Health care practices influencing health promotion in urban black women in Tshwane

Ke>wds: Abstract: Curationis 31 (3): 36-43 Health care practices, health promotion, TT . . . . . . . , , , , . . Health promotion is a multifaceted activity. Women and children are particularly black women. , f , .■ vulnerable regarding access to quality health care, with young African women reportedly the poorest and most economically marginalised and least educated sector in South Africa. Understanding the context within which a person lives is an essential component in the health educator’s teaching strategy. Understanding urban black women’s health care practices will enable health promoters to develop interventions that are successful. The problem investigated was to gain an understanding of the health care practices of urban black women that could influence health promotion activities. The design was qualitative exploratory. The respondents were women living in an urban township in Tshwane, South Africa. The sampling method was convenient and purposive and the sample size was determined by saturation of the data. Data was gathered through semi-structured interviews using six specific themes and the analysed using open coding. The results indicated that the social environment created by the registered nurses in the primary health influenced the health care practices of the women negatively. Practices regarding the seriousness of a health problem suggest a possible reason for late admission of a person with a serious health problem.


Introduction
Health prom otion is a m ultifaceted activity.W omen and children are particularly vulnerable regarding access to quality health care, with young African women reportedly the poorest and most economically marginalised and least educated sector in South Africa (Gilbert & Walker, 2002:152).A healthy life for a m other and a child is esse n tially dependent on the level of knowledge and education of the mother as the recipient of health care messages.This in itself would be the key factor for successful healthy living (Bunton, Nettleton & Burrows, 1996:2).
The m ultifaceted nature o f health prom otion can be illustrated by the example of educating a mother on the prevention of dehydration to treat a child with gastro-enteritis, without knowledge of the prevailing feeding practises, the socio-economic circumstances or the environment in which the family lives.Not know ing or im proving these circumstances will lead to little or no change in the health status of the child.If dehydration prevention is the only message, the gastro-enteritis will re occur.Only if all of these complex factors in the household are taken into account and improved, can the lives both mother and child be conducive to healthy living.In short, health prom otion should embrace all facets of the living reality of the mother and child.It is accepted in literature that a child's health is dependent upon the mother's educational level (Gilbert & Walker, 2002:151).From a health perspective, being m arginalised and uneducated, places the mother and the child_in a very vulnerable position.On a personal level, for the mother to be knowledgeable, she must be taught.Inherent in teaching is readiness and willingness to learn, taking into co n sid eratio n factors such as lan g u ag e, cu ltu re, literacy levels, previous knowledge, trust, time, space and in terp erso n al re la tio n sh ip s.Understanding the context within which the m o th er lives is an essential component in the educator's teaching strategy.Also, being taught in ways that are insensitive to a person's expectations and values will not result in changes in her feeding or health care practices.
A cco rd in g to K elly and C harlton (1 9 9 6 :9 0 ), to u n derstand hum an behaviour, there should be sufficient understanding o f social structure, the in d iv id u a l's com prehension o f this structure and how it impinges on their lives.The person must be set into context.S harp (1 988:15) in an essay on 'Constructing social reality', writes that the fact that people identify with a specific group, for example Afrikaner, Zulu or Tswana, does not entitle one to suppose that the groups in question are all-encompassing, and constitute the one and only identity that their members will acknowledge.The classic error is to presum e th at people, who identify themselves as 'Zulu' for example, will be the same and that the label o f 'Zulu' says all that is to be said about them.Every person is a unique individual in a social context.
A range of factors delineates the social co n tex t.C u ltu re is such a factor.A cco rd in g to G ilb ert and W alker (2002:46), all communities understand health in term s o f th eir culture.Associated with the values and beliefs about health, every community has set ways o f maintaining health, preventing illness and treating the sick.The problem is that the use of the term 'community' according to the author indicates a ho m ogeneous unit, but m odern communities are geographically defined and inherently heterogeneous.The geographical location o f a community also has an explicit influence on a community's health.Educational efforts and preventive measures therefore need to take cognisance o f the social and cultural factors in communities.
Understanding urban black wom en's health care practices and their rationale for acting in a specific way will enable health p ro m o ters to develop interventions that are successful.O f specific interest are their ways of doing within their culture, namely on when a health problem occurs, on how decisions are made, on when a health problem is considered as serious and on how long symptoms should be present before action is taken.A nother factor o f p artic u la r co nsequence for health prom otion is the phenom enon o f personal acquiescence when a person is in the presence o f an authority figure.The practice o f saying 'yes' when health education is given without the person u n d erstan d in g at all, n egates any positive effect the health education could have had.Health promoters need to have an un d erstan d in g o f the p ossible differences and influence o f health care p ractices in a com m unity.Some stereotypes exist from the past.If the women in a specific culture were known to behave in a certain way when there was a sick person in the household, the behaviour is regarded as fixed.Influences such as urbanisation and westernisation, and living in a global context and a heterogeneous society must influence individual's ways o f doing.
C om m unities are not cu ltu rally homogeneous and thus there may oe various w ays o f doing w ithin a community.An outline o f the various practices con cern in g health in a community will enable health promoters to develop strategies based on this know ledge and understanding.One definition of health promotion that is often used is enabling people to increase control over, and to improve, their health (Dennill, King & Swanepoel, 2004:13).The 'people' are adults, not children.A child does not have the knowledge or capacity to make decisions about his own health.The role o f the mother in health related matters in the household are therefore im portant.Due to the tradition that the women in the extended family are the decision makers concerning health problems, their ways of doing will influence the decisions made when a health problem occur in the household.

Research problem
The research problem investigated in this study was the lack of understanding of the health care practices of urban black wom en that could influence health promotion activities.
The purpose o f the study was to determine the health care practices of urban black women that could influence health prom otion activities.Without u n d erstan d in g local h ealth care practices, registered professional nurses will not be able to develop educational strateg ies and health pro m otion interventions congruent with or the local health care practices.Health promotion will be ineffective if local health care p ractices are not taken into consideration.

Research Design and Method
The strateg y for the study was exploratory (Bums & Grove, 2005:356).The context o f the study was Ga-Rankuwa, a township 20 km north of Tshwane in South Africa.The population is heterogeneous in terms o f culture, socio-econom ic characteristics and health related needs.

Design
The research design was qualitative exploratory.According to Burns and Grove (2005:27), qualitative research is any kind o f research that produces findings not arrived at by means o f statistical procedures or other means of quantification.It can refer to research about person's lives, stories, behaviour, but also about o rg an isatio n al functioning, social m ovem ents, or interactional relationships.The health care practices of the women o f an urban community were explored.The qualitative paradigm is applicable, as there was no intent to generalise the findings to a larger context.

Population
The respondents for the study were women living in an urban township area.The women o f the households were included in the study due to th eir decision making role in health related matters.The criteria for inclusion in the study were: • willingness to participate; • married woman with children; and • living in the chosen area.Being m arried gave the wom en an accepted social position w ithin the

Prolonged engagement
The field worker interviewing the respondent at her home in her own language will ensure a trusting relationship.

Referential adequacy Source data
Enough data was gathered to ensure saturation for each question individually.Referential adequacy was ensured.

Consistency
An interview schedule was used as the basis for the interviews.

Field Worker
The field worker had a health care background.She was trained to do qualitative interviews and a quality check was done throughout the data gathering.

Audit trail
An audit trail was developed to serve as proof that the results are grounded in the data.Initial and final categories were traceable to the interview that generated the category.A record of the key decisions made during the data analysis was kept.

Dependability audit
The raw data o f the interview was coded, audited, and archived to permit checking of the findings against the raw data.Tesch's approach was used to analyse the data.

Peer examination
The research proposal was evaluated and accepted by the Faculty Research Committee and the Ethics Committee of the Tshwane University o f Technology before implementation o f the study.
extended family and she would be able to use the social resources in the family, whether it was health related knowledge or needing a decision for a health related action.The sam pling m ethod was convenient and purposive and the sample size was determined by saturation o f the data (Lincoln & Guba, 1985, chapter 11).
The sample size was 50 respondents.Data analysis was done concurrently with the data gathering to be able to determine when the data was saturated.

Data gathering
Due to the qualitative nature of the data needed for the study, semi-structured interviews (Bums & Grove, 2005:396) were conducted to gather the data.To guide the interview s, an interview schedule with six themes was developed.The themes were as follows: 1.
Personal acquiescence with a person in an authoritative position e.g. a health care worker.

2.
Behavioural patterns when a person in the household needs health care.

3.
Assessment o f the seriousness of a health problem.4.
Help seeking preferences for health related problems.5.
Decision making processes when a person needs health care.6.
C oncept of time in health related problems.
The interviews were conducted at the participant's home during the day.As this was the natural setting of the participant, she was comfortable and at ease.One trained field worker, a registered nurse, was employed to gather the data.The field worker was more suitable due to the language needs of the participants and to im prove rap p o rt betw een the participant and the research team.As the field w orker was the prim ary data instrum ent in the study, a trusting relationship was important and thus realised.
The research protocol was presented to and approved by the Ethics Committee of the Institution.Informed consent was obtained before the interview.The field worker completed a prepared form with the themes during the interview.The field notes were numbered sequentially to ensure anonymity and confidentiality.

Data analysis
Open coding using Tesch's approach (Creswell, 1994:135) was done.Initial and final categories were generated from the data.The data was analysed in terms of health care practices that could influence health prom otion.Data an aly sis commenced after the first interview.S aturation was obtained for each question individually.

Trustworthiness
T rustw orthiness was estab lish ed according to the principles promoted by Lincoln and Guba (1985) and presented in Table 1.
A ppropriate ethical principles were upheld in the study.Informed consent was obtained from the participants before commencement of the semi-structured in terview s.
A nonym ity and confidentiality was ensured through numbering the transcribed interviews sequentially.Participation was voluntary and the participants could withdraw from the study at any point during the interview.

Results of the study
The results will be reported in two sections, nam ely a dem ographic overview of the group interviewed and the health care practice in terms of the six interview themes.

Demographic overview of the respondents
The group consisted o f 50 m arried

Health care practices
The h ealth care p ractices w ill be described in terms o f the six interview themes.
Theme 1: Personal acquiescence with a person in an authoritative position, for example, a health care worker Data saturation was obtained after 29 interviews.Two main categories were developed from the data: willingness to o btain h ealth in form ation and u n w illin g n e ss to obtain health information.

* W illingness to obtain health information
The majority o f the respondents (72%) reported that they would ask questions if they did not understand.The respondents contextualised the question in th eir local clinic w ithout being prompted to do so.Asking questions about health issues were however, not always w ithout risk.The registered nurses working in the clinic had a definite in flu en ce on the re sp o n d e n ts' willingness to ask questions.Some of the respondents who were willing to ask qu estio n s did so regardless o f the registered nurses attitude towards them.
"I ask when I don't understand though the sisters in the clinics are very short tempered." "I d o n 't care i f they (the registered nurses) become rude to me but as long as they give me the information I need " Some respondents indicated that they have learned to avoid the registered nurses who are rude when they need information.
"I ask questions i f I do not understand though I know that some o f the nurses are easily irritable but I ask the ones I feel comfortable with." "I know that nurses are rude and cruel but I w ill ignore that and ask the question.I 'm not scared." Another factor that became clear from the in terv iew s w as th at, though the reg istered n u rses did give health education, their focus was on HIV and the other conditions and diseases were neglected.According to a respondent "Even though the sisters give a lot o f health education about Aids, nothing else ... without answers o f the other diseases like arthritis."

• Unwillingness to obtain health information
About a third o f the women were not willing to ask questions even if they needed additional inform ation.Two factors are indicated as the reason for their unwillingness to ask questions.These factors are the attitude o f the registered nurses in the clinic and the group setting in which health education takes place.Several respondents indicated that they actually fear the registered nurses and would not ask a question at all.One respondent said, '7 do not ask questions because some o f the nurses are very rude and they scream at m e." O ther respondents were very clear that they will not ask any questions, for instance: "The way I am being treated by the nurses leads me to end up being scared o f the nurses One respondent mentioned that she does not ask questions when she is part o f a group because she is too shy but that she will ask if she is in a one on one situation.
Theme 2: Behavioural patterns when a person in the household needs health care Data saturation was obtained after 45 interviews.
The frequency of the five main categories is presented in Figure 1.

• S e lf-m e d ic a te fir st b efore seeking help in the health care system
Almost half o f the group (43%) would self-medicate first before they would seek help in the health care system, traditional or biomedical.One respondent reported that they would not just go to the clinic; they would try every medication possible like Panado® (paracetamol).They would use cooking oil mixed with vinegar and give that to a child for coughing.Lingana (herb) is also given for flu.The woman would treat herself by inducing vomiting to reduce headache and she would use lukewarm water to treat the headache.Another respondent reported that they would use herbs as they are told to do so by the nurses because they should not b o th er the nurses w ith " little complaints A third respondent said the whole family used Lingana, Wenreid and cooked Senokolo (herbs) as these would open up the chest.A mother reported that she would use gripe water and Panado® for fever as there is no need for a child to go to the clinic in case of a fever.If her husband is sick, he would go straight to the doctor but she looks after the hypertension.
children's health.Respondents also reported that they "tried nothing" and preferred to go to the clinic immediately.One respondent reported that she would not give a family member anything before taking him to the clin ic as she was scared that the registered nurses would think the health problem was her fault.

•
Religious care (5.4% ) Some respondents preferred to include religious care in their decisions about a person needing health care.'7 would also go to the Zionist Christian Church fo r prayers and tea.I f everything tried, fail, I w ould go to the clin ic ."A nother respondent said that she would go to church first.They pray for her and then for her leg; they at least give her olive oil to smear on her leg.

• Non-clinic option (5.4%)
Some respondents reported that they would not take a sick family member directly to the clinic, but rather to the general practitioner or the hospital.Several reasons are given, for example: ''My first action is to go to the private doctor, not to the clinic because the doctor acts quickly and refer my sick one straight to the hospital.The clinic is not a good option when someone is seriously ill they take their time to help them and people working in the clinic are unapproachable." Theme 3: Assessm ent of the seriousness of a health problem Data saturation was obtained after 43 Four main categories emerged from the data.The four main categories are the occurrence o f specific symptoms (68%), if self-medication is ineffective (14%), observation first (11%) and all complaints are considered serious (7%).
The majority of the participants regarded a specific symptom or combination of symptoms as serious.The frequency of the specific symptoms is presented in Figure 2.
Weakness is most often considered as a sign o f a serious health problem, often associated with the family member not wanting to eat anymore.The combination of weakness and anorexia in a child is considered as a sign o f serious health problems.
"  Some respondents (12%) reported that their decision is based on the health problem.They would decide to go to a traditional healer, doctor, clinic or the church depending on the evaluation of the health problem.Three respondents reported that they prefer to go directly to the hospital.One respondent reported as follows: ' V prefer going to the hospital but i f I do not have money, I will go to the clinic.The hospital only wants a referral letter during the week, not weekends so I can go to the hospital on Saturday." Some respondents (4% ) make their d ecisio n in term s o f the financial resources available.If they have the necessary finances, they prefer to go to a general practitioner and if not, they will go to the clinic.
Theme 5: Decision making processes when a person need health care Data saturation was obtained after 20 interviews.
Three main categories emerged from the data.The categories are making the decision alone (86% ), m aking the decision as a family (8%) and consulting with the expanded family (6%).
The m ajority o f the w om en (86% ) reported that they decide what should happen to a family member in case of a health problem.The role of the woman of the household was taken very seriously."As a woman, I do make the decision; a man ktiows nothing about children." "I make the decision myself.I will not wait fo r the husband because what i f the condition is serious and a child is very sick and might complicate while still w aiting f o r som eone to m ake a decision." A small group (2%) reported that the decision is made as a family but not to the detrim ent o f the person needing health care.Half of the respondents would wait more than a day, sometimes even a week or longer to seek help."N ot m ore than three days but in betw een I w ill g ive D isprin® and herbs." "A week then i f the condition stays the same they will go to the clinic." "2-3 days, not more than a week." "For myself I have high blood pressure.I wait fo r the return date though I feel sick before the return date.I will drink whatever I can, I will not go to the clinic." Three out o f every ten respondents reported that they would wait less that one day.They considered any health problem as serious and no time is wasted.
A person is taken to the clinic or hospital in case of a health problem.When the person in need of health care is a child, the time allowed before a decision is taken, varies.Often the child would be taken to the clinic sooner than an adult, though this was not always the case.
"Depends on the condition, but i f it is a child I go straight to the clinic." "A day is enough fo r a headache fo r myself.I f it is a child, two days is enough while I will be checking the seriousness o f the condition." "A week fo r m yself fo r a child a day is given fo r a trial o f my own medication then taken to the clinic."

Discussion
Several issues emerged from the research that health care providers should take cognisance of.
The role o f the registered nurse in the prim ary health care clinic is very important.Often their behaviour, not their clinical knowledge and skills, determined the benefit the community can obtain from the proximity o f the clinic (Tlebere etal., 2007:342).In addition, Mills et al. (2004:938) add that nurses in urban clinics were criticized for their attitude and treatment of the patients, rudeness, lack of confidentiality and blatant favouritism tow ards those th at they knew or perceived to be more affluent.From the other side o f the coin, G ilson and Schneider (2007:29) report that the registered professional nurses in South Africa themselves admit that they take their own frustrations out on patients and abuse the pow er relatio n sh ip between provider and patient.
Only 58% of the women reported using the clinic as their first contact in case of a  , 1984).In addition, acco rd ing to the assum ptions un d erpinning adult learning, adult learners need to feel that they are responsible for their own decisions and to be treated as self-directed.Also, adult learners have usually had many life experiences that they consider to be the best source of learning.Adults usually w ant to use w hat they know from experiences and would like to receive ackn ow led g em en t for having the acq u ired know ledge.If the health education at the clinic is focussed on HIV/AIDS to the exclusion o f other diseases and conditions, a valuable opportunity is lost.O f concern, is the remaining three out of ten who indicated an unwillingness to learn.There is an indication that the social environment in the clinic is not always conducive to learning.
The behavioural patterns when a person needs health care raise some concerns.et al. (1989:82) who write that due to mothers' limited knowledge and poor diagnostic ability, the self medication may be inappropriate.Bussing et al. (2006:871) add that s e lf care strateg ie s are commonly used and appear to co-exist with professional therapy.They urge health care providers to explore possible self care strategies used by mothers as these may interfere with prescribed treatment.
The time interval until health care is obtained is also indicative o f a possible obstacle in maintaining the health of the com m unity.D elayed help seeking occurred in half of the group and in some respondents, the decision regarding ch ild ren is dangerous.The social environment in the primary health care clinic was again mentioned as a reason for the delay.
From the results, it is clear that the woman in the household independently makes decisions regarding h ea lth related matters.This consistency provides an opp o rtu n ity to develop a health in terv en tio n to teach w om en new practises regarding health matters.

Recommendations
As most o f the women in the study sample were from one socio-cultural group namely the Tswana group, the study research should be repeated on a larger scale to ensure that a complete understanding of health care practices in the specific community.Based on this know ledge and u n d erstan d in g , an intervention targeting all the women in the community should be developed and implemented.Health care professionals should be made cognisant o f the self care practises of mothers as the self care could either have contributed to the current health problem or may interfere with the treatment.

Conclusion
Without an understanding o f the range of health care practices used by mothers in a specific community, registered professional nurses may misdiagnose a serious health problem in a patient.The misdiagnosis may result from not fully understanding the history or not asking the mother the appropriate questions.In both cases, the result could be serious for the patient.

Figure 1 :
Figure 1: Behavioural patterns when a person in the household needs health care

Figure 2 :
Figure 2 : Specific symptoms considered as an indication of seriousness

Figure 3 :
Figure 3: Help seeking preferences for health related problems

TABLE 1 :
Principles of trustworthiness applied in the study drinking Aloe boiled in water for high blood pressure, there might be an inherent danger in these practices.The propensity to self-medicate against the background of when a health problem is considered serious, presents health promoters with a challenge.Weakness or physical inability was most often (36%) considered as a sign o f serious health problem s.O nly tw o out o f ten respondents considered anorexia or pyrexia as a sign o f a serious health problem.One in ten considered dizziness as a problem and then only in terms of hypertension.The health risks related to self medication are supported by Tupasi Seven out o f ten respondent (68%) would self medicate first.Self-medication involves a delay in obtaining healthcare.I f the self-m e d icatio n consists o f measures such as vomiting to reduce headache or