orthodox medicine and practice Attitudes of doctors towards Traditional Medical Care (TMC) There are some attitudinal issues that came up as a challenge. It was realised that the attitudes of some doctors towards Herbal Medicine (HM) are not all that encouraging for the integration process. One TMP lamented “some doctors have a very poor attitude towards the work we do”. Notwithstanding the fact that OMPs belief that TMPs “play a role in healthcare delivery in their society”, they will not be happy at all if a patient tries to “seek traditional care before coming” to the orthodox hospital or while in the hospital “request to seek care from a herbalist”. A doctor accepted this but will however have a reason for his attitude. “You see we deal with evident based medicine. The signs and symptoms used in handling a case could be masked by virtue of the person taking a TM before coming to the hospital. In that case, you might provide the wrong medication or an inadequate medication. How do I be happy in such case?” So according to the OMPs taking in herbal medicine before coming to the hospital makes their work difficult and at times impossible. In the same way, they think taking herbal medicine after orthodox treatment has similar if not same effect as above. So one medical doctor accepted when asked about how it feels if a client seek traditional treatment either before or after seeking treatment from OM, “my brother, I feel bad and I think I have to. This is especially when you see you have the capacity to treat a disease but a patient will not allow you and request rather to seek treatment from traditional medicine”. A participant in trying to explain further why they seek OM first before TM said the following, “though I know for sure TM is better, I use OM first because if you use TM and later go to hospital, University of Ghana http://ugspace.ug.edu.gh 75 the doctor will say the sickness is due to the TM”. This surely buttresses the point that OMPs have very bad attitude towards TM practice and use. Challenges relating to referral of cases Another challenge of the integration process relates to the issue of referral of cases by doctors to the TMPs. None of the OMPs interviewed ever referred a case to a TMP and some even “don’t think…will ever do”. Perhaps this is what one TMP described “a very poor attitude” in the section under attitudes of doctors. A medical doctor at WMH confirmed this in the following words when asked if he has ever referred a case to a TMP. “I have never done one and I have never received any referral case from them. When asked why, the response was that: “this is because medically and scientifically I have no basis to do that. Doctors refer cases base on certain principles and practices and what will be my basis for doing that. The basis of their operation I don’t have much knowledge about. If I have a case that relates to surgery, I refer to surgical unit, if it’s relates to gynaecology, I refer to gynaecologist. Now, on what grounds will I refer to them, spiritual... But am not saying they are not good o, but what I am saying is that I have no grounds to refer to them. But I think that, it is an area we need to sort things out because it is very important.” What is surprising however is the fact that even though the OMPs “don’t have evidence” if clients who seek OM and are not healed will later seek for a TMC, a medical doctor will want the researcher to “belief” him “with all sincerity that they do.” He continued, “At times they themselves write to request (on especially cases relating to fractures and stroke) that they want to seek for traditional care. At times they are successful but at times they may come back worse…. but I don’t follow them to know if they actually do”. This was confirmed by a TMP when asked if had ever received a referral case from the hospital. The answer was, “oh no, they have never done something like that”. University of Ghana http://ugspace.ug.edu.gh 76 This is however not the case with the TMPs. All the TMPs interviewed accepted that when they see that cases are beyond them, they will refer to the hospital. A TMP who doubles as a snakebite specialist said. “Though I can treat snakebites within no time, one time, some ‘Sisala’ man came here with snakebite and I sense a danger so I led him myself to WMH and in fact I was hailed for that”. However, whether there is a practice of referral from practitioners or not, the users sometimes do refer themselves without the knowledge of the practitioners. In a personal encounter with some of the survey respondents, they agreed to have occasionally “resort to TM, after first using OM especially if sickness doesn’t go after using OM. In that case, they try TM” and according to them, “it have been successful in most cases when they try the TM”. According to the traditional medical practitioners, some of the cases they usually refer to the hospital include “cases relating to surgery.” Even according to them, since they “don’t have machines to diagnose to know what is actually the cause of the disease”, they will and have occasionally “advice their patients to go to hospital first to know the cause of the disease” and “come back except when the disease have a spiritual cause.” 4.7 Conclusion In this chapter, both the quantitative and the qualitative data was analyzed. An ANOVA results confirmed the hypothesis that educational attainment has a significant effect on the use of medical systems in Wenchi Municipality, such that an increase educational attainment cause a corresponding increase in use of orthodox medicine and vice versa. University of Ghana http://ugspace.ug.edu.gh 77 On the other hand, a t-test results show that though place of residence affects the use of medical systems, this effect is not statistically significant. This means whether one lives in a rural or urban area does not have influence on using either TM and/or OM. The qualitative analysis identified a number of challenges hindering the integration of TM or OM from the perspective of the providers. These are: legal and ethical; inadequate traditional medical practitioners; health insurance challenges; challenges relating to referral of cases; poor attitudes of doctors toward Traditional Medicare Care (TMC); extinction of certain medicinal plants in the municipality; poor conditions of preparation and old tools for manufacturing traditional medicine and lack of proper diagnosis before treatment by traditional medical personnel. University of Ghana http://ugspace.ug.edu.gh 78 CHAPTER FIVE DISCUSSION 5.1 Introduction The study examined the use of traditional and orthodox medicines in the Wenchi municipality. The main purpose was to examine how traditional and orthodox medical systems are utilised and the challenges of integrating these two medical systems in the Municipality. This chapter provides a detailed discussion of the results that were presented in chapter four. It starts with the discussion of the results obtained through the hypotheses testing and followed by the discussion of results of the research question which tackles into detail the challenges of integrating traditional medicine and orthodox medicine into Ghana’s 21st century healthcare system. 5.2 Education and use of medical systems Hypothesis one states that educational attainment has a significant effect on the use of medical systems. The ANOVA results show that the effect of education on the use of medical systems is significant F (3, 94) =21.72, p =.000. This means educational attainment is considered a factor that affect a person’s decision and choice of medical systems such that educated people are likely to use TM than OM and the opposite is true. Four levels of the independent variable (i.e. education) namely; no formal education (NFE), basic education (BE), secondary education (SE) and tertiary education (TE) were further analysed using the Least Significant Difference (LSD) post-hoc multiple comparison analysis. The LSD results show a statistically significant difference in the choice of medical systems between NFE & BE, NFE & SE, BE & TE and SE & TE but no statistically significant difference was fund between BE &SE. University of Ghana http://ugspace.ug.edu.gh 79 This means that people without any form of formal education have higher preference for traditional medicine than people with TE (p =.000) as in the case of people with NFE and those with BE (p = .03) as well as those with NFE and those with SE (p =.004). In the same way respondents with BE orientation has higher preference for TM than those with TE (p = .000) and as well people with SE has higher preference for TM than those with TE (p = .03). However, the preference for TM is significantly the same among people with BE and those with SE. These findings have several interrelations with the literature. While they are consistent with some aspect of the literature, they contradict with the literature on a number of occasions. The fact that educational attainment influences the choice of medical systems is not a new phenomenon. William (2007; Dovi et al., 2008) have previously found education to be a factor that influences ones choice of medical systems with (Dovi et al., 2008) stating categorically that people with formal Western form of education will less likely use TM and more likely use OM. Similarly (Tabi et al., 2006) has found that education, perception and a host of other factors negatively influence ones choice of traditional medicine as a means of health seeking behaviour. Perhaps with formal education, people learn about diseases and their causes. They also learn about western form of treatment. As a result, their orientation shift from personalists to emotionalists and naturalistic (Asare-Danso, 2005) as far as explanation for causes of diseases are concern. Again, through education, an individual’s social networks may shift from parochial to cosmopolitan. As a result, his/her close and more traditional social relations that makes him/her reluctant to incorporate new information and uses lay referrals when sick will give way for new social relations that are open to new information. This will make such an individual likely to utilize scientific approach of health seeking behavior (Wolinsky, 1988). With education, people are less University of Ghana http://ugspace.ug.edu.gh 80 likely to see diseases as culturally bound but instead see illnesses as caused by germs or malfunctioning of the biological system which should be treated as such (Ventavogel, 1996). The practice of educated people aligning themselves more to the utilization of western orthodox medicine than traditional-alternative medicine is perhaps the factor that have tempted some researchers to belief and conclude that technological advancements and innovation brought by education may relegate TM to the background and pose serious threat to its survival (Asare-Danso, 2005). This assertion has however been contested by the results of this study. From the results, although education was seen as a factor that positively affects the use of OM and negatively affects the use of TM, it was realized that some educated people still depend on TM to a substantial extent. During the interview, a medical doctor even mentioned to “have used traditional medicine before”. The reasons for usage of TM even by medical doctors are not farfetched. According to (Darimani, 2007), people may use medical systems irrespective of such demographic factors including education. This may be as a result of the belief that certain diseases can only be treated by TM which was also confirmed by a medical doctor in the following words: “for such illness like stroke and fractures, they will always like to go to a traditional healer”. Even those who send such illnesses to the hospital may later write “to request that they want to seek traditional care”. In the comments of some respondents it was mentioned that some health problems like bone settling, piles, among others can only be treated through the use of TM. Education as a factor on the choice of medical systems in this study was established in accordance with the aims of the study and subsequently through hypothesis testing. However the reasons why educated people will prefer OM to TM were derived through logical analysis of the literature and its relations with the findings. It will therefore later be recommended to do more studies on the University of Ghana http://ugspace.ug.edu.gh 81 reasons which make educated people opt more for OM than TM before drawing scientifically absolute conclusions. 5.3 Area of residence and use of medical systems The second hypothesis of this study states that there is significant difference between rural and urban areas in the choice of health seeking behaviour in the Wenchi Municipality. Using the independent t-test in relation to this hypothesis, an insignificant value of p =.11>0.05 was found in the choice of the utilization of medical systems among rural and urban residence. This means there is no significant difference in the choice of medical systems between rural (M=3.40) and urban (M=3.13) users. Therefore the hypothesis that there is a significant difference between rural and urban areas in the choice of health seeking behaviour in the Wenchi Municipality was rejected by the results of the study. This result also has mixed relationships with the results of other early and contemporary studies. To begin with, the results contradict the results of studies by (Twumasi, 1975; Evans-Anfom, 1986; Asare-Danso, 2005; Dovi et al., 2008). For instance, (Dovi et al., 2008) opined that area of residence including a host of other factors like age, education (already discussed under hypothesis one), employment etc. are factors that provide explanation for the choice of either TM or OM such that urban residents are less likely to have knowledge on traditional medicinal plants and go ahead to use them as compared to their rural counterparts who are mostly uneducated. Similarly (Evans- Anfom, 1986; Asare-Danso, 2005) have argued that, place of residence have great effect on the choice of medical systems. This assertion have later been buttressed by (Tabi et al., 2006) who even went further to attribute this practice to the fact that when people are removed from village University of Ghana http://ugspace.ug.edu.gh 82 by moving to new locations/towns/urban areas, they begin to act independently of traditional values including a change in preference for traditional medical systems. Dovi et al (2008) also think rural people will use TM because they are more familiar with and have more knowledge of the plants use in disease treatment as compared to their urban counterparts. This premise is not found to be true so far as the results of this study are concern. The sharp contrast might be due the fact that, though the raw plants might be more available in the rural areas, urban subjects confirmed that products from these plants are in the herbal shops which are even abundant in urban centers than in rural areas. Therefore while rural villagers may have knowledge of medicinal plants and use herbal plants in their raw form (Dovi et al., 2008), their counterparts in the urban areas are blessed with products from these plants in the herbal shops that are spread across the length and breadth in the urban center. Further linking the results, (Tabi et al, 2006) in buttressing the point made by (Evans-Anfom, 1986; Asare-Danso, 2005) stated that, urban people’s use of OM more than TM is due to the fact that their movement from rural to urban areas makes them independent of all forms of traditional practices including the use of traditional medicine. Perhaps the urban participants in this research are original settlers and thus did not migrate from the rural areas. They might therefore not fall within the category of urban dwellers that Tabi et al. was referring to. This is true to an extent that in Ghana, rural migrants usually target Accra, Kumasi and sometimes the regional capitals. The results of the hypothesis agree with some aspect of the literature however. For instance, when we carefully analyze the works of (Sena, 2001; Cunningham, 2001; Barimah and Teijlingen, 2008; William et al., 2013; Sadick et al., 2013), it can be seen that even if place of residence influences health seeking behavior, it cannot be considered a strong socio-demographic factor that influence University of Ghana http://ugspace.ug.edu.gh 83 the choice of MS around the world. For example, Twumasi have found on two occasions within a period of ten years that the residential factor have no influence on the choice of medical systems in Ghana. In 1982, he found that despite the fast spread of modernity and the emergence of modern OM, TM continued to monopolize the Ghanaian health system. Earlier on in 1972, he had made the same or at least a similar observation. According to Twumasi, (1972) the colonial masters all over Africa attempted to educate the people on disease causation and western ways of treatment. As if this was not enough they further went ahead to deny traditional healers any official mandate and legitimacy to practice, still many people (in both rural and urban areas) continued to frequently demand TM alone or as a compliment to OM. Despite the perpetration of the attempts to de-legitimize TM over the years by discrediting TMPs and consistently portraying them as incompetent, quack, illiterates, etc. (Sena, 2001), OM have not been able to relegate TM to the villages as one would have expected in this modern Ghana (Arare-Danso, 2005). This thesis is a strong indication that place of residence does not have much say in the choice of medical systems and this is not different from the findings of the current study. Meanwhile (Cunningham, 2001) have also found that there is even a rapid increase in trade worldwide for traditional medicinal products. He explained that this is because urbanization instead of decreasing the demand and use of TM as expected is even increasing the demand for Plant Medicine (PM). In another instance, (Tabi et al., 2006; William 2007) listed a host of social and demographic variables that are important in explaining the attitude of people towards medical care systems and use. In this list, place of residence is missing giving an indication that residential status is not a strong factor (if at all) in the determination process. University of Ghana http://ugspace.ug.edu.gh 84 Recently (Barimah and Teijlingen, 2008) have extended the findings of their predecessors like (Twumasi, 1972; Twamasi, 1982; Sena, 2001) to Ghanaians living in cities in Europe. Their observation that a large percentage (73) of Ghanaians living in Toronto-Canada still use TM and that they still attach strong importance to TM is a strong signal that urbanization is not a factor that makes the Ghanaian deny himself the usage of TM. The major reasons that have been cited by authors who argue for a disparity between rural and urban dwellers in the choice of medical systems are poverty and accessibility. They assume rural dwellers to be poor in most of the time and will therefore not have the financial capacity to access good-modern-orthodox health facilities. For instance (Williams et al., 2013; Sadick et al., 2013) have said rural people use TM for several reasons including the inability to afford the high transport cost to places where there are hospitals. One surest conclusion that can be drawn from such literature is that where rural inhabitants have similar income level with urban dwellers, or even richer than them, the rural factor will not count in their decision on using medical systems. It is therefore not far from right to think that in the current research, rural and urban respondents were on equal level in terms of income therefore making both categories of respondents assessing whichever healthcare system they want to. However it must be quickly admitted that the level of income of respondents was not considered in this study and that the statement was made on logical relations between existing literature and the finding of this research. Again, in the current research, respondents agreed to have knowledge of both TM and OM. They also think that both of them are readily available. This is perhaps because rural residents have easy access in terms of transport to urban centers where there are hospitals when they want to use OM. University of Ghana http://ugspace.ug.edu.gh 85 Some respondents said they have enough access to orthodox medicine because there are enough druggist in their area(s). The urban residents on the other hand have enough knowledge at least about the existence of traditional medicinal plants and where they can get them. They also commented that, though they may not know how to prepare traditional medicine, they still use traditional medicinal products. This is because, as earlier on said, there are so many herbal shops, clinics etc. around where they can buy almost any herbal product they want. But as mentioned, the main reason why both rural and urban residents use OM is because they have a perception that it is quick in relieving pains. However in most cases it only suppresses the illness in a form of a pain killer. On the other hand, they both use traditional medicine because of the perception that it gives lasting cure to the disease condition. They however agreed that traditional medicine works slowly. 5.4 Challenges of integrating TM and OM The problems that were identified to be hindering the integration process are not totally isolated from the literature. Earlier in the literature, it was noted that current TM practices are faced with some ethical, research, professional etc. complications. Some of them that were identified included quackery, safety and efficacy of traditional therapies which are mostly unknown; dosages which are not standardised; toxicity levels which may be unknown as practitioners usually undermine toxicity levels etc. (Phungwako, 2006). It is these problems associated with the practice of medicine in Ghana and other related issues that were identified to be hindering the integration process in WM. The rest of this section presents discussion on how some issues were identified to be hindering the integration of traditional and orthodox medicine in the Municipality. University of Ghana http://ugspace.ug.edu.gh 86 The issue with attitudes of practitioners and referral of cases The attitudes of the traditional medical practitioners as indicated by the results of this study have been positive towards the orthodox medical practitioners and their practices and will always embraces integration. Because of this they don’t hesitate to refer cases that they think they can’t cure to the orthodox medical practitioners however, the orthodox medical practitioners have always set boundaries between ‘modern’ and ‘traditional’ healthcare systems, ‘purifying the space of biomedicine from all that was not deemed scientific or modern’. For instance, in the current study, the orthodox medical practitioners think TM “plays a role in healthcare delivery in their society”. Despite this, they still think it is not “evident based” and will therefore “feel bad” if they find out any of their clients uses it. They have also accepted that they will never refer cases to them because they have no bases to do that. Therefore any form of education to correct the 'wrong impressions' of practitioners towards each other should be directed more at the orthodox medical practitioners. This is because since the emergence of modern healthcare system in Africa, the traditional healers and initiation leaders have not shown much concern in distinguishing between what is orthodox medicine and what is traditional medicine (Langwick, 2006). They have rather made conscious and continuous efforts to invite modern medical personnel, especially those that work as physicians in hospitals with the sole aim of bringing their antiseptic regime into their communities including all the actors and agents that this involved (Langwick, 2006). The idea that the traditional medical practitioners have very good attitude towards OM and have ever since been prepared to embrace integration is not unanimous in the literature. According to some writers, it is even the traditional medical practitioners who set divisions and will not like to University of Ghana http://ugspace.ug.edu.gh 87 hear about anything orthodox. This is evident in the work of Twumasi. According to him, the traditional medical practitioner’s belief that there is a balance state between man and the environment. Base on this balance, they have immutable supernatural laws that help them in explaining disease causation. Therefore, they always view biomedical knowledge of germ theories to disease causation as something which is very irrelevant to their traditional cosmology and conceptual explanation of disease (Twumasi, 1982). The issue of unavailability of trained TMPs Result of the current study seems to contradict with the literature on the issue of availability of Traditional Doctors (TDs). It has been clearly demonstrated that “there are very few of them” that are trained (referring to traditional doctors). It is however a common knowledge by some writers that there are far more traditional medical practitioners in the country compared to orthodox medical practitioners. Evidence of the later argument is given by STEPRI. According to (STEPRI, 2007) the ratio of Traditional Medical Practitioner (TMP) to the population is 1:400 whereas that of the orthodox doctor to the population of 1:12,000 in Ghana. The implication is that the purpose for the creation of the Traditional Medicine Unit in 1991 (WHO, 2001) has not been effective. This is because the aim of the Act to develop a comprehensive training programme in traditional medicine from basic to tertiary levels has either not been realised or not been able to provide the needed manpower resource needed to enhance the practice of TM in the country. What we must take notice of is, it is not just TMPs that are scares in the country. It is rather the trained ones who are scares. It means the majority of the TMPs in the county are not trained and University of Ghana http://ugspace.ug.edu.gh 88 certified. This provides additional explanation for the issue of quackery that will be later explained under this section. National Health Insurance issues In the words of the orthodox medical practitioners, it is not any wonder that “as of now they haven’t thought of making herbal drugs insurance covered” nor included even a single herbal product on the National Health Insurance Drug List (NHIDL). Because, “who will prescribe it even if” they do. “If it is not thought,” it can’t be included because there will be no professionals to prescribe it. The big question is however, whether someone must learn TM in the classroom before s/he can be considered a Professional Traditional Doctor (PTD) and before s/he can prescribe herbal drugs. It is a known fact that, Traditional Medical Practitioners don’t choose their profession until they have a sense of spiritual calling or here a ‘voice’ that will make them feel they have a form of spiritual calling from the world. After this calling they try to obtain permission from their community (including relatives). After this spiritual and social screening, they now enter into the apprenticeship of another person whose practices are usually under the same influence (Twumasi, 1975). "A minimum of three years after the training", they now graduate into full practitioners of the field (Abel and Busia, 2005). What makes the training more rigorous is that, in the course, if the "trainee fails to observe even one of the core instructions, he or she starts the whole process again". Examples of such instructions are that throughout the three years, trainees "don’t shave their heads, don’t have sex" etc. It therefore sounds somehow confusing to think that people with such training who have gone through such rigorous screening are not professionals and can therefore not be able to prescribe herbal drugs. University of Ghana http://ugspace.ug.edu.gh 89 The question that rises from the above is that, do professionals necessarily have to learn in the classroom? There are seamstresses, tailors, headdresses/barbers etc. who learned as apprentices from other practitioners. These people are still considered professionals in their various fields. Why therefore consider a TMP under similar circumstances as an unprofessional who cannot prescribe even drugs? Inasmuch as the classroom learning from basic level to tertiary level is good and in no way condemnable, emphasis should be placed on current practitioners without any form of or little formal education, test the efficacy of their drugs/treatment, license them and allow them to do the work we are talking of. Issues with improper diagnosis and dosage of traditional medicine The data from the key informants (i.e. both traditional medical practitioners and orthodox medical practitioners) confirms a problem relating to diagnosis by traditional medical practitioners and dosage of TM. Except one traditional medical practitioner, who doubles as a snakebite specialist at Subinso, who always insist on dosage, all the others were fund to have made little effort to control dosages of their own products. To confirm the issue, a respondent admitted that at times cases become worsen after taking some quantities of traditional medicine. In a way, this provides an explanation to why some modern/orthodox health authorities feel reluctant to accept traditional drug preparations (The Foundation for Medical Research, 2006) in some cases. This phenomenon is very serious and risky because it has being established that most of the plants that are used for herbal preparations contain chemicals as those contained in modern-orthodox medicine which when taken wrongly can be harmful. Example, certain medicinal plants are known to contain such chemicals like; phenolic compounds, acids (Abajo et al., 2004; Oliveira et al., 2009), serpentine (Pereira et al., 2010), tetrahydrocannabinol (Schomacher et al., 2008), alkaloids, University of Ghana http://ugspace.ug.edu.gh 90 saponin, tannins and phenols (Asongalem et al., 2004), a varied number and amounts of compounds (De Magalhaes et al., 2012) etc. The problem of dosage can be overcome by expanding the knowledge base of TM. That is to say through research, dosage of traditional remedies ought to be standardized and their efficacy established. Also the issue of quality assurance as well as issues of safety and efficacy including quality control may be addressed by providing guidance on regulatory mechanism (WHO, 2001). But it must be noted that, it is one thing producing and another establishing efficacy, dosage etc. The practitioner can produce the TM, since s/he have no scientific knowledge on chemical content of the herbs used, there can be an established institution to do that, and as well test for efficacy and establish dosage issues before licensing the drug and allowing for public consumption. Issues with ethics On the issue of ethics, bringing two different types of practitioners together, (those that are guided and those without any guidelines who does things the way they like) is worrisome. It even becomes more complicated to understand after finding out that there are clear rules and regulations guiding the practise of TM while on the ground the practitioners are claiming with all sincerity to have no knowledge about any of them. An example is a chief traditional healer testifying that: “as for us, we are not regulated by any rules, regulations, ethics or whatever. Everybody does things in his/her own way. Except during the time the priest at Nwoase was alive.... That time, we use to meet at his shrine occasionally to discuss issues relating to our practice”. However, after the Medical and Dental Decree of 1972, the national drug policy and the Nurses and Midwives Decree of 1972 allow indigenous inhabitants of Ghana to practise traditional University of Ghana http://ugspace.ug.edu.gh 91 medicine that do not use life-endangering procedures (MOH, 2004), several rules and regulations have been put in place to guide the ethical conduct of traditional medical practitioners. For instance, the Government use to work with the Ghana Psychic and Traditional Medicine Practitioners' Association to license and register traditional medicine practitioners. The Ghana Psychic and Traditional Medicine Practitioners' Association is also tasked to ensure a standard of care of traditional medical practitioners ͼWHO, 2001ͽ. As a result, the Traditional Medicine Practice Act 595 was passed as far back as the year 2000. Through this Act, a council has been established. The purpose of this council is to regulate practices of traditional medicine practitioners. It also see to it that practitioners are licensed. The council is also tasked to regulate the preparation and sale of herbal medicines. To be more precise, parts two and three of the Act covers the registration of traditional medical practitioners and licensing of all their practices (including mandatory licensing; method of application and conditions for licensing; issuance and renewal of licences etc.) respectively (WHO, 2001). Then in 2002, WHO came out with a strategic policy plan that provided four critical areas to be looked at in the process of integrating TM into a healthcare system. Among other things these areas include policy, safety, efficacy and quality of traditional medicine. There is therefore a question of why despite the numerous policies, the practitioners are not aware of the regulations. This arises because, it is a bit surprising to find out that till date, none of the numerous policies have been materialised in the Municipality (Asante, 2010) resulting in the traditional medical practitioner in Wenchi Municipality to “do things in his/her own way”. Though it has been argued that this might be because of the slow pace of development and manufacture of herbal products (MOH, 2004), we can also not rule out the matter of poor policy University of Ghana http://ugspace.ug.edu.gh 92 implementation. It looks as if the information on the regulatory mechanisms has not even been passed on to the practitioners on the ground let alone trying to enforce it. 5.5 Conclusion This chapter provides discussion and adequate explanations to the findings in chapter four. It is therefore the flesh of the research. In providing these discussions, the findings were linked to the literature and efforts made to explain why each of the finding is contrary to the literature or in line with it. The discussion begun with the effects of socio demographic features on the choice of medical systems and how such features can aid the integration and effectiveness of these medical systems. Then the problems of this integration process were discussed. These problems are said to be multi-dimensional and ranges from legal to attitudinal to policy making and others. University of Ghana http://ugspace.ug.edu.gh 93 CHAPTER SIX SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 6.1 Introduction The chapter presents a summary of the findings from the study as well as the conclusions and recommendations. The Chapter also focuses on the implications of the findings from the study for policy making. The chapter also provides directions for future research. 6.2 Summary The study examined traditional and orthodox medical systems use in the Wenchi Municipality with specific focus on finding out if educational attainment and place of residence have a significant effect on the preference for medical systems as well as looking for the challenges of integrating traditional and orthodox medicines in healthcare delivery in Wenchi Municipality. The first objective addressed the relationship between educational attainment and the choice of medical systems in the Wenchi municipality. The key finding was that; Educational attainment has a significant effect on the use of medical systems. This means that the higher ones educational attainment, the more likely the person is to use orthodox/modern medicine as compared to traditional medicine. In the same way, the lower ones educational attainment, the higher the probability of using traditional medicine. The LSD Post-hoc analysis indicated that, people without any form of formal education have higher preference for traditional medicine than people with TE. The same was the case with people with NFE and those with BE as well as those with NFE and those with SE. It was further noted that, participants with BE has higher preference for TM than those with TE and as well people University of Ghana http://ugspace.ug.edu.gh 94 with SE has higher preference for TM than those with TE. However, the preference for TM is significantly the same among people with BE and those with SE. It can therefore be concluded that, the higher ones education, the higher the preference for TM all other things being equal and the opposite is also true. What is not clear from the findings however is what actually caused educated/more-educated people to use orthodox medical systems than traditional medicine as compared to the uneducated/less-educated. The second objective tried to compare rural and urban population’s preference for medical systems. Using the independent t-test, the analysis shows that use of medical systems is independent on the location of the respondents, and that both rural and urban dwellers are likely to use traditional and orthodox medicine when the need arises. The final objective looked at the integration of traditional and orthodox medicine with a focus on the challenges of such integration of healthcare delivery in Wenchi Municipality. Although; 1. A significant proportion of the respondents were of the view that traditional medicine should be integrated with orthodox medicine in order to provide effective healthcare delivery; and 2. That the majority of respondents are overwhelmingly in favour of a policy driven integration process because of the possible benefits that such an integrated healthcare system will provide in enhancing quality healthcare delivery in Ghana. The findings still show that such integration will face a number of difficulties. Some of which include; University of Ghana http://ugspace.ug.edu.gh 95 1. Inadequate trained traditional medical practitioners. 2. Poor attitude of doctors towards TMC. 3. Inadequate information on dosage, safety, efficacy and quality of traditional medicine. Besides the above, other findings that emerged which need to be highlighted include the following. 1. Cases that are frequently sent to Traditional medical practitioners are diseases that are chronic in nature or those for which orthodox medicine has not proved efficacious in treatment. 2. Though practitioners from both perspectives generally belief in the integration, the orthodox practitioners don’t usually refer cases to the traditional practitioners or are not happy when patients first seek treatment from them though this is not the case with traditional practitioners. 3. Extinction of certain medicinal plants in the municipality is making the practice more and more difficult. 4. Poor conditions of preparation and old tools of manufacturing traditional medicine raises a question on the hygiene of herbal products. 5. Lack of proper diagnosis by traditional medical doctors before administering treatment may lead to wrong and inappropriate treatment being administered. University of Ghana http://ugspace.ug.edu.gh 96 6.3 Conclusions The findings from the study indicated that traditional healthcare system is widely used, and that traditional medicine will therefore continue to be with the people despite the introduction of new techniques of modern and scientific therapy. Though highly educated people will likely use orthodox medicine, a significant proportion still use TM. Besides, urbanization which is a strong force in Ghana today does not influence the choice of medical systems. This is perhaps because traditional medicine is culturally accepted, as it is guided by a shared local knowledge system that instructs its use and has been with the people since time immemorial. That is to say the use and provision of traditional medicine combines cultural beliefs, natural and supernatural modes of operation. Traditional medical therapy also deals with holistic way of diseases management. The modern medicine on the other side has been fully accepted and it is used side by side with the traditional medicine. It combines natural and scientific mode of diseases management. In terms of efficacy, both the traditional and modern medicines were found to be effective though the people think that either of them is sometimes effective in certain areas of medical treatment. For example, respondents say TM is effective for the treatment of chronic diseases, fractures etc., on other hand, orthodox medicine is fast in relieving pains. Educational attainment has been found to have a significant impact on the choice of people towards medical systems. The highly educated are less likely to be associated with traditional medicines. However, residential status was insignificant in influencing people’s choice of medical systems. University of Ghana http://ugspace.ug.edu.gh 97 This study also concludes that an approach to harmonizing activities between orthodox and traditional medicine will promote a clearer understanding of the strengths and weaknesses of each, and encourage the provision of the best therapeutic options for patients which also will guide policy directives in healthcare planning in Wenchi Municipality and Ghana at large. 6.4 Recommendations The recommendations given after careful analysis of the literature and the results of the study are grouped into two. These are implications for policy making and directions for future research. 6.4.1 Implications for Policy Making In response to the findings and conclusions arising from the study, the following recommendations are made for policy making: 1. Traditional healthcare providers should be placed on the National Health Insurance Scheme (NHIS). This would help in the integration of both medical systems. Since the services of TMPs as well as herbal products are relatively cheap, it will help lessen the burden of the poor since traditional medicines have become an integral part of the health system in the country. 2. To effectively integrate traditional medicine into a modern healthcare system, the study suggests that such integration should begin at the grass roots level. For example, the Act on TM should be properly implemented so that as a country, we include TM in our school curricular and start with the training of traditional physicians and doctors. University of Ghana http://ugspace.ug.edu.gh 98 3. The study further recommends the development of a unified medical system as the final stage of full integration. This unified medical system should be an inclusive medical system, which could help the nation to expand the available medical resources. 4. More value should be added to the branding of traditional medicines during packaging to include information on dosage. 5. The monitoring of health service providers should be enhanced by the national pharmaceutical council. This will help to ensure that drugs which are not supposed to be sold on the counter are not done at the detriment of the general public. 6. Government need to establish and update mechanisms for the regulation of traditional medicine and its practitioners and, in doing so, require more scientifically–based evidence to support decision-making. 7. Modern-orthodox medicine practitioners and researchers are required to achieve adequate education and awareness of the practice, principles and context of traditional medicine. 6.4.2 Directions for future research Based on the key findings and conclusions, the following recommendations are made for future research. 1. As stated in the framework for this study, there are other demographic, social and economic factors that are likely to influence the choice of medical systems in the municipality. Some of these factors include but not limited to; age, sex, income, employment status and ethnicity. Future studies should be focused on some of these factors. University of Ghana http://ugspace.ug.edu.gh 99 2. Besides, the current study looked at the problems of integration from the perspective of providers, future studies to look at these problems from the perspective of the users will be useful. 3. A future research to examine the effectiveness or the impact of existing national policies that aim at integrating both traditional and modern medicines should be conducted. This will help to provide a better overview of the challenges and prospects that such policies have to enhance a better integration of both medicines. In other words, studies should focus on the rationale, strategies, and process of integrating traditional medicine into the modern healthcare system of the county. 4. It will also be necessary to look at how the people use traditional medicine for self- treatment and specific herbs that are used to treat particular diseases in the municipality. This is because it was realised that traditional medicine is effective in certain areas of medical treatment than others. 5. There should be further research and collaborative measures at the national and local level to examine how the activities and operations of traditional medicine practitioners help in the promotion of culture. 6. It is also recommended that more studies be done focusing on the reasons which make educated people opt more for OM than TM before drawing scientifically absolute conclusions. 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Yimer, S., Bijune, G. and Alene, G. (2005). Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia. A cross sectional study. BMC infectious Diseases, 5(1), 112. Zhang, X. (2000). General guidelines for methodologies on research and evaluation of traditional medicine. World Health Organization, 1-71. University of Ghana http://ugspace.ug.edu.gh 116 APPENDIXES Appendix one Department of Public Administration and Health Services Management University of Ghana Business School Questionnaire The purpose of this study is to examine the use of medical systems in the Wenchi Municipality. Your responses and cooperation will be very much appreciated. The information you will provide shall be used ONLY for academic purposes and shall also be kept confidentially. Section A 1. Age Below 18 years 18-30 years 30-45 years 46-60years 60 years+ 2. Place of residence Wenchi town suburb of Wenchi other (specify)……………………………… 3. Highest educational level No schooling Basic Secondary Tertiary Other (specify)……………………………………………………………………………... Section B. This section has items on knowledge, attitude and perception on medical systems. Please tick {√} the response that appropriately much with your idea on each of the following items where: 1=strongly disagree 2=disagree 3=neutral University of Ghana http://ugspace.ug.edu.gh 117 4=agree 5=strongly agree Knowledge about medical systems and 1 2 3 4 5 Traditional 4. I have knowledge about traditional medicine { } { } { } { } { } 5. Traditional medicine is much available in this area { } { } { } { } { } 6. I can prepare some traditional medicine myself { } { } { } { } { } 7. There is no difference between traditional and orthodox medicine { } { } { } { } { } Orthodox 8. I have knowledge about orthodox medicine { } { } { } { } { } 9. I have knowledge about both traditional and orthodox medicine { } { } { } { } { } 10. Orthodox medicine is much available in this area { } { } { } { } { } 11. Traditional and modern medicines are available here{ } { } { } { } { } Attitudes towards medical systems use 1 2 3 4 5 12. I accept the integration of Traditional medicine into orthodox medicine { } { } { } { } { } 13. The last time I got sick, I used traditional medicine { } { } { } { } { } 14. I have always used traditional medicine { } { } { } { } { } 15. I prefer traditional medicine to orthodox medicine { } { } { } { } { } 16. More herbal hospitals should built just as modern- Orthodox hospitals { } { } { } { } { } University of Ghana http://ugspace.ug.edu.gh 118 17. We should always use both traditional and OM { } { } { } { } { } 18. I think certain diseases are better treated by TM { } { } { } { } { } 19. Even if I use OM, I must supplement it with TM { } { } { } { } { } 20. I go to traditional healers when there is no hospital (s) around { } { } { } { } { } 21. I use TM to treat some diseases but not others { } { } { } { } { } 22. Traditional medicine is my preferred choice { } { } { } { } { } 23. I always seek for OM first when I’m sick { } { } { } { } { } Perceptions on medical systems and use 1 2 3 4 5 24. Traditional medicine has improved the utilization of healthcare delivery in this area { } { } { } { } { } 25. Traditional medicine is too dangerous to use { } { } { } { } { } 26. Traditional medicine treat diseases better than OM { } { } { } { } { } 27. Traditional medicine has fewer side effects than OM{ } { } { } { } { } 28. Traditional medicine is cheaper compared to OM { } { } { } { } { } 29. I think certain diseases can only be treated by OM { } { } { } { } { } 30. There are beliefs that prevent me from using OM` { } { } { } { } { } University of Ghana http://ugspace.ug.edu.gh 119 Appendix Two Department of Public Administration and Health Services Management University of Ghana Business School The purpose of this study is to examine the use of medical systems in the Wenchi Municipality. Your response and cooperation will be very much appreciated. The information you will provide shall be used ONLY for academic purposes and shall also be kept confidentially. In-depth Interview guide 1. Age Below 18 years 18-30 years 30-45 years 46-60years 60 years+ 2. Place of residence Wenchi town suburb of Wenchi other (specify)……………………………... 3. Highest educational level No schooling Basic Secondary Tertiary Other (specify)…………………………………………………………………………… 4. Type of healthcare provided a. Orthodox medical care b. Traditional healing c. Faith healing d. Druggists e. Diviners f. Other (specify)……………………………… 5. What are the services/care you offer at your facility? University of Ghana http://ugspace.ug.edu.gh 120 6. What categories of people come to your facility for your services? E.g. children, illiterates, etc. 7. Do your patients try to seek other source of medicine before coming here? 8. If yes to 6 above, a. What is your feeling when patients seek other sources of healthcare before coming here? b. Tell me about some of the cases when people seek other source(s) before coming to you. 9. Do you think other sources of healthcare play a positive role in healthcare delivery in this community? 10. If yes to 9 above, what is the role? 11. Is there a possibility for patients who are not healed by your facility to seek care from other source(s)? 12. If yes to 10 above; a. What is your feeling when people seek other sources of healthcare provision after here? b. Tell me about some of the cases who visit other sources of healthcare provision after coming to you. 13. Do you refer cases that you are not able to treat to other sources of healthcare providers? 14. Do you receive referral cases from other sources of healthcare providers? 15. Are your activities here guided by ethical rules and national laws/bye-laws? 16. Do you think your activities here must be guided by ethical rules and national laws/bye- laws? University of Ghana http://ugspace.ug.edu.gh 121 17. Are you prepared to collaborate with other sources of healthcare providers in providing healthcare delivery? 18. In general, do you think orthodox medicine and traditional medicine should be integrated? 19. Why or why not? 20. Will legal issues be a barrier in trying to integrate the health systems? Explain 21. Will Non acceptance of herbal drugs by doctors and the sick be a barrier in trying to integrate the health systems? Explain 22. Will attitude of doctors towards herbal drugs be a problem in integrating the medical systems? Explain 23. Will there be a problem relating to NHIS activities in trying to integrate the health systems? Explain. University of Ghana http://ugspace.ug.edu.gh 122 Appendix Three Department of Public Administration and Health Services Management University of Ghana Business School Informed consent information and form Information Thank you for agreeing to participate in this study. This form outlines the objectives of the study and provides a description of your involvement and rights as a participant. This study is a partial fulfilment of the Master of Philosophy Degree in Health Services Management at the University of Ghana. The objectives are to examine the relationship between educational attainment and utilization of medical systems; compare rural and urban population’s preference for medical systems; and to examine the challenges of integrating traditional and orthodox medicines in healthcare delivery (from the perspective of service providers). The information from this study will be used to write a thesis on healthcare utilization which will be useful for academic purposes and for policy concerns. Respondents’ are guaranteed of anonymity and voluntary participation. They also have the right to withdraw at any point of the study, without owning explanation to anybody. University of Ghana http://ugspace.ug.edu.gh 123 Form 1. I Confirm that I have read or it has been read to me in a language I understand and I understand the purpose of the above study and have had the opportunity to ask questions that were answered to my satisfaction; 2. I understand that, I am free to withdraw from this study at any time without owning explanation to anybody because I understand my participation is voluntary; 3. Finally, I agree that the information I provide can be used for academic purpose but my identity should not be disclosed. ……………………………………… …………………… ……………… Name of participant Date Sign/thumbprint Researchers’ contacts: Name: Opoku-Mensah, Foster Abrampa Address: UGBS, Department of PAHSM, Legon-Accra Phone: +233-247-163-769 Email: ofostera@yahoo.co University of Ghana http://ugspace.ug.edu.gh 124 Appendix Four University of Ghana http://ugspace.ug.edu.gh 1 University of Ghana http://ugspace.ug.edu.gh