Because of the complexity of the problem of hypertension amongst the Shangaans , nurses need to increase and direct their efforts towards prevention and towards helping clients to implement lifestyle alterations that will assist in controlling hypertension ( Boyle

Curationis 30(2): 4-11 The study explored the cultural care beliefs, values and attitudes of Shangaans patients’ and traditional healers’ management strategies of hypertension in the Limpopo Province. The study aimed to describe the cultural values, beliefs and practices including taboos, rituals and religion within the world-view of the Shangaans. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of recommending improvements to patient care in this area. Data collection was done by conducting focus groups and individual interviews. The following themes emerged


Introduction
This study focused n the cultural care beliefs, values and attitudes relating to hypertension among Shangaans in the L im popo P rovince o f South A frica.N urses should render com petent and culturally sensitive nursing care to all clients.Newman (1990:199) stressed that nurses with different cultural insight and a deep appreciation of human life and values would be able to render culturally appropriate, individualised care.
Nurses should be knowledgeable about hum an diseases and the beliefs and custom s o f different cultural groups concerning these diseases.In addition, nurses should show respect, develop a non-judgemental knowledge about other cultures, and understand how culture influences health and illness in different ethnic groups.A m ajor challenge facing the nursing p ro fe ssio n is to p ro v id e c u ltu ra lly sensitive care and possibly to move away from a narrowly defined biomedical model o f c a re .T h is stu d y fo c u se d on hypertension amongst the Shangaans in South Africa.

Background to the problem
Hypertension is a serious health problem because the treatm ent poses com plex nursing and medical problems.Because of the complexity of the problem of hypertension amongst the Shangaans, nurses need to increase and direct their efforts towards prevention and towards helping clients to im plem ent lifestyle alterations that will assist in controlling hypertension (Boyle& Andrew 1995:238;Nkhensani Hospital 1996: 53).
T he h o sp ita l in the G re a te r G iy an i Lowveld region of the Limpopo Province has three health centres and the clinics as well as mobile clinics, attached to it.The nearest clinic is about 10 kilometres, and the furthest are about 55 kilometres from the hospital.Hypertensive adults between the ages 40 and 65 are admitted to the hospital monthly due to collapse, stroke and high blood pressure.Other p a tie n ts d ie b e fo re th e y re a c h th e hospital.
T h ese p ro b lem s m ay be due to the d if f ic u ltie s p a tie n ts e x p e rie n c e in complying with long-term drug regimens and lifestyle changes that require major behavioural adaptation.O ften, these b e h a v io u ra l c h a n g e s m ay p re s e n t challenges to cultural values, patterns and traditions such as dietary habits, daily activities and lifestyle.
The hospital in G reater Giyani has one adult m edical w ard w ith 70 beds to a c c o m m o d a te all m e d ic a l p a tie n ts including hypertensive patients.This creates an accommodation problem for the hospital, and leads to some patients sleeping on the floor.Such a situation is not conducive to proper recovery, and re n d e rin g o f n u rsin g care b eco m es impossible.The hospital uses Open days to examine hypertensive patients and to distribute treatments.Open days means patients with different problem s such hypertension are allowed to go to the hospital any day o f the week and this promotes accessibility of Health services to all the clients.
A co m m o n v ie w o f h y p e rte n s io n amongst the Shangaans in the Limpopo Province was expressed on the radio (M unghana Lonene on 9 June 1997 at 1 9 h00).S ta n le y Z ith a , th e SA B C p re se n te r, in te rv ie w e d o n e p a tie n t suffering from hypertension.The patient said hypertension was caused by high salt intake and she was not sure of the tre a tm e n t o r o f the e ffe c ts o f hypertension and its complications.

Problem statement
During 1992-1993, the researcher worked as a professional nurse in different PHC clinics in the Greater Giyani area.Many S hangaan p atien ts w ere adm itted to h o s p ita l due to c o m p lic a tio n s o f hypertension, specifically "strokes" or cardiovascular incidents.At one o f these clinics three hypertensive women were brought to the clinic with "strokes" .This m otivated the researcher to do re s e a rc h on S h a n g a a n s w ith hypertension.Treatm ent facilities for hypertensive disorders are available, but there is nevertheless proof o f a high m o rta lity ra te a m o n g st p a tie n ts diagnosed as hypertensive.
Such incidents indicated that a possible cultural gap between the medical staff at the hospital and the Shangaan patients could exist.The question which arose was: "W hat are the cu ltural care beliefs, values, a n d a ttitu d e s in re la tio n to h y p e r te n s io n o f S h a n g a a n s o f the Limpopo Province?"

Research objectives
The objectives of this study were:

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to explore cultural values, beliefs and practices such as taboos, rituals, socio-cultural religion within the worldview health, disease specifically in relation to hypertension of selected shangaans in the Mopani region in greater giyani in the Limpopo province.
• to make recommendations for health education in order to make it possible to provide culturally sensitive patient care.

Population and Sample
The p o p u latio n s for the study w ere hy pertensive patients and traditional healers who were Shangaans.Polit and H u n g le r (1 9 9 5 :2 3 0 ) d e s c rib e d an accessible population as those people who conform to the eligibility criteria.For this study the accessib le popu latio n com prised that portion o f the target population that the research er could a c c e s s , h y p e rte n s iv e p a tie n ts and traditional healers in M opani Region in Limpopo Province.
A sample refers to the subset of units or elem ents/hum ans that com prise o f the population (Polit & Hungler 1995: 230) .In this study the elem ents were named informants.Field and Morse (1990: 138) described an informant as the one from whom the m ajority o f inform ation is obtained.
A nonprobability purposive sam pling design was used to select inform ants.
The informants who met the eligibility criteria as hypertensive patients making use of the care provided by traditional h e a le rs, and the tra d itio n a l h ealers concerned with providing such care were selected for the study.The informants were contacted and agreed to participate in the research, with informed consent (Bless& Higson-Smith;1995:95;Streubert & Carpenter;1999: 58;Treece & Treece;1986: 127).T he size o f the sam ple included 30 hypertensive patients and 15 traditional healers.

Data collection
Traditional healers who met the sampling criteria were interviewed individually and hypertensive patients particip ated in focus group interviews at various points in comfortable environments (Streubert & Carpenter;1999:23;Wood;1988:326).
T h e r e s e a rc h e r e n c o u ra g e d th e informants to speak in Tsonga as they would be speaking to each other in their cultural context in order to be able to present the true reflections o f the data w ith o u t d isto rtin g the in fo rm a tio n , translations were done by an expert in Tsonga and English and after translations information was presented to informants in order to confirm if the information still carries the presented data during the initial interviews for their confirmation.Bracketing, intuiting and reflexivity were continuously review ed to prevent bias of the researcher (Polit & Hungler;1995: 636;Wilson;1993:179).
Bracketing is the process of identifying and settin g aside any p reco n ceiv ed beliefs and opinions one m ight have about a phenomenon under investigation it involves laying aside what is known, the researcher laid aside inform ation known related to hypertension (Brink; 1999:120). Intuiting

Data analysis
Data analysis was started immediately a fte r d ata c o lle c tio n u sin g co n te n t a n aly sis and T esch 's stages o f data a n a ly sis.B ra c k e tin g , in tu itin g and re fle x iv ity w ere u sed to e x c lu d e preconceptions of the phenom enon in order to enter the world of the informants with open mind.data.Data that belonged to one group was assem bled in one place to assist further reading.Themes and categories were also formulated according to the data themselves with the assistance of data obtained during literature review.

Measures for ensuring trustworthiness
The goal o f qualitative research is to accurately represent the in fo rm an ts' experiences.Guba (1981) and Lincoln and Guba (1984) 1986:30).Payton as cited in( Krefting; 1991:216) defined external validity as the ability to g en eralise from the study sam ple to the larger pop u latio n and h en ce, the im p o rta n c e o f sam p lin g te c h n iq u e is e s ta b lis h in g e x te rn a l validity.
Sandelow ki (198 6 :3 2 ) suggests that g e n e ra lis a tio n is re le v a n t in m any q u a lita tiv e re se a rc h stu d ie s.T h ese studies are undertaken in naturalistic settings with few controlling variables.Each situation is unique and thus less a m e n a b le to g e n e ra lis a tio n .G eneralisation is an illusion as every research situation is made up of particular informants.Applicability is irrelevant to qualitative research as its purpose is to describe a p articular phenom enon or experience, not to generalise to others.Guba (1981:81)  C o n siste n c y re fe rs to w h e th e r the findings would be consistent if the study was replicated with the same informants or in a similar context (Guba;1981: 80).In co n trast to the relatively controlled, structured experimental environment, the qualitative settings may be complicated by extraneous and unexpected variables leading to an unstructured and often spontaneous settings (Duffy;1985:230).The instrum ents that are assessed for consistency in qualitative research are the researcher and the informants, both o f whom vary greatly within the project.
Q u a lita tiv e re se a rc h e x p re sse s the uniqueness of the human situation, so that variation in experience, rather than id e n tic a l re p e titio n is so u g h t (Sandelowki; 1986:33).Thus, variability is expected in qualitative research and c o n s iste n c y is d e fin e d in term s o f dependability.Guba (1981: 81) defines dependability as track able variability, that is, variability that can be ascribed to identified sources (Krefting;1991:216).Since well consistency is defined in terms o f dependability* this study ensured dependability of the study by providing a complete description o f methodology, coding of data by the researcher together with independent coders.Therefore the study followed requirem ent to ensure consistency of the data obtained.
Neutrality refers to the degree to which the findings are a function solely of the informants and conditions of the research and not o f b iase s, m o tiv a tio n s and perspectives, that is, freedom from bias in the research procedures and results (Krefting;1991:216) During qualitative studies, the researcher tries to increase the worth of the findings by decreasing the distance between the researcher and informants, for example, by prolonged contact with informants or lengthy periods o f observation.Lincoln and Guba (1985) as cited in (Krefting; 1 9 9 1 :2 1 7 ) sh ifte d the e m p h a sis o f neutrality in qualitative research from the researcher to the data, so that neutrality and not in v e stig a to r n e u tra lity was c o n s id e re d .T h ey su g g e st th a t c o n fo r m a b ility be the c rite rio n o f neutrality.This is achieved when truth value and applicability are established (Guba;1981:82).For this study neutrality was achieved because truth value and applicability were clearly explained and achieved by describing the informants real experiences presented by informants th e m s e lv e s and th is a llo w s fo r applicability of information to other areas.It w as a lso a c h ie v e d by d o in g 7 Curationis June 2007 conform ability audit where data was given to independent coders from one of the University in the Limpopo Province for coding together with the researcher.

Ethical consideration
Ethical considerations were adhered to, prevent ethical problem s.Perm ission from G reater Giyani Municipality was obtained (annexure).Rights of informants w ere re s p e c te d th ro u g h the study.In fo rm e d c o n s e n t, c o n fid e n tia lity , anonymity and risk / benefit ratio were maintained throughout the study.

Informed consent
This principle was addressed by giving inform ants full inform ation about the purpose of the study, its significance, and data collection procedures before data was collected.This principle received priority consideration since informants w ere p a tie n ts and they m ig h t have p e rc e iv e d the re se a rc h e r as h aving authority over them.They were informed that participation was strictly voluntary and a c o n se n t fo rm w as sig n e d by informants (see annexure D for consent form).

Confidentiality and anonymity
Confidentiality in this was not easy since precise quotations from transcripts had to be included in the collection o f data.In fo rm a n ts w ere re a s s u re d th a t information gained would not be linked to their names.Anonymity was provided by p ro te c tio n o f the in f o rm a n t's identities.They were assured that their nam es w ould not be used after data analysis had been completed.Anonymity was m aintained during publication by omitting identifiable data, such as names on transcripts.

Risk/benefit ratio
This principle means that the degree of risk taken by those participating should never exceed the potential humanitarian benefits o f the knowledge to be gained.Q ualitative research is considered noninvasive, depending on the topic under study.This study focused on a significant topic that had a potential to improve care o f hypertensive patients.

Theme one: Hypertension
A ccording to inform ants discussions four categories emerged from the data related to hypertension.Each category was discussed separately.

Category one: Synonyms for Hypertension
According to informants own views and perceptions no subcategory em erged as only three nam es are associated with hypertension according to the Tsonga / Shangaans culture namely Ngatileyikulu, N 'ombe or High blood.All the informants presented these words only.

Category 2: Signs and symptoms
The results revealed that specific signs and symptoms were related to high blood.
A cco rd in g to th e ir v iew s sig n s and sy m p to m s d is c u s s e d in c lu d e d continuous headaches, dizziness, painful body, swelling, failure to see properly, p ro tru d in g b lo o d v essels, tire d n e ss, nose bleeding, collapse and faint.Results revealed that Shangaans believe that all symptoms have cultural meaning.As they ex p erien ce sym ptom s, they interpret them and react in ways that are related with their cultural norms.

Subcategory 2: Remedies indications/prescription
In fo rm a n ts p re s e n te d d if f e r e n t p re s c rip tio n s fo r tre a tm e n t o f Ngatileyikulu / N 'ombe as well as correct times for utilization o f such prescribed herbal medicine the signs and symptoms presented by hypertensive patients were the guidelines for the prescription hence each patient would be treated according to the signs and symptoms on admission to the traditional healer as follows:

Subcategory 4: Remedies Negative
In fo rm ants illu stra te d that there are specific remedies that are not supposed to be used for specific people due to their c o n d itio n s in o rd e r to a v o id complications.
• Do not do phungula (steam inhalation) to people with stroke because it is believed that the method will lead to collapse of the people exposed to the treatment method.

Subcategory 5: Remedies Preparation
In fo rm a n ts gave c le a r m e th o d s for preparation in order to yield positive results.Methods were summarized and presented Inform ant's results revealed that the Shangaan/Tsonga people have knowledge with regard to remedies to be utilized for hypertension.

Category 6: Treatment Fe edback
From the category, there are no themes 8 Curationis June 2007 that emerged.Some informants explained that after the sick person has taken the m e d ic a tio n , th ey m u st go b ac k to traditional healers to explain the results of herbal medicine in use.

Theme two: The traditional healer: The instrumental role
Inform ants described specific aspects related to diagnostic procedures followed by T ra d itio n a l h e a le rs d u rin g the treatment process.This explanation was coupled by the presence o f confidence for the procedures done.Two categories emerged from the data and each category was discussed separately to represent data units in each category.
Category 5: Sources for diagnostic assistance

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Throwing of bones and procedures -payment, untie the bag, client blow air onto the bones then throw bones down.
• Interpretations of bones -look at position adopted by the bones and assign meaning, then diagnose the person.
• Throw bones to ask the ancestors the herbal medicine relevant for the disease.

•
Diagnosis and dreams -Ancestors can come to you in a dream to tell you events which are going to happen the following day indicating the specific person, diagnosis, and treatment to be implemented.

Theme three: Traditional medicine versus western medicine Subcategory 1: Attitudes towards Western Medicine
In fo rm a n ts e x p la in e d th a t W estern m e d ic in e m u st be u tilis e d fo r complications such as stroke because the tra d itio n a l h e a le rs do n o t have the n e c e ssa ry f a c ilitie s to c a te r fo r complications.

Subcategory 2: Feelings about preparation of Western medicine towards hypertension
O th e r in fo rm a n ts b la m e d W estern medicine for prolonged use of medicine for treatment of hypertension.

Subcategory 3: Recommendations by traditional healers
• Inviting traditional healers to assist in treatment of chronic conditions such as hypertension.Western medicine for treatment of complications only such as stroke.

Theme four: Magicoreligious
Informants displayed the presence of the a n c e s to rs th ro u g h o u t th e ir liv e s whether; they are healthy or sick and stressed that for things to go normally p ro p e r c o m m u n ic a tio n m u st be maintained throughout.The presence of a n c e s to rs re p re s e n ts th e M a g ic o religious aspects of Shangaans according to informants' views.

Category 8: Relationship with Ancestors
Inform ants in this study revealed that there must always be peace between them and the ancestors.T hey s tre s s e d th a t th re a te n in g the relationship or causing ancestors to be angry might bring ill health.To resolve that problem , a cerem onial sacrifice should be done w here a w hite g oat/ c h ick en is s la u g h te re d and, p e o p le specifically relatives are invited to come and enjoy the ceremony and to eat the slaughtered animal.
They believed that good relationship w ith an cesto rs is g o in g to p ro m o te som eone's health and if he is ill, the tra d itio n a l h e a le r w ill p ro v id e the treatment for different diseases such as h y p e rte n s io n .To m a in ta in , th e relationship there m ust be continuous com munication between ancestors and people through the process o f libation.B reach o f ta b o o s o r ta lk in g ab o u t confidential information to strangers will make ancestors to be angry and therefore it must be avoided

Theme five: Cultural beliefs of shangaans and hypertension
From the discussions with informants, certain cultural beliefs and values with regard to hypertension as a disease were outlined.

Beliefs Subcategory 1: Causes of hypertension
Info rm an ts ex p la in e d that there are several aspects responsible for causing hypertension though others seem ed to be beyond their control.

•
Excessive intake of salt and fat, anger of ancestors and it seem to run in families and the cause is not clearly known.

Subcategory 2: Report to ancestors
T he in fo rm ants stressed that all the events occurring in the family must be reported to ancestors, if someone is ill, ancestors must be informed.

Subcategory 3: Medication
Inform ants discussed that there is no need for a person to live on life-long m ed icatio n because h y p erten sio n is curable.
Subcategory 4: Cultural care of a hypertensive patient.
Informants demonstrated that there are specific people such as the elderly who are allowed to look after this person when ill because they are no longer exposed to issues which make them to be HOT.

Subcategory 5: Prognosis
Informants illustrated that people with hypertension are treated successfully without any need for prolonged drugs.

Theme six: Experiences of hypertensive patients with regard to traditional healers and hypertension
The informants described many aspects u n d e r th e ir e x p e rie n c e s , fro m the descriptions the following category and subcategories emerged.

Category 1: Experiences sign and symptoms
Informants tried to indicate the intensity o f the headache experienced on first attack which was followed by dizziness as the haunting problems.

Category 2: Experiences and causes
Informants explained that there are many aspects responsible for hypertension.

Category 3: Experiences with Sources for Diagnostic Assistance
In fo rm a n ts re p o rte d th a t th e y are expected to pay specific amount before the diagnosis is done.

Category 4: Experiences with Remedies
Informants indicated fear, pain and agony related to some other methods utilized as remedies, such as Ku lumeka and steam inhalation

Recommendations
Based on the conclusions deduced from th e fin d in g s o f th is re s e a rc h , recommendations were made.Changing of attitudes by health professionals such as developm ent of positive relationship tow ards the traditional healers, close collaboration between Western medicine and traditional healers, workshops with th e tra d itio n a l h e a le rs and fu rth e r research.

Development of positive relationship towards the traditional healers
Health professionals must learn and try to develop good attitudes tow ards the T ra d itio n a l H e a le rs.O n ce the relationship is established, it will promote good w orking relationship.This will prom ote reliance o f both system s for som ething and in return; the m edical systems will rely on Traditional Healers for som ething.This is very important because both traditional healers and medical practitioners have one common goal, to help the patient get well.Both they are patient orientated.O nce the Traditional Healers became satisfied with relationship and negotiations that they are being consulted, as equals in their own right mistrust will be dispelled.
The nursing profession need to avoid stereotyping o f the herbal medicine, but rather must take time to learn something about the practice o f the T raditional Healers in order to be able to view it in cultural context Development o f good attitudes towards the Traditional Healers will drew them n e a re r to h e a lth p ro fe s s io n a ls and therefore close collaboration will be easy.

Workshop with traditional healers
Health professionals including nurses, m edical p ractitio n ers m ust o rg an ize workshops for the traditional healers in order to share more information in relation to hypertension.
During the w orkshop, the Traditional Healers need to be given on opportunity to present their point of view.Thorough assessment o f their information must be done by the health personnel.At the end, the three modes of Leininger's sunrise model must be adopted.Good practices which help the Shangaan to retain and p reserve relev an t cu ltu re v alu es & maintain their well being and help them re c o v e r fro m illn e s s re la te d to hypertension will be m aintained and preserved.
The harmful practices such as the use of razor blade during the treatment process to cut the skin to allow blood out in a patient with hypertension negotiations can be made in order to help them to r e str u c tu r e w h ile re s p e c tin g th e ir cultural values, beliefs in order to assist them to cope with the disease.

Strenghs of the study
S tre n g th s o f th e stu d y in c lu d e th e following: • The qualitative approach and unstructured interviews allowed the informants to speak for themselves.
• This was not a laboratoryoriented study, but was implemented in the field.

•
The researcher was conversant with the situation and was more accessible to the traditional healers due to familiarity with the context in which the study was conducted.

•
The findings have made a contribution to the knowledge of management of hypertension amongst the Shangaans.The findings increase the knowledge of the phenomenon and establish an understanding of Shangaan culture and hypertension

Limitations of the study
Lim itations for this study include the possibility of researcher's bias and data collection as well as data analysis.The occurs when the researcher tries to develop an awareness of the lived e x p e rie n c e s w ith o u t fo rc in g p rio r e x p e c ta tio n s o r k n o w le d g e in the process.The researcher review ed the data again and again until there was c o m m o n u n d e rs ta n d in g .(B rin k ; 1999:120).R e fle c tiv e r e m a r k s re fle c te d any thoughts, feelings, ideas, or insights the researcher wished to make, the researcher e x p lo re d p e rso n a l fe e lin g s and experiences that may influence the study and integrated that understanding into the study.(Burns& Grove; 1993: 567).

Field
notes from different interviews with in fo rm a n ts w ere p a rtitio n e d in to individual docum ents.All data were docum ented and transcribed verbatim from the tapes.Observations made from all informants during interviews were documented.The pages were numbered from the first interview in the first village to the last interview and this data put together according to the file-card system (CreswellJ 1994:154-155) Data was then compared against the tapere c o rd e d and d o cu m e n ted ones for accuracy.The data was then coded by the researcher using the mnemonic codes to assist in remembering the category.Data coding was constructed from the 6 Curationis June 2007 refers to fittingness or transferability as the criterion against which applicability of qualitative data is assessed.Qualitative research meets this c rite rio n w hen the fin d in g s fit into contexts outside the study situation that are determined by the degree of similarity o f g o o d n ess o f fit b etw een the tw o contexts.Lincoln and G uba (1985) as cited in (K re ftin g ; 1991: 2 1 6 ) sta te th a t transferability is more the responsibility o f the person w anting to transfer the fin d in g s to a n o th e r s itu a tio n or population, than the researcher o f the original study.As long as the original researcher presents sufficient descriptive d ata to a llo w c o m p a riso n , she has addressed the problem of applicability.T h e stu d y a d d re ss e d th e issu e o f applicability in this study because all sufficient d escriptive data related to cultural care beliefs, values and attitudes of Shangaans in relation to hypertension was clearly presented in chapter four w hich allow s for com parison o f the inform ants with other cultural groups namely the Venda speaking, Sotho, Zulu as well as Tsonga / Shangaans from other areas outside the villages used for this study.
T h e m e s and c a te g o rie s w ere also fo rm u la te d a c c o rd in g to the d a ta themselves with the assistance of data o b ta in e d d u rin g lite r a tu r e re v iew .Form ulated them es for data obtained d u rin g in d iv id u a l in te rv ie w s w ith traditional healers are as follows.

R
e m e d ie s d is c u s s e d by in fo rm a n ts included a variety o f activities moving from indications, prescriptions, positive remedies and negative remedies as well as the preparation m ethods, related to individual remedies from which individual themes emerged.
r e s e a r c h e r 's b ia s in v o lv e d in th is research might include aspects such as th e r e s e a r c h e r 's k n o w le d g e o f hypertension w hich indicate that the researcher came into the conduction of the study with the know ledge though bracketing was done.Certain limitations w ere identified in the study nam ely: participant effect, and data collection and analysis.This is a contextual study and the findings o f this study cannot be generalised.ConclusionsCultural care beliefs; values and attitudes are available amongst the Shangaans and o th er m em bers o f d ifferen t cu ltural groups.Shangaans have their own perceptions o f h ig h b lo o d / N g a tile y ik u lu / hypertension and this is influenced by the presence of their own world views, cultural perceptions as w ell as their experiences in their own culture.Failure to recognise these beliefs, values and attitudes by nurses and other health personnel who are rendering health care might lead to many complications such as fa ilu re o f S h a n g a a n s w h o are hypertensives to cope with the chronicity o f their condition and failure to adjust to life style changes brought by the disease.Delivery of culturally competent health care requires that nurses develop positive attitudes towards people from different cultural backgrounds.Nurses need to acquire the knowledge available amongst the different groups of South African p o p u la tio n fro m d iffe re n t c u ltu ra l background which influence the way people react to health and illness.
suggested four criteria to support trustworthiness, these criteria are credibility, dependability, confirmability and tran sferab ility .T he c riteria and strategies w ere used in the study to ensure trustworthiness.It is the ability to generalise from the findings to larger populations.In qualitative studies applicability refers to how well the threats to external validity h av e b een m an a g e d (S a n d e lo w k i; Truth value establishes how confident the researcher is with the truth o f the findings based on the research design, informants and context.In qualitative studies truth is assessed by how well threats to the internal validity of the study and the instrument as a measure of the phenom enon under study, have been managed.Internal validity is supported when changes in the dependent variable are accounted for by changes in the independent variable, that is, when the d e sig n m in im ise s the e ffe c ts o f com p etin g con fo u n d in g variab le by control or randomisation.Lincoln and  G uba (G uba; 1981:80)term ed this credibility(Krefting; 1991:215).wh ile th e r e s e a rc h e r liste n e d and recorded all the information said by the informants.Applicability refers to the degree to which the findings can be applied to other co n tex ts and se ttin g s or w ith o ther groups.