Perceptions of and management practices for diarrhoeal diseases by traditional healers in Northeastern Nigeria.
Abstract: In Nigeria, there is a paucity of data on the beliefs and practices of traditional healers concerning diarrhoeal diseases. This study was undertaken to provide baseline data for integrating activities of traditional healers into the national Control of Diarrhoeal Diseases (CDD) programme. Interviews of 14 traditional healers, drawn from two large ethnic groups in northeastern Nigeria, were conducted. All but one of them willingly discussed their beliefs and practices. Almost all traditional healers used herbs expecting that it would stop diarrhoea episode. Most traditional healers (n=11) were, however, aware of the sugar-salt solution (SSS), and six of them had positive impression about it. Ten were willing to be further trained in the preparation/use of SSS, and five reported its past use. Some healers strongly believed that breast-feeding was an important cause of diarrhoea and that, in some cases, diarrhoea was only amenable to traditional treatment. The results of this study suggest that the traditional healers in the region may contribute to promoting the appropriate home management of diarrhoea. However, their perceptions and practices need to be upgraded to ensure success.

Key words: Diarrhoea; Knowledge, attitudes, practice; Medicine, African traditional; Nigeria
Article Type: Report
Subject: Diarrhea (Care and treatment)
Diarrhea (Research)
Perception (Research)
Authors: Akpede, George O.
Igene, John O.
Omotara, Babatunji A.
Pub Date: 06/01/2001
Publication: Name: Journal of Health Population and Nutrition Publisher: International Centre for Diarrhoeal Disease Research Bangladesh Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2001 International Centre for Diarrhoeal Disease Research Bangladesh ISSN: 1606-0997
Issue: Date: June, 2001 Source Volume: 19 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Nigeria Geographic Code: 6NIGR Nigeria
Accession Number: 212210105
Full Text: INTRODUCTION

Despite the launching of the national programme of Control of Diarrhoeal Diseases (CDD) in Nigeria in 1986, the home management of diarrhoea has remained suboptimal (1-4). Although awareness of oral rehydration therapy (ORT) is high, its use-rate is still low (5); many child caretakers incorrectly prepare sugar-salt solution (SSS)-the recommended home fluid in the Nigerian CDD programme-and use it only for brief periods during the diarrhoea episode (3,4,6); many caretakers also lack appropriate knowledge of the action of ORT and expect that it would stop diarrhoea (4); and about two-thirds of children with diarrhoea in some areas are given drugs, alone or with ORT (5). This situation might be due to conflicts between the culture-specific perceptions, practices, and the recommendations of the CDD programme. This demands understanding of the local cultural beliefs and practices, some of which may be built upon to promote the home management of diarrhoea (7).

Lack of alternatives to medical treatment is associated with increased use of ORT (8). On the other hand, folk assessment of diarrhoea in a medically-pluralistic society may hinder its adoption as the treatment of choice (9).

Nigeria is medically pluralistic. This pluralism includes traditional healers as an important group of caregivers who are usually more readily available than orthodox medical services, especially in rural areas (10). The traditional healers specialize in treating specific folk categories of diarrhoeal illnesses (11-13). Diarrhoea and dehydration are popularly thought of as symptoms of folk illnesses and may be treated as such (11). For example, in Brazil, diarrhoea, perceived to be due to 'evil eye,' may be treated ritually; diarrhoea due to 'sunken fontanelle' may be treated by physical manouvers; and diarrhoea is thought to be due to 'spirit intrusion' by negotiation with the spirit (12). In Cameroon, the traditional treatment is also based on the perceived causes (13). Thus, herbal solution is administered to mothers to restore the quality of 'sour' breast-milk (13). Despite this 'specialization,' the traditional healers can be trained to become effective promoters of ORT (11).

Diarrhoea is an important cause of morbidity and mortality among Nigerian children (14,15). As in other developing countries (11, 13), a good proportion of child caretakers in Nigeria often resorts to the traditional healers and traditional practices in the management of diarrhoea. In this context, the problem of food taboos among the Yorubas is illustrative of the diversity or complexity of traditional medical practices in the management of childhood diseases in Nigeria (16).

Despite the significance of diarrhoea and the involvement of traditional healers in its management, and despite the fact that the knowledge and practices of traditional healers can be built upon and strengthened to promote the appropriate home management of diarrhoea (11,17), no study had, to our knowledge, specifically assessed their role in the home management of diarrhoea in Nigeria. There is also a general need to involve them in disease management and control (10,18,19). This study, part of a larger project that also examined perceptions and practices of caretakers regarding diarrhoea (4,20,2 1), was carried out to provide baseline qualitative data on the beliefs and practices of traditional healers as a first step toward their integration into the national healthcare-delivery system through the CDD programme. The study also compared their perceptions with those of child caretakers in the region (20,21).

MATERIALS AND METHODS

The study focused on two ethnic groups (20,21)-the Kanuris who are predominantly Muslims and the Buras who are almost equally Christians and Muslims. The Kanuris are relatively less literate (western education) than the Buras due to the influence of several decades of Christian missionary activity in their area (Bwala BA. Personal communication).

Northeastern Nigeria is characterized by a diversity of traditional and biomedical practitioners and facilities. As in other tropical African countries, such as Uganda (17), the traditional healers in the area include herbalists (the most common group), Mallams (traditional healers whose practices are based on Qur'an), diviners, spiritual healers, traditional birth attendants, and bone setters.

The study was conducted during March-November 1994 in two rural local government areas of Borno State, Bama and Hawul local government areas, as described previously (20). The traditional healers were chosen from the same villages/towns used in the study of caretakers (20). The study involved 14 traditional healers-seven (six males and one female) from each ethnic group. They represented several categories of traditional healers in the area.

The village heads, community leaders, and members were consulted while identifying the traditional healers. Due to limited resources, emphasis was placed on interviewing at least one traditional healer known to be involved in the management of diarrhoea in each community.

Data obtained from focus-group discussions, involving the caretakers (4,20,21) were used for designing a culturally-sensitive, semi-structured interview guide, which was used in key-informant interviews with the traditional healers. The focus-group discussions with the caretakers included the identification of common types of illnesses among children aged less than five years, with emphasis on illnesses with diarrhoea as a defining characteristic or symptom, help-seeking behaviour, severity signs, and treatment practices (20). The interviewers conducted interviews in the practice settings of the healers and in languages; these interviewers had earlier served as note-takers in the focus-group discussions. Information on recognition of diarrhoea, assessment of severity, typology, perceptions of cause, signs and symptoms, attitude toward breast-feeding by a pregnant mother whose child has diarrhoea, and treatment patterns was sought. Treatment was further explored in terms of the preparation and administration of remedies and expectations from the use of these remedies. Information was also sought on the attitudes of traditional healers toward ORT/SSS and their willingness to be trained in the preparation and use of SSS. The practice settings of traditional healers were chosen to use the opportunity of a child being brought for treatment to observe the actual practices, but no such opportunity arose. However, because of this expectation, the interview guide had not been designed to ask the traditional healers about recent experiences to obtain specific examples of case management.

The interviews were transcribed and translated into English, then coded and analyzed classifying data into categories of perceptions of causation, signs, patterns, and categories of treatment. Analysis of the interviews with healers in both the ethnic groups is presented together, except where notable differences exist, to highlight the similarities and differences.

RESULTS

Eleven of the healers were aged over 45 years and had been in continuous practice for at least 10 years; one was aged 80 years and was described as 'a consultant' by others in the area. All the Kanuri traditional healers were Muslims and were herbalists, except one who was a Mallam. Among the Buras, two healers were Christians, two adherent to traditional religion, three Muslims, one a Mallam, another a combined diviner/herbalist, and others were herbalists.

All but one of the healers were quite cooperative in discussing their practices. The exception was the Bura diviner/herbalist who said, "I got my knowledge from spirits who warned me not to tell anybody, and I have no information on SSS, which is a whiteman's medicine."

Types, symptoms, and causes of diarrhoeal diseases

The typology constructed from various diseases described by the traditional healers was of four categories: (a) non-specific diarrhoea, such as watery diarrhoea (yerte, tiha); (b) specific diarrhoeal types, such as 'typhoid, cholera', 'teething' (kelfnye); (c) diarrhoeal types based on stool appearance, e.g. bloody and mucoid diarrhoea (tiha mamshi); and (d) diarrhoeal types based on perceived cause(s), e.g. breast-feeding diarrhoea. The perceived types of diarrhoeal diseases between the two ethnic groups are shown in Table 1.

The recognition of diarrhoea was based on the mother's complaint and/or divination; according to the Bura Mallam, "we use certain methods to see diarrhoea directly." Diarrhoea was also recognized from 'experience.'

The perceived signs and symptoms were in two categories. The first set was used as an aid to recognize diarrhoeal disease, while the second set assisted to assess the disease severity. The latter is described below. Table 2 includes the first set of signs/symptoms. Except for the signs of dankanama, there was no uniformity or specificity of the signs and symptoms. One sign meant a different type of diarrhoea to different healers. Some types of diarrhoea had more than one sign, and some signs were common to different diseases. The Kanuri healers who were 'specialized' in the treatment of dankanama uniformly described a pattern of progression from early/mild to late/severe disease (Table 2).

The perceived causes of diarrhoeal diseases included: (a) poor hygiene, (b) specific diseases, (c) spiritual factors, (d) childhood development, (e) behavioural factors, either of the mother or child, (f) alteration of the quality of breastmilk as a result of pregnancy or other factors or 'over breast-feeding' (when a child is breastfed far beyond the age when he is supposed to have been weaned), and (g) unknown causes (Table 3). Description of 'specific diseases' was more common among the Kanuri traditional healers.

The Kanuri healers attributed the spoilage of breastmilk to pregnancy and noted, "the diarrhoea will not stop no matter the quantity of medicine used unless breast-feeding is stopped." They even recommended abrupt weaning as a measure to prevent diarrhoea when a lactating mother realizes that she is pregnant. The Bura healers described an alteration in the quality of breastmilk due to 'too much fat' causing 'sour and bitter milk which can be purified by herbs' and has different effects. 'Sour' breastmilk causes watery diarrhoea, and 'bitter' milk causes bloody diarrhoea. Among the Buras, "a man is not expected to meet with his wife until three years after the birth of a baby. The question of breastfeeding by a woman who is pregnant being the cause of diarrhoea does not arise."

Severity of diarrhoeal diseases

Loose motion and diseases associated with diarrhoea were listed by the healers without prompting as among common diseases in children aged less than five years. Diarrhoea was described as a dangerous disease which causes 'fainting and death,' weight loss, and 'loss of water from the body.' According to one healer, "as the child is stooling persistently, nothing will be left in his stomach."

Two patterns of perception of disease severity were described. The first pattern related the severity to the specific type of diarrhoea, and the second to the signs and symptoms associated with diarrhoeal disease, including stool characteristics. 'Cholera,' 'typhoid,' kawsu, dankanama, and tiha mamshi were considered to be most dangerous, because these 'lead to death,' 'fainting and death,' 'requires strong medicine,' or 'makes the child thin.' Dankanama was further considered to be dangerous, because "by the time there is blood and pus in the stool, it has eaten up all the inside of the stomach." The second pattern of severity assisted the healers in recognizing serious episodes of diarrhoea as "the child becomes slim and will be crying all the time" or has "a change in complexion and appears lazy." There are also "headache and hotness of the body," "loss of appetite," and "non-stop diarrhoea which leads to blood."

Treatment of diarrhoeal diseases and expectations from treatment

The traditional healers reported that the parents usually consulted them before they resorted to any biomedical facility. One Bura healer stated, "herbs are used first; there is no need to use herbs with drugs from the clinic because one can go to the clinic if the disease persists." Treatment practices among the Kanuris varied according to the types of diarrhoea. Four Kanuri healers reported that they treated many types of diarrhoeas, while three said that they were 'specialized' in the treatment of dankanama (two healers) or dankanama and kawsu only (one healer). Among the 'general practitioners,' there was no apparent relationship between the herbs used and the perceived cause(s) and types or signs and symptoms of diarrhoeal diseases. In contrast, the dankanama specialists gave rather specific and elaborate descriptions of treatment procedures, a combination of which was recommended.

Three recommendations for the administration of herbs were described. The first one was oral administration (the commonest and usual form), either as a drink of boiled herbs or of herbs mixed with food/ corn gruel. Some healers prescribed "one cupful three times a day for 3-5 days." The second one consisted either seating the child "in warm water containing the herb" or bathing the child with water treated with the herbs. The third one was administration of herbs "mixed with butter" and rubbed around the anus as well as inserted into the rectum.

The herbs were used mainly for treating diarrhoeal diseases, but were also used for treating other diseases, such as kange (malaria) and yellow fever. The healers advised not to take herbs with medical preparations, because "their action can neutralize each other" or "they are from different persons who have different ways of treatment." The herbs were expected to "stop diarrhoea rapidly and completely." This effect was thought to be facilitated by the bitter taste of the herbs.

The Mallam wrote verses from the holy Qur'an on a slate using gum Arabic. The writing was then washed with water into a cup and taken as a drink.

Six of the Kanuri healers did not recommend restriction of any food during diarrhoea, but warned the mothers not to give "contaminated or sour foods, such as rotten eggs and meat, over-ripe fruits, dirty water, or food contaminated by flies." Only the dankanama/kawsu specialist advised the mothers not to give "fatty food, especially butter," because "it makes diarrhoea worse."

Treatment practices among the Bura healers were not 'specialized,' but they all treated 'all types' of diarrhoeas. The healers used a large variety of herbs, which tended to be healer-specific rather than disease-specific; even the Mallam also used herbs.

A similar and relatively simple method of processing and administration of the herbs, which was common to all the healers, irrespective of the herbs used or the type of diarrhoea being treated, was described: basically, the oral administration of a boiled product mixed with corn porridge or given "one cupful daily for four days," "small cup 2-3 times daily for 3-4 days, depending on the seriousness of the illness," "small cup in the morning before eating," and "cup or spoonful 2-3 times a day, depending on the herb."

The Bura healers had wide treatment-expectations from their herbs, which "treat the child's blood and the diarrhoea," "add blood to the body," "give strength," and "purify sour or bitter breastmilk." They also expected, "herbs will just stop the diarrhoea, and there will be no need to visit the clinic unless they fail." The herbs were thought to work by "improving the child's blood," by "treating the cause of the diarrhoea and giving the child strength," and by "killing worms," and "treating stomach pain." Some traditional healers had the perception that herbs were superior to biomedical preparations. No reasons were given for this assertion.

The Bura traditional healers did not generally prohibit any mothers from administering their herbs along with biomedical preparations, but a traditional religionist remarked, "herbs and drugs cannot match at the same time." The Bura traditional healers also did not generally prohibit any food for children with diarrhoea, excepting groundnuts and beans cake. The herbs used for diarrhoea were also used in treating other diseases, such as jum jum (worms) and kitirkuta (stomach ache).

Awareness of, and attitude toward, sugar-salt solution

The variations in awareness of, and attitude toward, SSS are summarized in Table 4. Some favourable opinions expressed were: "it is very easy for mothers to prepare," "where a traditional healer or clinic is not available, a mother can prepare it by herself for the child who is having diarrhoea," and "SSS stops diarrhoea." Some healers who were willing to learn more about SSS remarked, "I like additional knowledge," "if it is good like our medicine, we shall welcome it," and "it is important to gain more knowledge to be recognized by the Government."

A female Bura herbalist noted, "I was given SSS at the hospital when I had diarrhoea recently, and I now appreciate it as it really saved my life." The opinions were not always favourable, however. The Bura Mallam narrated an unfortunate experience with SSS which led to his having to modify its use: "we used to give it to children but one of the children's body became swollen, and he died after taking it; bodies of some children do not like SSS, and I now stop it for any child whose body swells."

DISCUSSION

Both orthodox practitioners and traditional healers favour an integrated system of healthcare delivery (10), but practical and conceptual differences between them may hinder the successful adoption of such a policy. The scope of perceptions and practices of traditional healers regarding diarrhoeal diseases in this study closely parallels the perceptions and practices related by caretakers in the area (4,20,21). There are also points of similarity to the perceptions and practices in other developing countries (12,13,17). Some perceptions and practices may be of further significance to policy formulation and implementation. About six key issues in the results may be singled out for discussion in this regard.

First, the recognition of diarrhoea by the traditional healers was based only on the mother's complaint, divination, or experience. It is necessary to standardize this by teaching the traditional healers the WHO's simplified definition of diarrhoea-three or more loose or watery stools per day. This should, however, be within the context of the adaptation of the WHO's guidelines and standards to local perceptions. It is important that along the lines of an integrated approach suggested by Ojanuga (10), the beliefs of traditional healers are not only taken into consideration, but respected, discussed, and adapted. The experience of Nations et al. in Brazil (11) can be built upon in this regard.

Second, there was some 'specialization' among the traditional healers, with some seemingly adept only in the management of 'specific' types of diarrhoeal diseases, such as dankanama. This might hinder the integration of some traditional healers into the CDD programme. 'Specialization' has a further implication in that child caretakers in the area similarly believe that some types of diarrhoea are only amenable to traditional remedies and worsened by biomedical treatment (20). The Kanuri child caretakers used the hospital as a last resort for 'breastmilk diarrhoea' and observed, "the clinics have as yet been of no help" in the treatment of dankanama, which was thought to be aggravated by hospital treatment (20).

Third, the traditional healers in both the ethnic groups perceived breast-feeding, under certain circumstances, to be a cause of diarrhoea. While the Kanuris related this spoilage to pregnancy, the Buras related it to other factors. The Kanuri caretakers also strongly believe that breast-feeding during pregnancy causes diarrhoea and may even wean such a child abruptly (20). We found the attitude toward breastfeeding and the perception of dankanama to be major impediments to breast-feeding and the appropriate home management of diarrhoea in rural Kanuri settlements during a linkage project (22) which was an offshoot of the results of the study involving caretakers (4,20,21). These perceptions need to be addressed in both ORT and breast-feeding promotion campaigns, but allowance should be made for the inter-ethnic differences.

Fourth, the healers interviewed in this study had, on balance, a relatively favourable attitude toward ORT/ SSS. This self-reported behaviour of the traditional healers is judged to be truthful based on three observations: (i) unwilling healers gave reasons for their unwillingness to use, consider to use, or learn more about SSS which can be interpreted to mean that those who expressed a favourable opinion may not have been simply out to impress; (ii) favourable opinions of some healers were based on their personal experience, which had also influenced one of them toward a selective use of SSS; and (iii) those healers who were aware of SSS but were not using it gave practical reasons for not doing so. This attitude could be enhanced as a ready point of entry into the CDD programme.

Fifth, some traditional healers tended to imitate biomedical prescription practices, such as recommendation of a number of cupful of herbs 2-3 times a day. We could not be very certain about this conclusion, since there was no evidence of their prescribing practices prior to or outside of western influence. Nonetheless, this prescription practice could be interpreted to mean an attempt to convince caretakers that their treatments are comparable with those of biomedical practitioners or a felt need for rapprochement with biomedicine. In support of either interpretation, it has become a common observation that the traditional healers in urban areas in Nigeria want to be called 'doctors.' This could be a part of the complex referred to by Ojanuga (10). However, irrespective of the intent and interpretation, this felt need could also be used, after appropriate training, to integrate traditional healers into the national CDD programme as an entry point into the national healthcare-delivery system. Ojanuga (10) has discussed other relevant issues that would need consideration in planning an integration programme: remuneration of traditional healers and their institutional and geographical placement; technical differences between biomedicine and traditional medicine; and social differences which engender an inferiority/superiority complex (10). Dubey (18) and Tessendorf and Cunnigham (19) have also discussed the need for, and issues in, the integration of traditional medicine/traditional healers and biomedicine/orthodox health caregivers.

Sixth, the traditional healers in both the ethnic groups expected that their treatments would stop diarrhoea. This concern was also expressed by the caretakers in the area (4,20,2 1). This type of expectation is also common among the traditional healers in other African societies (17). Failure of treatment to stop diarrhoea is a frequent cause of disappointment with ORT/SSS which can lead to inappropriate management practices. This needs to be addressed in ORT promotion campaigns (4). The other perceptions and practices of traditional healers as identified in this study which, in our opinion, are in need of behaviour modification, are summarized in Table 5, along with the suggested modifications.

The use of only key-informant interviews in data collection in this study was not originally intended. As noted in the Materials and Methods section, the original intention was to use the opportunity of children with diarrhoea being brought for treatment at the traditional healers to observe the practices, but this could not be realized. Therefore, the use of multiple methods to triangulate and validate the results could not be realized in this study. However, as noted already, the perceptions and practices related by the traditional healers are corroborated by those of caretakers in the area (4,20,2 1).

In conclusion, the importance of understanding the local classification and practices relating to diarrhoeal diseases cannot be overemphasized (8,11,12,15,23). While we recognize the obvious need for further studies both within and outside Nigeria, we think that some perceptions and related practices identified in this study can be built upon to promote the appropriate home management of diarrhoea. We think that at least it is possible to replicate the success story of Nations et al. (11).

ACKNOWLEDGEMENTS

Financial support for this research was provided by the Applied Diarrheal Disease Research Project (ADDR) at Harvard University by means of a cooperative agreement with the U.S. Agency for International Development (USAID). Haj jia Fanta B. Kachalla was a note-taker in the interview with Kanuri folk healers, while late Mr. Thomas Marama served as a note-taker in the interview with the Bura healers. We are grateful to them. The critical review of the manuscript by Dr. Johannes Sommerfeld of the ADDR is also gratefully acknowledged.

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George O. Akpede [l], John O. Igene [2], and Babatunji A. Omotara [3]

[1] Departments of Paediatrics, [2] Food Science and Technology, and [3] Community Medicine, University of Maiduguri, Maiduguri, Nigeria

Correspondence and reprint requests should be addressed to: Dr. George O. Akpede

Department of Paediatrics

Otibhor Okhae Teaching Hospital

PMB 8, Irrua, Edo State

Nigeria

Email: public@fidelsemper.com

Fax: 234-1-7596434
Table 1. Types of diarrhoeal diseases

                     Kanuri

Type of diarrhoea              Name of diarrhoea
Diarrhoea                      Yerte
Dysentery                      Atani, kawsa, latuni
Over breast-feeding            *
Breast-feeding by
pregnant mother                Yerte chambe
Anal redness/protrusion        Dankanama
Teething                       Kellinye
Typhoid                        *
Cholera                        *

                      Bura

Type of diarrhoea              Name of diarrhoea
Watery diarrhoea               Tiha
Diarrhoea with blood
and mucus                      Tiha mamshi
'Milk problem' diarrhoea       *
Diarrhoea with
stomach ache                   Tihar kith kuta
Diarrhoea with white stools    Tiha faw
Diarrhoea due to spirits       Tiha wulsu,
                               tiha unga, tiha yimri

* No local names or only descriptions rather than names were given

Table 2. Signs and symptoms of diarrhoeal diseases

                          Kanuri

Sign/symptom group                     Disease

Fever, * watery stools, vomiting,      Typhoid, cholera
frequent stooling

Hot urine, pain on urinating           Kawsu

Stools with blood, mucus,
and water                              Kawsu

Stools with blood and mucus            Cholera, typhoid,
                                       Kawsu
Difficulty in sucking at the breast,
fever, * greenish stools, mucoid
stools, headache                       Kellinye

Non-stop diarrhoea which leads
to blood and weakness                  Kawsu

Redness of the anus, greenish
stools with air bubbles/'soapy
stool', watery stools initially but
'blood and pus' later, weight loss,
weakness, fever, * ill looking         Dankanama

                           Bura

Sign/symptom group                     Disease

Thin, shrinking, poor appetite,
stooling continuously                  Tiha

Weakness, persistent stomach
ache                                   Tiha mamshi

Watery stools                          Zhola (measles)

Muscle weakness, painful aches         Tiha mamshi

Bloody stools                          Tiha mamshi

* As indicated by 'hotness of the head,' 'hotness of the stomach,'
'hotness of the skin,' and 'hotness of the buttocks'

Table 3. Causes/categories * of diarrhoeal diseases

           Kanuri                                Bura

1. Contaminated food, water         1. Lack of general hygiene, e.g.
   (dirty food, rotten eggs,           exposure of food to flies
   unwashed fruits, over-ripe          'Bad food, water, milk'
   mangoes, guava)                     Lack of good care
   'Wandering about bare-footed'
   'Carelessness'

2. 'Over breast-feeding'            2. 'Milk problem'-'milk with too
   'Milk spoiled by pregnancy'         much fat', 'bitter type',
                                       'sour type'

3. Person-to-person transmission    3. --
   by insects Transmission by air

4. Exposure to rain-'children       4. --
   left to play in the rain'
   'Mother comes in at mid-day
   to breastfeed'
   'Mother stayed in a hot place
   when she was pregnant'

5. 'Teeth growing out of the        5. --
   gums'

6. --                               6. Measles

7. 'Cause unknown'                  7. 'Spiritual problems'
   'Brought by Allah'                  'God-caused'

* Represented by numbers: 1 = hygiene behaviour,
2 = breast-feeding, 3=contagious diseases, 4 = hot-cold effects,
5 = developmental, 6 = specific diseases, and 7 = unclassifiable

Table 4. Acceptance * of SSS by traditional healers

                                            Kanuri (n=7)
                                                             Non-
                                  Yes          No          responder

SSS-aware                          6     1                     0
Already advising mothers to use
  SSS                              4     2 ([dagger])          1
Willing to become SSS-trained      5     1 ([paragraph])       1
Has a favourable impression of
  SSS                              4     0                     3

                                             Bura (n=7)

                                                             Non-
                                  Yes          No          responder

SSS-aware                         5      2                     0
Already advising mothers to use
  SSS                             1      5 *                   1
Willing to become SSS-trained     5      2 ([section])         0
Has a favourable impression of
  SSS                             2 **   0                     5

* Awareness, recommendation to mothers, impression, and willingness
to be further trained in its preparation and use

([dagger]) The reason given by both was that they lacked
knowledge of SSS preparation

([paragraph]) Claimed that he already knows how to prepare
SSS and "I do not need more training"

** One felt that "some children's bodies do not like SSS" (see text)

([double dagger]) Reasons given were:
   --does not know the preparation of SSS=1
   --"not my work to do that"=1
   --SSS is 'whiteman's medicine'=1
   --"I have my own herbs but would use SSS only
      if stomach ache persists"=1
   --feels "herbs are better"=1

([section]) "I don't have time" and western education
"does not match our knowledge" (Mallam healer)

Table 5. Important perceptions and related practices of traditional
healers in north eastern Nigeria needing modification of behaviour

Perception              Practice                Modification needed

Contaminated food,      Advice to mothers on    Encourage
etc. causes diarrhoea   food and water
                        hygiene behaviour

Breast-feeding during   Stop breast-feeding     Discourage
pregnancy causes        when pregnant
diarrhoea

SSS is useful           Advising mothers to     Encourage
                        give SSS to children
                        with diarrhoea

Felt need for           Imitation of            Encourage useful
recognition and         biomedical              aspects, discourage
willingness for         prescription patterns   harmful ones
training in SSS
knowledge/use

Diarrhoeal illnesses    Mothers not advised     Encourage
not related generally   to restrict any
to type of food         particular food
                        type(s) when a child
                        has diarrhoea

--                      Preparation of herbs    Encourage useful
                        by boiling/cooking      aspects, discourage
                                                harmful ones

Herbs expected to       --                      Discourage
stop diarrhoea                                  the expectation

Herbal remedies and     The two should not      Further studies
biomedical remedies     be mixed                needed
may antagonize each
other
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