Indigenous Healers’ beliefs and practices concerning sexually transmitted diseases

Curationis 29(1): 46-53 A Grounded Theory study has been used, based on its Theory of Symbolic Interactionism, to explore indigenous healers’ beliefs and practices concerning sexually transmitted diseases amongst the Vhavenda. Initial data collection has been done, using purposive sampling and when categories started emerging, theoretical sampling was then used. Data were analysed by using three basic types of coding namely, open coding, axial coding and selective coding. The findings of the study revealed a variety of terms used to identify STDs. It then also became evident that there are similarities between gonorrhoea, syphilis and condylomata as shown in the orthodox Sexually transmitted diseases posters used in orthodox medicine with some of the STDs that the indigenous healers are familiar with. In accordance with the Grounded Theory, the description of types of diseases, disease patterns as well as signs and symptoms culminated in the emergence of the Dirt Theory. Based on the above findings, it was recommended that guidelines for designing a module for teaching health professionals be formulated to assist nurses in understanding the beliefs and practices of the people they serve.


Introduction
Healthcare service providers in South Africa are increasingly faced with the challenge of modelling their approach to h ea lth c are to m eet the needs and expectations of the diverse societies that they serve (Andrews & Boyle 1999:5).One of the things that became clear is that the multicultural environment, within which they operate, requires more than one approach to diagnosing and treating disease and illness.One such challenge pertains to Venda w om en, secretly consulting indigenous healers for the treatment of STDs, while simultaneously receiving treatment in hospitals.

Problem statement
Currently, the syndromic management of STDs is based on a biomedical model that focuses on secondary prevention by treating infected individuals.The issue of prevention is also emphasised in the use of condoms and restriction of the number of sexual partners as indicated in the revision on guidelines for syndromic management of STDs for 2001 (Smith 1999:79).The issue of cultural beliefs and behaviours, knowledge and attitudes of individuals as pertaining to STDs, may not be sufficiently accommodated within the orthodox healthcare services offered by hospitals and clinics to the Vhavenda people.According to the researcher 's own experience it was clear that the communities are also not involved in d ecisio n -m ak in g co n c ern in g th eir strategies of healthcare.This prompted this research to explore on the beliefs of indigenous healers concerning sexually transmitted diseases that are "unknown " in orthodox medicine.

Purpose of the study
The literature reviewed indicated that there is limited information on the subject.The shift in practice from hospital to community based care makes it a matter of urgency that healthcare professionals make a conscious effort to increase their knowledge of the varied cultures of the communities they serve.Recently with the increase in HIV/AIDS epidem ic studies and literature on the role and contributions of indigenous healers are g ain in g re c o g n itio n and are being p u b lish ed .A cco rd in g to BBC, [http: news.bbc.co.uk/1 /hi/world/africa/ 1 6 8 3 2 5 9 .Stm ] the p lan t used by in d ig en o u s h ea le rs, S u th erlan d ia Frutenscens , sub-species Microphylla, is to undergo clinical trials to assess its immune-boosting properties.
The study therefore aims to explore, describe and document of indigenous healers' beliefs and practices concerning sexually transmitted diseases.

Research question
This study is based on the following probing question: What are the indigenous healers' beliefs c o n c ern in g sex u ally tran sm itte d diseases?

Terminology
The present section is created to avoid misconceptions and misinterpretations of important concepts used in this article.The Venda words used will be interpreted in the text.

Indigenous knowledge System
Indigenous knowledge systems (IKS) refer to the complex set of knowledge and technologies existing and developed around sp ec ific co n d itio n s of populations and communities indigenous to a particular geographic area.IKS can also d ev elo p w ith in com m unities d escen d ed from p o p u latio n s that inhabited the country at the tim e of co n q u est or c o lo n iza tio n .These populations, irrespective of their legal status -retain some of, or their entire own social, economic, cultural and political in stitu tio n s (h ttp ://w w w .nrf.ac.za/ focusareas/iks).In the case of this study Indigenous knowledge refers to that knowledge that is held and used by a people w ho id entify them selves as indigenous of a place trade or occupation (in d ig en o u s h ea le rs), based on a combination of cultural distinctiveness and prior territorial occupancy relative to a more recently arrived population with its ow n d istin c t and su b sequently dominant culture (modem doctors).
Sexually transmitted diseases S exually tran sm itte d diseases are infections grouped together because they spread by transfer of organisms from person to person during intimate sexual intercourse (Clark: 372).In this article sexually transmitted diseases will be defined as diseases described as such by respondents.

Research design
Grounded Theory within the qualitative research paradigm was the appropriate approach to study the phenom enon involved, because its roots are found in the interpretive tradition of Symbolic In teractio n ism .P olit and H ungler (1999:195), explain that the purpose of field studies used in qualitative research approaches is to examine the practices, behaviours, beliefs and attitudes of groups and individuals as they normally function in real life.S treubert and Carpenter (1999:99) support this view and indicate that this approach is based on the assumption that each group shares in that particular setting, a specific social and psychological problem that occurs.

Population and sampling
U nlike in other research designs in G rounded theory, sam pling m ethod cannot be decided upon during research proposal or planning, the sam pling technique evolves during the process of data collection as concepts emerged.This sampling technique is supported by Strauss and Corbin (1990:180) who argue that the in itia l in terv iew s and observational guides in grounded theory are just used as the guidelines which helps the researcher to have focus.P urposive sam pling was used as a beg in n in g focus o f the re searc h er because only people with information according to the researcher's experience w ere selected.Pow ers and Knapp (1 9 9 0 :9 8 ) sup p o rt this m ethod o f sampling, arguing that key information interviewing involves selective use of m em bers o f the cu ltu re who are particularly knowledgeable, insightful and articulated, or who have specialised knowledge which is not shared by the rest of the com m unity (Streubert & Carpenter 1999:103).
As data collection continued, theoretical sampling was used.Theoretical sampling dictates that com parison groups be selected based on their potential for contributing to the emerging theory.The focus of the research question was on biographical information examined in oral h isto ries th at shed lig h t on past exp erien ces.As the theory starts evolving theoretical sampling was used to select key informants who were then interviewed in all areas of Vhembe district (Vhembe district is an area found in Limpopo Province where most of the Vhavenda resides), to shed light on past experiences and indigenous knowledge with regard to sexually transm itted diseases.

Data collection
D ata was co llec te d from d iffe ren t participants in the same study (Bums & Grove 1997:460).Focus-group interviews were conducted with hospital cleaners.This group had been chosen because they are the ones who help women to sneak from the hospitals to be treated by indigenous healers.The focus-group method has failed due to participants not being open enough to discuss the topic.Thereafter, some of the participants volunteered to provide information to the researcher indicating that the topic is too sensitive to be discussed in front of others.The researcher also noted that the participants were ashamed of being associated with traditional healing which is looked down upon (Mulaudzi 2001:15).
In view of the above experiences, the researcher changed from the focus-group approach into in -d ep th interview s.According to Denzin and Lincoln ( 1998: 60), The goal of an unstructured interview is to understand the participants' view.Nevertheless, the focus-group method that was used, helped in the identification o f indigenous h ealers who w ere recognised as being expert in treating sexually transmitted infections and thus facilitated snowball (network) sampling.Polit, Beck and H ungler (2001:254) describe snowball sampling as that type of sampling in which those who are already in the sample make referrals for p o ten tial p artic ip a n ts.In -depth interviews were later conducted with three female herbalists, seven traditional healers and two botanists in the age range of 40-65 years.
The botanists were also traced through network sampling.One of the indigenous healers indicated that they are also busy doing research on p lan ts used as medicines for STDs.They also helped in corroborating the findings of this study and data source trian g u latio n was enhanced.
All interviews were audiotaped.The re searc h er had tw o assistan ts who helped in conducting interviews, taking notes and m em ber checking as advocated by Glaser (1998:139).The question asked as a point of departure during focus groups and individual interviews was: What are the cultural beliefs and health practices of the Vhavenda in relation to STD's?The research assistants w ere given guidelines to continue with the dialogue to help them in probing more on the subjects.

Measures to ensure trustworthiness
There is a lot of debate concerning validity and reliability with regard to qualitative studies.
However, Leininger (1985:175) contends that validity in qualitative research refers to: "Gaining knowledge and understanding of the true nature, essence, meaning, attrib u tes and c h a ra c te ristic s o f a particular phenom enon under study.U nlike in q u an titativ e studies m easurem ent is not the goal; rather, k now ing and u n d erstan d in g the phenomenon is the goal."In th is study the m ethods of trustworthiness in the evaluation of data quality as described by Lincoln and Guba (in Polit & Hungler 1999:426) were used.Credibility of data refers to the accuracy of the findings.It can be described as a "truth formulating process" between the researcher and the informants.According to Lincoln and Guba (in Mouton & Babbie 2 0 0 1 ), truth-value is usually obtained from the discovery of human experiences as they are lived and perceived by the informants.In this study, credibility was ascertained when key informants and stakeholders who were interview ed, concurred with the interpretation and d escrip tio n o f STDs by traditional healers.The interviews were held in the respondent's language and translated into English by the researcher and a q u alified lan g u age practitio n er.Furtherm ore, the research assistants remained in the field for a prolonged period of time to enhance credibility.This enhanced free com m unication, and co n se q u en tly the p artic ip a n ts volunteered more sensitive information because of the increased rapport.The fin d in g s w ere d iscu ssed w ith participants themselves at the end of the research, to formulate guidelines for training healthcare providers.Member check is a process w hich involves checking with or getting feedback from the p a rtic ip a n ts to en su re that the researcher has captured their own words and their meaning by "playing back" to them the interpretation of data (Krefting 1991:219;Talbot 1997:428).In this study, the re searc h er w ent back to the participants or telephoned them for clarification where she felt there was a void in the inform ation elucidated.A ccording to P o lit and H u n g ler (1999:428), the technique known as triangulation is also used to enhance cred ib ility .
In this data source triangulation was met as the diverse key informants, namely hospital cleaners, h erb a lists, tra d itio n a l h ealers and botanists were interviewed on the same topic.F u rth erm o re, in v e stig a to r triangulation was also met as more than one person was used to collect data.The research assistan ts w ere also from different disciplines such as psychology and gender departments.

Ethical considerations
The researcher obtained permission from the University of South Africa to conduct the research.The researcher also wrote to the ethics com m ittee of Limpopo P rovince H ealthcare authorities for permission to conduct the research in the province.The researcher was invited to present her proposal orally.Thereafter, a le tte r o f p erm issio n was granted.Funding was obtained from the National R esearch Fund.To gain th eir c o operation, a consent form was read and interpreted to each participants in the language that they understand, wherein they were told about the nature and extent of the research.They were also informed about their right to withdraw from the study, without any fear of victimisation, should they feel uncom fortable.The illiterate participants were asked to make a cross where they were supposed to put a signature, to signify their acceptance to participate in the study (De Vos 1998:331).Literate participants were requested to read and sign a consent form.The interviewees' rights as regards confidentiality and privacy, as well as anonymity in publishing reports findings,

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were guaranteed and no nam es were used.N um bers w ere a llo c a te d to participants (Bums & Grove 1997:89).The audio taped interviews were kept under lock and key and were destroyed after the verbatim transcriptions of the interviews.The researcher and research assistants tried their utmost to establish a good relationship so as to ensure tru stw o rth in e ss and to en ab le the interviewees to be free and open during the research process.
The issu e o f sex u ally tran sm itte d diseases is a very sensitive topic.Gaining mutual trust was, therefore, essential for the p u rp o se o f d ev elo p in g and reciprocating honesty, thus enhancing the interviewer's success.
The research assistants were trained to create good rapport with participants.Denzin and Lincoln (1998:58) indicated the type of dress to be worn, as "dressing down to be presentable according to the culture o f the participants".This was taken into consideration.R esearch assistants w ere advised not to w ear trousers, as it is not acceptable among the Vhavenda elders that women wear trousers.They therefore, wore dresses and skirts, as trousers w ould have show n lack o f respect.R esea rch assistants were therefore trained to show respect by genuflecting as expected in the salutary mannerisms or protocols of the Vhavenda.
Indigenous healers used in this study displayed their knowledge and insight regarding ethics as they refused the researcher and research assistants to observe their methods o f treatm ents, feeling it would compromise patients' privacy.The researcher was left with no optio n but to use STD p o ste rs for in d ig en o u s healers to id e n tify the diseases that they were describing.

Data analysis
In Grounded Theory, data collection and data analysis occur simultaneously.The interviews were held in the respondent's language and translated into English by the researcher and a qualified language p ra ctitio n er.
D ata w as an aly sed according to the three steps of coding as described by Strauss and Corbin (1998: 54-247).That is open coding, axial coding and selective coding.Open coding is the first stage of the constant comparative analysis process to capture what is going on in the data, using the actual words Both partners are treated.Infertility

D ivhu (u w ela) (falling into)
Diarrhoea and vomiting.The man suffers weight loss, a dry mouth, protruding teeth that make it difficult for him to close his mouth, and has a distended vein on the forehead.In the last stages, the frontal fontanel will be pulsating like that of a baby and finally the man will die.
In the past it was difficult to treat the disease, as contact was supposed to be traced.Those women used to hide for fear of the stigma attached.The urine of both partners is m ixed with herbs and given to them to drink as oral treatment.Due to d iffic u lty in tracing contacts a new method of treatm ent has been devised.Herbs that do not need to be mixed with urine are used.
T here is an acu te and c h ro n ic phase o f the disease, depending on the immunity of the individual.In the acute phase the man starts sh iv erin g , has rigors, and complains of inability to pass urine.If he doesn't seek treatment he may die within three days.In chronic cases, the m an goes th rough d iffe re n t stages as described under "signs and symptoms".used by the participants.In axial coding, also known as level II coding, categories started em erging and in the process irrelev an t data was discarded.The emerging categories were grouped and compared with each other to ensure that they are mutually exclusive and cover the b eh av io u ral v aria tio n s (M unhall 2001:225).Lastly, selective coding is the form ation o f theoretical constructs.During the process the researcher kept returning to the data frequently, revising research questions and seeking out additional or missing data.The process was followed until different themes were generated.Categories and subcategories emerged under each theme.These are displayed in the form of tables.
Description and conceptualisation of data were both used in the study, as the main aim of the study was to document the beliefs and practices of indigenous healers concerning sexually transmitted diseases.
The researcher wrote memos on the notes cards and started categorising the diseases as indicated by the majority of participants.In this them e, sexually transmitted diseases were described after categories were generated through open coding.The diseases were then linked to categories in the form o f signs, sym ptom s and treatm en t.The information in Table 1 and the subsequent discussions that are to follow, are based on the results thereof.
Furthermore, in axial coding the researcher also looked at the theories behind the d iseases as id e n tifie d by the resp o n d en ts, su p p o rtin g them (the theories) with inform ation gathered during the literature review.Literature is used to support the emergent theory and it also provides alternative explanations for the data (Talbot 1995:447).
T he p a rtic ip a n ts w ent fu rth e r by categorising sexually transmitted disease into two different types, namely sexually transmitted diseases and sexually related diseases.

Sexually transmitted diseases
The participants reflected that amongst the V havenda sexually transm itted diseases is a family matter that should be known only to Maine (indigenous family physician).
Sexually transm itted diseases were described as diseases transmitted during sexual intercourse, whereas sexually related diseases are those diseases that affect the reproductive and sexual health of an individual, although not necessarily being tran sm itte d th ro u g h sexual intercourse.The most common sexually transm itted diseases m entioned were Dorobo (drop), Divhu (falling into) and thusula(sores).These are discussed below.

Dorobo (drop)
This disease is transm itted through sexual intercourse.The same disease can be contracted by sleeping with a woman/ man suffering from that disease.Dirt has been described as the cause o f the disease.(See table 1 for the signs and symptoms of the disease).The name "dorobo" is derived from the signs and symptoms where the sufferer has a thick, purulent discharge.Respondents were unwilling to reveal the medications that they use for the treatment of the diseases, but they indicated is usually given in the form of herbs which are prepared and given orally.One of the participants indicated that changing sexual behaviour is also emphasised.
The complications of the disease were described as follows: A w om an w ho has dorobo cannot become pregnant until she gets treated.A woman who contracts dorobo whilst pregnant will deliver a sick baby whose eyes will ooze those discharges that women had when suffering from the disease.
The symptoms explained are more similar to a disease called gonorrhoea in western medicine.When this was suggested to the healers, they showed that it can be the same, but the treatment will never be the same as western medicine treats only the symptoms and not the disease itself.Due to the recurrence of the disease in patients treated by western medicine, they will come to indigenous healers who eventually cure the disease.Contrary to the above view in a study conducted am ong an ten atal clie n ts on th eir perception and knowledge on STDs it was found that 33.8% of respondents still believe that native medicines and herbs provide an effective cure as compared to 67,7% who identified antibiotics as the most effective treatment.
From the literature reviewed, the same disease with its sym ptom s has been described in Swaziland and Mozambique as idrop ( Green 1994:181).According to a study co n d u cted by B rieg er, R am akrishna & A deniyi on Yoruba disease classification it was revealed that Schistosomiasis is often confused with gonorrhoea.Its local name is atosi aja or dog's gonorrhoea.In addition, in a study conducted by G reen (1994:181) on tra d itio n a l m edicine and sex u a lly transmitted diseases in Africa, a group of healers interviewed identified dorobo as a common STD in South Africa.After categorising this disease the researcher went back to the respondents to verify whether they agree with the researcher's findings.During member checking indigenous healers were asked to identify Dorobo from posters depicting various sexually transmitted diseases as used in orthodox medicine.They identified gonorrhoea pictures as symptoms of dorobo.The posters have been used due to the indigenous healers having denied the researcher and the assistants' permission to observe the sym ptom s on the c lie n ts d u rin g c o n su lta tio n s, on the g ro u n d s o f violation of patients' privacy.

Thusula(sores)
This disease is contracted through sexual intercourse with another infected person."Dirt" is identified as the cause of the disease.The symptoms of thusula and its treatm ent have been described in Table 1.From the western perspective thusula has almost similar symptoms as those found in syphilis.The disease thusula seems to be know n even in S w aziland and o th er n eig h b o u rin g countries where it is called Gcunsula or Gcushuwa in other languages (Green 1994:69).
One of the botanists interviewed, also agreed that there are similarities between thusula and syphilis, explaining that: "We are not really sure what thusula is, but the symptoms are those o f syphilis.I have a student who is going to obtain his Honours degree this year who has been researching this disease.He found the sym ptom s to be the sam e.He extracted discharges from a sufferer, took them to the laboratory and after testing, found that they were the same as those o f Syphilis.He treated these m icro o rg a n ism s w ith tr a d itio n a l medicine and found it to be very effective.

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The problem that we have is that it is claim ed that traditional medicine is n eith er m easured nor standardised.That is why we still need to put up a strong argum ent to legitim ise these medicines ".

Divhu (falling into)
A man who has slept with a woman who had an abortion contracts the disease.The woman who aborted and had not undergone dilatation and curettage is said to be dirty and has infectious discharges, which will infect the man (See Table 1: Signs and symptoms, treatment, and co m p licatio n s).Som e o f the indigenous healers explained that the symptoms look like those of HIV/AIDS.They further revealed that the disease m ig h t also be ca lle d L ufhiha (Tuberculosis).
The same findings have been revealed by a study on health seeking behaviour fo r sex u ally tran sm itte d diseases conducted amongst the Tonga in Zambia, where the disease is called kahungo.There is evidence that this is one of the diseases feared by men, which they relate to HIV/AIDS.
To em phasise that aspect, one of the former patients found at a healer's house said: "It starts with a terrible headache.I f not treated quickly, the p atient may die.Then you sta rt getting thinner and thinner by the day.This is caused by the f a c t th a t the p a t i e n t 's appetite disappears and its cause is linked to the fa ct that the patient' s bowel system stops functioning.Even the urine stops.Even if the patient feels like going to the toilet, nothing is released and this is very painful.Even if a little urine comes out, you will never want to go back to the to ile t again.A p e rso n w ith A ID S develops diarrhoea at some stage.This is when the AIDS is said to be full-blown.But what I believe is that because this person' s metabolism is not working, he/ she went fo r treatment, and the excretion c o n tin u e d a b n o rm a lly due to the disturbed metabolism.Normally people who are said to have AIDS are those who are used to going to hospitals and have been to hospital fo r treatment.And mostly these people are given laxatives to relax their bowel system ".

Tshovela (eruption)
Tshovela appears as warts, similar to cauliflower in form, and develop around the pubic area and in the vagina.Some healers and key informants described these warts as swelling white sores that grow and cover the genitals as they multiply (Green 1994:182).The symptoms are similar to what in orthodox medical n om enclature is referred to as condylomata.

Tshimbambaila (magically locking)
Tshimbambaila is a disease that is also called u reiwa( to be trapped).

One of the participants described it as follows:
"Then there is u reiwaito be trapped).Men mix medicines.I do not know how, but if a man sleeps with a woman fo r whom this has been done, he would get sick because the woman would not be compatible with him.Even women do g et this disease.It is ca lled Tshimbambaila and the local healers cannot treat it.Usually those who come from Central Africa are able to treat ". Green (1994:182) describes the disease as a type of sorcery, a spell cast by a husband to prevent a w om an from infidelity.It was reflected that the symptoms are like those of Thusula.The participants in this study indicated that in certain instances the woman and her boyfriend might be "locked" together during intercourse.The treatment is to inform the husband who will decide to unlock them if he so wishes.They further explained that With modern medicine, unlocking the two partners might also be done in the hospitals.
The disease is also common in other parts of Africa.In Swaziland the disease is called likhubalo lenja (Green 1994:68).The same type of disease is also known in Southwestern Nigeria where it is called magun.It is caused by a charm or curse put on a married woman by her husband w hen he th in k s she is having an extramarital affair.The result is almost instant death to the boyfriend and often the wife if they do engage in sex.Ajuwon, Oladepo, Adeniyi & Brieger.
A Zimbabwean healer who claims to have devised a preventive method for HIV/ AIDS, which is better than condoms and abstinence, also supports the above findings.He asserts that there is a 51

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traditional herb that can be used to ensure fidelity.He claims that he can cast a spell that involves magically "locking" women and immobilising men to bar them from having extra-marital sex.The herb and the technique has become popularly known as the " central locking system," or "immobiliser" (Mail & Guardian 10 October 2001).

Mafa(related to deaths)
Participants described mafa as a disease contracted by a man through having sexual intercourse with a woman who had not been cleansed after her husband's death.These same beliefs seem to be shared by other ethnic groups in South Africa.Shai-Mahoko (1996:114) for instance, describes boswagadi as one of the sexually transmitted disease that is common amongst the Batswana.She confirms that it is rife in the community and that it is thought to be associated with sexual intercourse with a widow.It is believed that during this period a woman will contaminate a man, who will in turn transmit the disease to any woman with whom he has sexual intercourse.There are forbidden periods where a woman is said to be dirty and therefore not supposed to have sex with men.This view is co rro b o rate d by H elm an (1996:357) who describes an indigenous Tswana sexually transm itted disease meila as an infection that is attributed to having sexual in terc o u rse during forbidden periods, for example, during menstruation, or after childbirth.It is believed that during this period a woman will pollute a man who in turn will transmit the disease to any woman with whom he has intercourse.A juw on,O ladepo,A deniyi & Brieger support this view when they assert that among the Yoruba it is taboo for a woman to have sexual intercourse while a mother is breastfeeding and during postpartum periods.
A study co n d u cted in K enya also revealed that tran sg ressin g certain traditional rules is pathogenic.Those activities related to prescribed and prohibited sexual relatio n sh ip s are thought to lead to a disease called thavhu (Ginneken & Muller 1987:285).The above view is supported by Chirwa & Sivile (1988:226) who asserts that among trad itio n al h ealers in Z am bia amakombela is a disease believed to be acquired by a m an who has sexual intercouse with a widow who has not undergone cleansing rites.All these researchers agree that those diseases can only be treated by indigenous healthcare m ethods, p o sin g challen g es to biomedical medicine.

Gokhonya / Goni (Martial eagle)
The name gokhonya means "knocking down" whereas goni means "martial eagle".The belief is that the martial eagle looks for chickens, picks one and knocks it down for its food.Similarly, if a baby has been misdiagnosed and goni is not seen or treated immediately after birth, the goni will pick up the baby (chicken) and knock it dow n or kill it.In Mozambique the same disease is known asnyokadzoni (Green 1994:128).
One of the symptoms associated with the disease is the appearance of warts in the vagina.It is b eliev ed th at a baby contracts the disease during delivery as he/she passes through the vagina.The infected baby is said to be weak and cannot m aintain good eye contact.Another sign is that the baby will not be able to hold its head upright, resulting in the head always hanging forward.
A cco rd in g to the p a rtic ip a n ts, the disease was previously not common due to v ag in al in sp ectio n s that w ere conducted repeatedly while the girl-child grew up.With the advent of children's rights which advocate privacy, vaginal inspections are no longer conducted and thus the disease is only discovered after such a person has delivered her own baby.This disease is believed to be one of the major causes of infertility and p rem ature labour.G iven the high statistics of infertility amongst women, u n exp lain ed p rem ature labour and spontaneous abortions as well as cot deaths, it is imperative that further studies be conducted to increase research about the condition.

Discussion
Some of the diseases that were mentioned have the sam e sym ptom s and co m p licatio n s as th o se in m odern m ed icin e, fo r exam ple doropo (gonorrhoea), tshovela (condylomata) and thusula (syphilis).This was verified during m em ber checking where the traditional healers were shown posters w ith d iffe re n t ty p es o f STDs and identified those that were familiar to them.However, further research need to be done regarding certain diseases for example goni(Martial eagle), which is more like "warts" in modem medicine.The disease is said to be one of the major causes of infertility, a point as far as warts are concerned, that has not yet been proved in modem medicine.
A disease such as divhu( falling into) is unknown in modem medicine as it is said to be caused by p o st-ab o rtio n discharges.In modem medicine dilatation and curettage is done following abortion to clean the uterus.It rarely occurs that one find a woman who stays at home after abortion without having undergone dilatation and curettage.If that is not the case, infections leading to sepsis may occur.There is no evidence which shows that women can have sexual intercourse during that period as verbalised and show n by indigenous practitioners.D iseases such as lukuse (fur), tshim bam baila and m afa(related to death) are also unknown in modern medicine.
The above findings provide a realistic portrayal of people's beliefs, meanings and practices associated with sexually transmitted infections.

Recommendations
F urther research needs to be done, especially on diseases that are unknown in m odern m edicine.It is said that goni(martial eagle) is a major cause of infertility, abortions and neonatal deaths and therefore it needs further research.D ivh u (fa llin g into) has also been described as a fatal condition that is either acute or chronic, depending on the patient's immune system.There is a need to do more research to see whether there is a relationship between divhu and HIV/ AIDS.D iseases such as /n a/« (re lated to deathjand tshim bam baila (m agically locking,) are related to taboos that helped in the preventive and promotive health by promoting good sexual behaviour and discouraging people from infidelity.
The findings of this study show that most of the indigenous healers who are able to trea t sex u ally tran sm itted infections are h erb alists.They can therefore be used and incorporated into primary healthcare that will assist in trying to ease the strained economy and ease the implementation of health service planning.This findings are similar with those of Orubuluye, Caldwell & Caldwell who indicated that in a study that they conducted in Ekiti district Nigeria, the reported levels of STDs were high, as were the beliefs that these diseases could be treated successfully by traditional healers.
Nurses need to know the variety of terms used by consumers to identify sexually transmitted diseases.The information can be used as a point of departure in their health education.It is recommended that guidelines for designing a module for teaching health professionals about indigenous sexually transmitted diseases be formulated.
"Dirt" became the emergent variable in the findings of this study.In this case d irt is p lace d in the c o n te x t o f uncleanliness in the form of discharges such as m en stru atio n and lo c h ia (postpartum discharges).Furthermore, uncleanliness following the death of a spouse (husband) is also considered to be the cause of ill health.These beliefs and practises can serve as points of departure in teaching clien ts about sexually transmitted diseases by moving from the known to the unknown.

Conclusion
The norms and customs that are inherent in th ese indigenous c u ltu re s are fundamental in the day-to-day existence of the people concerned and may hold a key to the understanding of many aspects o f th e ir lives, in c lu d in g the understanding of sexually transm itted diseases.Also inherent in culture are socially generated sexual behaviour that may be different for women and men.In the case o f the V havenda and other indigenous groups for instance, it is some o f these gender-based b eh a v io u ral patterns and practices show n in this article that are arguably linked to the spread of sexually transmitted diseases.The understanding and incorporation of these concepts into conventional ways o f healthcare could go a long way towards solving some of the problems facing professional healthcare providers in South Africa.
A major finding herein that has string implications for STI treatment is the belief that w estern m edicine m ay treat symptoms, while indigenous medicine gets at the root of the problem.As long as people doubt the efficacy of orthodox treatment, such problems will persist.This also show s that th ere are expectations in the com m unity for a "good" or "correct" medicine for every condition.If orthodox medicine do not m eet his ex p ectatio n s they w ill be rejected.This has often been the case with oral rehydration powder for the treatment of diarrhoea, people use chalk, starck and kaolin to treat diarrhoea expecting that a good diarrhoea medicine will stop the problem, while ORT prevents dehydration and does not stop diarrhoea immediately.In short indigenous healers and indigenous medicine are providing a service that meets client expectations.

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