Health Seeking Behaviour by Cape-Townians : a ' mini-research by first year student nurses at a College for Nursing in Cape Town

The author was asked by a student nurse to use South African examples when teaching, as the textbooks were either American or English, and they wanted sociology that applied to their own environment. In the next year of teaching the prescribed objectives j concerning "Health Seeking \ Behaviour", it was suggested that the j students question the populace, and ' find out for themselves how South I Africans behaved when they thought j they were ill. By doing this it was j hoped that it would also give deeper j insights into the meaning people | attributed to illness/sickness. I I Opsomming Die skryw er was deur student verpleegkundiges gevra om Suid-Afrikaanse byvoorbeelde te gebruik wanneer sy Sosiologie onderrig, want alle teksboeke was of Amerikaans o f Engels, en studente wou iets he wat toepaslik by hul eie omgewing is. Tydens die volgende jaarse onderrig van "Health Seeking Behaviour", het die skryfsterdie klas gevra om hul eie navorsing te ondemeem. Die artikel beskryf hul ondervindinge en wys aan dat dit 'n werklike metode is om studente te help leer van hul eie land, mense, en 'n nuwe vak. Sodoende was dit gehoop dat studente 'n grooter insig sou behaal oor die betekenis wat mense aan hul sieke toepas.

The author was asked by a student nurse to use South African examples when teaching, as the textbooks were either American or English, and they wanted sociology that applied to their own environment.In the next year of teaching the prescribed objectives j con cern in g "H ealth Seeking \ Behaviour", it was suggested that the j students question the populace, and ' find out fo r themselves how South I Africans behaved when they thought j they were ill.By doing this it was j hoped that it would also give deeper j insights into the meaning people | attributed to illness/sickness.I I Opsomming Die skryw er was deur student verp leeg ku n d ig es gevra om Suid-Afrikaanse byvoorbeelde te gebruik wanneer sy Sosiologie onderrig, want alle teksboeke was of Amerikaans o f Engels, en studente wou iets he wat toepaslik by hul eie omgewing is.Tydens die volgende jaarse onderrig van "Health Seeking Behaviour", het die skryfsterdie klas gevra om hul eie navorsing te ondemeem.Die artikel beskryf hul ondervindinge en wys aan dat dit 'n werklike metode is om studente te help leer van hul eie land, mense, en 'n nuwe vak.Sodoende was dit gehoop dat studente 'n grooter insig sou behaal oor die betekenis wat mense aan hul sieke toepas.

Introduction:
In the first year of teaching Sociology at Carinus Nursing College I was asked by nurses to use South African examples as the text books were either American or English and they wanted sociology that applied to their own environment.In the next year of teaching the prescribed objectives concerning: "Health Seeking Behaviour" I suggested that they go out, question the populace, and find out how South Africans behaved when they were ill.
By doing this it was hoped that it would also give deeper insights into the meaning people attributed to illness/sickness.Another reason for doing this was that this module fell in the stu d e n t's last block after their w ritten examinations, and teaching new material was no easy task.
Purpose of the Study: de Jong (1987) discusses, under health care from a medical-anthropological viewpoint, th e h e a lth -s e e k in g b e h a v io u r of Guinea-Bissau African folk.He describes what he sees as the different health care sections in that country: the popular, folk and professional care sectors.He adds that there are three functions of any health care system: the first -to give meaning to suffering; the second -healing per se; and the thirdcommunication during the healing process.
W hether one accepts that Africans have migrated South or not, it was felt that it would be relevant to use de Jong's Guinea-Bissau w ork to g ive th is study an academ ic framework.If one quotes from Leininger (1981), Leininger & Watson(1990), Mashaba & B rink (1994), M cGee(1994), Spector (1991), Masi et. al. (1993), or de Villiers & van der Wal (1995) the message is that one should be more culturally aware.And, not only of our patients or clients as we go into Primary Health Care, but of our student nurses for they too have rich cultural diversity to be explored.
The Question: The study centres on giving meaning to suffering; taking suffering in its widest sense and asking: "W hat meaning do sick persons attribute to their illness"?It is felt that the answer to this question would ultimately affect the other two functions especially from a cultural point of view.

Methodology:
Basically this was a qualitative study at a very elementary level.Students were given a week to ask five people, whom they could choose, three questions.The questions posed to people were; 1.How do you know that you are sick; 2. What do you do when you are sick; and, 3. What do you think causes you to be sick?A total of 74 (five male-and 68 female-) students took part in this project'.This gave an interviewee population of 365 persons^.These persons were of the usual ethnic groups of the Cape: Xhosa, Caucasian, Indian and Coloured.A lthough the m ajority o f the interviewees were female (number identified = 166), there was also a representative male group (79 males).Ages ranged from 6 to 70+ years.They were variously employed from scholars (2), students (not only nurses), h o u se w iv es, ac co u n tan t, b o at b u ild er, te ach ers, d o cto rs, p ro fe ssio n a l n u rses, storeman, pensioners.A full list was not given as not all nurses mentioned employment.
One must remember that these were first year R425^ student nurses engaged in their second module of Sociology.They had no previous research experience.Research as a main subject features in their fourth year.They were instructed about research fix)m the point of view of using the structured questions and writing down verbatim what the interviewees said in response to them.They had to identify themes, similarities and dissimilarities, and make a summary or conclusion.The results w o u ld co u n t as th e ir test (co n tin u o u s assessment) mark.Some students did well, even going beyond their five interviewees, some asked less than five.Some students gave no demographic details (age, gender, race, employment); some gave ethnic grouping only, some gender only.Marks ranged from 3 0 -8 0 % .288 re s p o n d e n ts c o u ld be categorised as given in Table 1 (79% of total number interviewed).
Analysis: Individual students sorted their questions into categories i.e. either each person and the three answ ers; or, each question and their interviewees' answers.It was then a matter of creating a demographic grid, and sorting into themes.The question of c a te g o riz in g in to e th n ic g ro u p in g s is controversial.If all groups were totally westenuzed' there would be no problem, but also nothing of interest.However the results As students undertook this 'research' in their ow n tim e and am ongst p eers, fam ily, neighbours, friends, and the local public no formal proposal nor official permissions were sought.

TABLE 1: to show (Ethnic
Even with the given limitations the results reveal the health-seeking behaviour of the interviewed population.Having realised this, I informed the students that I felt their work had academic value and that I would attempt to have it published.The work is theirs, my c o n trib u tio n is g iv in g it an academ ic framework and typing it.My reason is to show 1) that sociology can be learnt in this innovative manner; 2) that given the right directions students can be involved in research from early in their training; 3) that whatsoever material is obtained in this way could be utilized in other subjects e.g.community health, health promotion, ethics, etc., and 4) that the data has socio-culmral value and enabled them to learn that sociology can be fiin!
Results: W ill be given as per question, highlighting themes, many of which were repeated to saturation point and others merely one-offs.
Question 1: "How do you know that you are sick?"(see Table 2a).
'Westernised' people look for symptoms.The commonest reaction was: "when my body feels different" (and some added; "from yesterday, or my normal se lf).Two doctors compared how they had felt the previous day.
Many "listened to what their body was saying".Non-westemised Africans went by dreanw or experiences (see Table 3) feeling something moving in/or eating that part of the body that was thought to be sick e.g. in their stomach, or back.One interviewer concluded: "Nobody can tell anybody that they are sick.
Its very personal.Some people say they are sick when they have a common cold, others don't take it as sickness.They are in their own ways responsible for their health".
Question 2. What do you do when you are sick?(see Table 2b).
It was surprising how many Westem/ized people took panados or grand-pa powders and med-lemon tablets together in the initial stages of their illness.A large number commented that unless one belonged to a medical aid it was too expensive to visit a doctor.Therefore they treated themselves.Either they obtained something from the chemist or they took their own familiar 'home remedies'^.Those who belonged to medical aid said they would go to their doctors in the first instance, especially if a certificate was necessary.Others felt that because they belonged to medical aid they could rush to the doctor at the slightest disease.
N urses divid ed th eir interview ees into categories.One coloured nurse commented, "There is a belief amongst older persons in traditional Hollandse or patent medicines".Another called them "raatjies".One wrote: "The coloured race resorts to westernised medicine.""Cultural beliefs play an important role in the management of illness by an individual".People from traditional African culture said that they would "slaughter an animal", "m ake beer", visit a diviner (a sangom a), "ask the elders for a second opinion", "have a family 'come together'", use 'herbs' or 'muthi', and "ask the ancestor for protection".In one instance it was said that "the Sangoma would cut a little hole in my body and put in some mud (like immunisation) to prevent demons (tokoloshe) from doing harm".Others would go to the herbalist (or Inyanga).How people view their health has implications for health care providers and its consumers.As question 3 indicates it sets the pattern regarding the subsequent action that consumers will take.I believe that this could be researched further with great profit.
Question 3; "What do you think causes you to be sick?"(see Table 2c) This question uncovered cultural diversities, and confirmed that people want to make sense of illness or disease.One interviewer wrote: "I've asked black people from my sQ-eet.Most of them are Christian meaning that they don't believe in the traditional way of healing, neither do they believe in witchcraft."

I-
Some interviewees came from rural areas.There was talk of "bad spirits", "forefathers", of "ancestors (who had) stopped protecting me", "witchcraft poison", and "umthakathi".This is in line with de Jong (1987:44) "When somebody feels sick, he will try to find out what (or who) is bothering him.To answer this question is the first function of a health care system, i.e. to give meaning to suffering or illness in order to engender the healing practice"."The sufferer's judgement rather th an th a t o f b io m e d ic in e d e fin e s the underlying problem" (op.cit.45).
One nurse commented: "It's a loss of harmony in the body".And from a homeless man: "I just go around asking for a tot of liquor or asking for money to buy panado.I am sure it is not getting any liquor at all because when I'm finished with drinking the pain goes".
And again, "Younger people felt that getting sick was more self-inflicted e.g.alcohol, drugs, not being dressed warmly, change of seasons, allergies ... whereas older people acknowledged that it is more stress-related, loneliness and depression".This question revealed that people do seek meaning for their illness/sickness and that it affects their perception in terms of healing (see Table III)

Conclusions and Recommendations
Oosthuizen (1996:193) says in dealing with culniral differences ethically: Nurses "should be able to explain why it is necessaiy to develop cultural awareness".Many nurses interview ed respondents from their own ethnic culture and furnished cultural and ethical recommendations that they felt came out of their work, and, which could be taken further when reseach is studied in the final year.Add to this the student's own insights and so m e v ery in te r e s tin g s o c io lo g ic a l observations came forth confirm ing the African literature; interesting cultural patterns for other ethnic groups also came to light.This project had other benefits: 1.It gave students a taste for research.
Many said how they had enjoyed doing it.They wished they could do more as they leamt so much about people and their health-seeking behaviour while they were doing i t It made the text-book discussion on this topic more 'alive'.

It shows something about student nurses' own health seeking behaviour.
There is tremendous use of the word 'stress' which partly reflecu their own feelings at that time of the year (just after their written examinations); and partly that of odiers.Many interviewed their peers (there was no o v e rly in this: if a student had been interviewed once she was not interviewed again).
Poor diet, lack of vitamins and overwork became tiiemes amongst interviewed student nurses.
3. It gave the students a chance to be both interviewer and interviewee.I believe it gave them skill and confidence in interviewing.One must realise that these students have studied no pathophysiology.
4. Many became aware of the costs of health through their respondents' replies.The expense of going to a doctor was shown and the fact that these respondents felt that they could not afford to go unless they were really sick.
5. Some became aware of flie total lack of health knowledge in their interviewees and recommended that more health education be given to these people.One such respondent said, "First (the interviewee) had pain in her breast, loses weight, the pain gets worse and she becomes anxious.People advised her to buy some kind of herbs which would be good for her problem from the Rasta.She buys these herbs and wrapped her Isreast with these herbs as she was told.Instead o f getting cured she feels some lumps from her breast which seems as if they are going to make sOTes.She goes to the hospital and her teeast was cut off because it was damaged".
Treadwell (1992) shows that 46.7% o f persons with cervical cancer visited the traditional healer, and that the medicine s/he prescribed was taken.The efficacy o f the treatment was not addressed.Only 3% o f her respondents had their cancer discussed by the healer.Another nurse who came across a very uncertain diabetic recommended; "The patient needs to be educated and told in the language that he knows.The person needs to be told why various tests are done." Although one can look at this study as an innovative method in teaching students one aspect of sociology -a method that gave the stu d e n ts th e o p p o rtu n ity to b e c o m e empowered and responsible for their own learning -it makes no claim to be academicaUy erudite.It is merely a first step.To have done more, taken it furfter, would not show what students are equable of in their first year.
TABLE 3: African experiences and dreams (as told by the interviewee and written by the interviewer)®

Dreams Experiences
1. "A 20 year old lady from Gugulethu w*iom I metatShoprite.She told me that before she gets sick she started to lose weight, lose her appetite, and that the sight and smell of food caused her to vomit She went to the clinic for two years and they could not help her.Instead she was getting thinner and thinner.She was sleeping at midday and she dreamt of a man who was talking to her and pleading with her to accept the job they were offering her.He said she had been ^pointed by her ancestors to be a healer and if she accepts she will be healed.On telling her parents this c^eam they encouraged her to accept so that she would be cured and th^ would not lose her.They had a big feast sacrificed a goat to the ancestors, African beer was made and she was cured".
1. 'If she got bad luck at home or work she knows that someone is after her.If her face develops pimples, instaitly she knows she is sick and she must do something.She goes to a dense forest and picks herbs, finds roots of some trees (inqvrebeba).Ttien she does 'nyafutha' meaning she wraps herself with blankets, sits with the boiling water with the hert)s, and her facing the boiling herbs.Then her whole body sweats and she knows that the bad luck and pimples will disappear.She knows that it is the witches that make bad luck -the disease is 'ungqwaliso' which means bad luck*., 2. "When I doni sleep well and have bad dreams every night then I go to the priest The one who uses water to heal -'umthan-dazeli'.The illness is the evil spirits' 3. 'A 32 year old man I met in the train.He was with his wife.He said,' First she feels dizzy, after some few seconds she falls down, after that I don't know what happens.Her body is jeildng and she hears some voices although she seems to be unconscious at that time'.They go to the traditional healer as they believe that this sickness is caused by evil spirits from witches (due to these funny voices) The traditional healer gave them meicine and promised to stop these witches from doing this evil work*.
4. 'I met an African lady and asked her how she knows she is sick?She said when she is notfeeling well strange things happen to her like bad dreams, crying In her sleep during the night and a tendency of not wanting to speak to people.She puts some herbs to the fire before she goes to sleep Cukuqhumisa') so that she can get rid of bad dreams.If this does not help she consults the traditranal healer ('isangoma') to diagnose her illness.He will refer her to the herbalist ('inyanga') for treatment Evil spirits are the cause of her disease'.

4.
'A 29 year old man who I met in the bus temriinus.He said he stays in tanga.
When he feels sick he just feels as if there is something moving inside his back and then his joints get weakened and he cant move.He feels lots of pains.He wentto the traditional healer and even to the hospital and nothing helped him.He went to a church where priests make a big prayer for him so that God can take away these evil spirits from him, after that he gets cured and all those evil spirits were gone'.
5. '1 know I am sick by ct^eaming about someone that you suspect is a witch.I make African beer and ask the ancestor to protect me against the evil.It could be the ancestors causing the illness.They stop protecting me because I never made African beer.So I talk to them and ask for protection against the evil spirit and witchcrafr.
5. 'A Christian gentleman said that when he is not feeling well he feels dull.When he feels pain he knovre that he is sick.When he is sick he pray^ to God to relieve his suffering.He does not go to the doctor because his religion does notallow him to use medicine.He believes that the cause of his illness is a test from God to deter-mine how deep is his faith'.Many of these dreams/experiences were reported by other interviewers (where any student -black, white, or coloured had interviewed traditional and/or njral Africans.No dreams as such were reported by interviewers ^o had inten/iewed the other cultural groups).
5. These recorded inteiviews are very similar to those discussed by de Jong i d his book (q.v.) to specific cultural groups, and the health care sectors mentioned by de Jong.For that reason alone the results were classified.Com ments: At the time of this study there was absenteeism from a 'flu epidemic amongst the stu d en ts.T h o se stu d en ts w ho becam e interviewees (19 nurses) reflect this in their identifying symptoms, analysing diet, taking vitamins, and feeling exceptionally stressed.

Table 2a : T1HEMES from Question 1. Question 1: "How do you know tliat you are sick?*
2. 'When I feel down, frightened and sweating, always during the night Then I go to the Sangoma who will throw bones and tell me what is going on'. 3a.'I do not sleep well and have bad dreams every night I go to my church prophet and he interprets my dreams.I believe that sickness is caused by the evil spirits and demons'.3b."When I feel something moving inside my stomach and it causes pain sometimes.I go to the 'isangoma' he uses bones and throws them in front of me, they tell him what is wrong with me.I believe In what the sangoma tells me that I have got black poison ('idliso') in my stomach'.