The Attitude of Community Health Nurses towards Integration of Traditional Healers in Primary Health Care in North-west Province

Opsomming South Africa is called " the rainbow nation " because it has so many different cultures. These have an impact on the provision of primary health care. The purpose of this research is to foster good relationships between commu­ nity health nurses and traditional healers and to explore, identify and describe the attitude of community health nurses towards the integration of traditional healers into primary health care. A non-experimental, explorative and descriptive research strategy was designed to explore the working relationship between community health nurses and traditional healers. Data was collected using a struc­ tured questionnaire. Quantitative as well as qualitative data analysis techniques were adopted to interpret the find­ ings. The results indicated that respondents demonstrated posi­ tive attitudes towards working with traditional healers, especially in the provision of primary health care. Posi­ tive opinions, ideas and views were provided about the integration of traditional healers into primary health care. Respect, recognition and sensitivity were emphasized by respondents. Suid-Afrika word die " reënboog nasie " genoem omdat so baie verskillende kulture deel daarvan uitmaak. Die verskeidenheid van kulture het impak op die voorsiening van prim êre gesondheidsorg. Die doel van hierdie navorsing was om goeie verhoudings tussen die gemeen-skapgesondheidverpleegkundiges en die tradisionele genesers te kweek en om die gesindheid van die gemeen-skapgesondheidverpleegkundiges ten opsigte van die integrasie van tradisionele genesers in primêre gesond­ heidsorg te verken, te identifiseer en te beskryf. 'n Nie-eksperimentele, verkennende en beskrywende navor-singstrategie is ontwerp om die werksverhouding tussen gemeenskapgesondheidverpleekundiges en tradisionele genesers te eksploreer. Data is ingesamel deur gebruik te maak van 'n gestruktureerde vraelys. Kwantitatiewe sowel as kwalitatiewe data analise tegnieke is gebruik om die bevindige te interpreteer. Die resultate dui aan dat respondente 'n positiewe gesind­ heid teenoor samewerking met tradisionele genesers dem onstreer, veral in die voorsiening van prim êre gesondheidsorg. Positiewe opinies, idees and sienswyses is voorsien aangaande die integrasie van tradisionele genesers in primêre gesondheidsorg. Respek, erkenning en sensitiwiteit was deur die respondente benadruk.


Introduction
South Africa is called "the rainbow nation" because it has so many different cultures.These diverse cultures make special demands on primary health care services because nursing aims to provide nursing care to all the people of South Africawhatever their creed, cultural traditions or ethnic origin.One of the most recent initiatives in South African health care is a plan to coordinate the work of community health nurses and tradi tional healers in order to meet the health needs of everyone in the country by the year 2000.The National Health Plan states that primary health care should be accessible and available to every member of the community in such a way as to promote health and prevent illness.If Such a comprehensive curative and preventative primary health care programme is to succeed, traditional healers will have to be integrated into the national primary health care programme because -as this study will attempt to show -they too have a vital and indispensable role to play in the provision of health care.Suitable mechanisms for integrating traditional healers into the National Health system need to be identified and implemented (ANC, 1994:72).

Outline of the problem
Health and illness may, from one point of view, be interpreted and explained in terms of a personal experience and expecta tions.Although the term illness refers to the experience of a sick person, all illnesses are determined by how a particular society defines such illnesses.An illness is only an illness in a particular society once it has been defined as such by a health practitioner, a physician and by the community itself (Spector 1991:15,49).According to Bouwer, Dreyer, Herselman, Lock and Zeelie (1997:34), African people who view illness from an indigenous point of view believe that illness can be intention ally caused by a malevolent agency which has control over supernatural (mystical) forces.Black South Africans tradition ally believe that practitioners of witchcraft and sorcery can cause certain kinds of illness.The reasons why people in a community consult health care providers depend on their choices, their personal experience and their cultural background.Africans from communities in the North West Province consult traditional healers because they know from experience that their interpretation of health and illness is often different from the interpretation that would be placed upon their experience by a Western practitioner.Such people also expect and rely on different remedies to heal their illnesses.People in communities like this one consult tradi tional healers because of:

Background of the problem
According to Searle (1987:7), primitive people believed that all diseases were caused by supernatural agencies.It was among such people that the art of traditional healing developed over millennia until it became the highly sophisticated and complex system that we know today.In cultures all over the world, shamans, medicine people and traditional healers have tradi tionally been rendering indispensable service to people.Tradi tional healing was regarded by the missionaries of the nine teenth century as a manifestation of heathen culture that a convert to Christianity should renounce.The devaluation of traditional African culture by missionaries and colonisers cre ated a kind of cultural schizophrenia in the hearts and minds of African converts to Christianity.While many Africans found much of value in the new religion, most found it impossible to forget the ways of their ancestors.While many therefore were outwardly, and quite genuinely, Christians in their beliefs and practices, most continued to observe the traditional ways by, for example, consulting traditional healers when they felt that Westem-style medicine was not able to help them.A tremen dous amount of research has been done to establish the value of traditional healing practices, and in many cases traditional African remedies and healing techniques have been vindicated by this kind of research.It is now also accepted in Western medicine that faith in the healer is an essential part of the cura tive process (Mahape 1995: 12;Abdool-Karim 1994: 12;Swift and Strang 1993:690-691).

Significance of the problem
This research is important because it sets out to investigate the attitude of community health nurses towards the integra tion of traditional healers in primary health care.This research could lead to an improvement in the quality of life of individu als and a renewed respect for human and cultural rights.South Africa has a long and unfortunate history of disregard for hu man rights and cultural diversity.The identification and reso lution of the problems experienced by community health nurses and traditional healers (such as, for example, poor communica tion) will have the effect of improving the provision of health care for the whole population.This can only happen if health care methods are recognised and accommodated on an official level and if traditional healers and community health nurses are officially regarded as being of equal importance in statusin spite of diversity and differences in methods, techniques, treatments and world view.This research aims to create and nurture a trusting relationship among healers and community health nurses.Such trust, once created, will lead to an improve ment in the quality of health care services for all the people of South Africa -and not just the privileged few.Conflict will be eliminated and new forms of trust and respect will arise as people who were previously hostile to each other find that they have every reason to respect and support each other.

Aims of the study
The purpose of this study is to foster a good working relation ship between community health nurses and traditional healers.
The specific objectives of this study are to: • identify the attitudes of community health nurses to wards integrating traditional healers into primary health care • identify and describe the role which traditional heal ers play in the community The researcher devised the following research questions as the basis for her research plan: • What is the attitude of community health nurses to wards the integration of traditional healers into pri mary health care?• What roles do traditional healers play in the commu nity?

Operational definitions
For the purpose of this study, the following definitions will apply:

Attitude
A way of thinking and acting; it is the behaviour of a person towards a situation (The World Book Dictionary 1994: 132).

Prim ary health care
According to National Health Care Plan of South Africa, pri mary health care is based on practical, scientifically sound and social, acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at the cost that the community and the country can afford to maintain at every stage or their devel opment in the spirit of self-reliance and self-determination (ANC 1994:20).

Traditional healer
According to the Oxford Dictionary (Hawkins 1986:237), a tra ditional healer is a practitioner who bases his/her healing prac tice on an ancient system of culture, custom and beliefs that had been passed down from generation to generation from time immemorial.

Research method
A non-experimental, descriptive survey was conducted to col lect the data from selected community health nurses who are providing primary health care.The purpose of this study was to seek information, identify problems with current practices, justify current practices and make judgements after determin ing what others in similar situations are doing (Bums and Grove 1993:293).

Population
Subjects in this study were nurses who were registered in terms of the Nursing Act no 50 of 1978, as amended (South Africa, 1978), who are providing primary health care in Odi region of the Northwest Province.Odi region is comprised of three (3) districts, namely Odi, Brits and Moretele.

Sampling
A systematic probability sampling was chosen to select one hundred (100) respondents from the target population in Odi region.
Lists of Odi region clinics were compiled.The lists were re quested from Odi district clinics (23 clinics), Brits district (6 clinics) and Moretele district (24 clinics).Selection was done systematically.Each list was used individually from an indi vidual clinic.Every second clinic was selected as a sample.Three (3) clinics were selected from Brits district; twelve (12) clinics were selected from Moretele district, and ten (10) clinics were selected from Odi district.In total, twenty-five (25) clinics were selected from fifty-three (53) clinics in Odi region.Partici pation was voluntary and subjects were approached directlyexcept in some cases where community health nurses had the day off or were on leave.The table below reports on the number of subjects from the various areas of study.

Table 1 : Number of subjects participating
Only registered nurses who are providing primary health care in clinics were included in the study because they have the experience specific to the study in question.

Research instrument
Structured questionnaires were used to collect relevant data from community health nurses in Odi region.Open-ended and closed ended questions were used to collect data.Open-ended questions allowed the subjects to respond in their own words whereas closed ended (or fixed alternatives) questions offered respondents a number of possible replies from which the sub jects had to choose the one that most closely matches (in his or her opinion) the appropriate answer.

Data collection
A questionnaire was used to collect data from community health nurses.Privacy and anonymity were ensured by assigning a number to each respondent.The researcher personally distrib uted one hundred (100) questionnaires to the selected clinics and the respondents were given a week to complete the ques tionnaire as some clinics were very far away and difficult to reach.The questionnaire required thirty (30) minutes to com plete.Data collection was performed over a six week period, namely May-June 2000.

Ethical consideration
A written permission was requested from the University ethics committee, Odi district services and from participants.Full ex planation on the purpose of research was explained to the par ticipants in order to obtain verbal and written consent.Indi vidual rights to confidentiality were guaranteed.

M easures to ensure validity and reliability
The content of the questionnaire was developed by the re searcher from literature consulted, radio news and newspaper, television programmes and with the help of colleagues who had experience in research design.A pilot study was conducted to ensure validity and reliability of the instruments.Few prob lems were identified by participants and corrected before the main study.The research instrument was tested for face and content validity.The instrument was given to the supervisor and two independent people for validation, acceptance and to check ambiguities in working and repetition of items.A profes sional statistician was consulted and she detected a few mis takes which were also corrected.

Data analysis
The data was quantitatively analyzed.Tables and percentages were used to explain the results.The attitudes were determined by means of responses to options: agree, disagree and uncer tain.

Discussion of the findings Respondent's demographical data
The demographical data provided crucial information about the research.References regarding the influences of demo-

Ethnic group to which respondents belong
This item determined the ethnic groups in Odi region (Odi, Brits and Moretele districts) to which the respondents belong.
The ethnic group could have an influence on the attitude of community health nurses towards integration of traditional healers into primary health care.
terms of the specific ethnic groups to which they belong.
The ethnic group to which respondents belonged influenced the attitude of respondents to the provision of primary health care.It is obvious that different ethnic groups have their own folk health beliefs and practices.One should appreciate that sensitivity, respect and recognition need to be preserved with regard to ethnic differences.Table 2 shows that the majority of respondents (65 or 67.7 %) in Odi region (Odi, Britz and Moretele districts) are Tswana-speaking.Because Tswana is the most common ethnic group in the North West, the number of nurses who are Tswana probably re flects the demographic composition of the community in that area, who, one may assume, all adhere to the same value system.It must be noted that as the respondents were composed mostly of black nurses, they belong to sub-groups within sub-cultures which are peculiar to their own tribal life styles (Mahape, 1995:42).One may assume that these nurses understand their patients in the region understand their patients better as they belong to the same culture as their clients.All respondents were also South African citizens.
According to Searle and Pera (1995:72), the South African Nursing Council keeps registers and rolls to ensure the legal ity of nursing practice among all nurses in South Africa.All the respondents in Odi region are South Africans and they all practice legally in their communities and their modes of prac tice are dictated by the statutory requirements of South Af rica Nursing Council.Community health nurses have different attitudes that may influence the integration of traditional healers into primary health care.This section is of vital importance because it deter mines the attitudes of community health nurses to integration.It deals with attitudes to consultation, the referral system and the formation of partnerships.Statements were made to which respondents had to respond.Of the 95 respondents, 86 (90.5 %) agreed that traditional heal ers should be encouraged to refer their patients to the clinics immediately after consultation.This substantial percentage indicates that integration is possible as long as all health pro viders are willing to cooperate.Eighty five respondents (88.4 %) agreed that patients should visit the clinics before consult ing traditional healers.This shows that community health nurses are of the opinion that if patients consult the clinic before traditional healers, all conditions/diseases can be prop erly treated according to particular protocols.The majority, 79 (83.2 %) of the respondents agreed that community health nurses should accept referral notes from traditional healers.An acceptance of a referral note will facilitate continuity of care and prevent further complications.

Question
An outstanding number of the respondents, 80 (84.2 %) agreed with the statement "Traditional healers should form part of primary health care".It is community nurses who need to have a more positive attitude if they are to form part of the primary health care team because traditional healers are al ready available, accessible and acceptable to the community.While 38 respondents (40.4 %) disagreed with the statement "Patients should consult traditional healers for their ill-health", only 24 (25.5 %) agreed with the statement, and 32 (34.1 %) were unsure.This is an important finding: while some com munity health nurses emphatically agree that patients should be able to consult a traditional healer for their health prob lems, some disagree that patients should be given any free dom to choose the health services which they might prefer.
The results indicate that respondents demonstrated different opinions, beliefs, views and ideas about the integration of traditional healers into primary health care delivery.Upvall (1992:32) stresses the importance of training traditional heal ers so that they will know when to refer patients to health services and when and how to prescribe medicines.Nurses and traditional healers must focus on those health objectives which they have in common to ensure improved health care.
With regard to possible integration WHO's regional commit tee for Africa suggested the following steps if integration is to be successful: • All traditional healers should be registered.

•
Collaborative organizations for traditional healers should be promoted.

•
Traditional healers should be legalised once they have passed competency tests.

•
Research should be carried out into the medical knowl edge of traditional healers.
Different attitudes were obtained.The integration of traditional healers into primary health care was emphasised.These find ings showed that the respondents were positive towards the idea of integration of traditional healers into primary health care.It is concluded that traditional healers should be fully empowered with the skills of need identification, diagnosis and the management of clients particularly referral of their clients.Shai-Mahoko (1997:137) is of the opinion that traditional heal ers should be included in the immunization schedule.Such participation will contribute towards their empowerment if they cooperate fully and effectively with community health nurses.
It is also necessary for community health nurses to improve their attitude towards traditional healers if they wish to pro vide clients with holistic care.

The role of traditional healers in the community
The information gathered in this section is important because it will guide the researcher to comprehend the roles of tradi tional healers in the community.The integration of traditional healers into primary health care will be influenced by the atti tude of the health care practitioners.Table 4 : The roles of traditional healers in the com m unity (N = 9 1 -9 5 ) The majority of the respondents 88(93.6 %) emphasised that traditional healers should participate in health education pro grammes and 87.4 percent of the respondents emphasised that the traditional healer is a person who is respected by the com munity.If a person is respected in the community, this is usu ally an indication that, that person does some kind of special work or plays a particular role which benefits the community.
Of the respondents 68(73.1%) agreed that traditional healers are acceptable, accessible and available for continuity of care.This is one of the reasons community members visit traditional healers.Respectively 62(67.4%)and 59(64.8%)indicated that traditional healers provide care and treat certain diseases ef fectively.An almost equal percentage 55 (59.8%) agreed that traditional healers are more involved in community care.Of the 96 respondents, 72.3 percent indicated that traditional healers cause disruption in families because certain healers attribute disease to witchcraft and blame family members for practising witchcraft.
To understand the role of the traditional healer in the commu nity it must be realised that some people have a dualistic ap proach to illness.They may adhere to Christian beliefs and customs while at the same time believing in and practising traditional rites and rituals.Many Africans, for example, be lieve that illness is caused by witchcraft and the dissatisfac tion of the ancestors.For those who believe this, it is only logical to consult a traditional healer.Conditions that drive people to consult traditional healers are marital problems, work, children, family, love and poverty (Pera & Van Tonder 1996:237-238).Because many patients consult the traditional healers be fore consulting the clinic, it is understandable that nurses feel that traditional healers should be integrated to assist in health promotion and disease prevention.
It is important to note that costs, comfort, beliefs and values play a role in influencing the choice which a patient makes when he or she wishes to consult a health care provider.Because the Westem-type of health care is often inaccessible, there is often a lack of continuity in care and this means that the health needs of people are not being met (Pera & Van Tonder, 1996:243).
Different roles for traditional healers were identified.The infor mation obtained from community health nurses shows that traditional healers should be involved in the HIV/AIDS pre vention programme.This was also confirmed by Swift and Strang (1993:690-691) in their study of health promotion and illness prevention.Proper utilization will reduce infection and mortality rates in South Africa as the country is rapidly being overwhelmed by the HIV/AIDS pandemic-not to mention very high rates of infection in those in contact with tuberculosis and various sexually transmitted diseases.
The statistics which emphasise the seriousness of the HIV/ AIDS pandemic have been brought to public attention again and again by the Department of Health (1997:140), and the department's line is now that individuals should play a much more active role in caring for their own health and preventing infection.This research has highlighted the fact that traditional healers are indispensable in the provision of health care to the community because they are: • people who are respected and highly regarded in the community.• often far more accessible and available to the commu nity than Western biomedical staff especially in rural and dis advantaged areas.Although many traditional healers currently lack certain skills in health promotion and illness prevention, they are respected and are always accessible to help members of their communi ties.The successful incorporation and integration of traditional healers into the health care system will contribute to a better quality of life for all South Africans

Recommendations
In the light of the findings and problems identified in this study, the researcher makes the following recommendations: • The Department of Health should ensure that inte gration between traditional healers and community health nurses takes place at a national level.Strate gies to ensure the integration of both kinds of health providers should be designed and implemented.

•
Community health nurses should conduct in-service education and workshops which will give traditional healers the opportunity to participate in health edu cation programmes that will empower them to edu cate their clients to avoid common infections and ill nesses such as HIV/AIDS.

Implications for nursing practice
For nursing education Nursing syllabuses in South Africa should all be designed in terms of transcultural principles and all nurses should be trained in the techniques of multicultural nursing and care giving.
Nurses must be taught to be self-reflective about their own cultural premises.They should also be taught to view their own attitudes and health beliefs objectively and to respect the attitudes and beliefs of those whose health care practices are based on culturally alien paradigms.Above all, nurses should be taught not to impose their own prejudices and attitudes onto their patients.

For com m unity health nursing
Nurses should be allocated to rural communities so that they can empower such communities to make their own choices about health care and so that they can teach members of the community the basics of health practice and self-care.

For policy making
The South African government needs to pass legislation that will grant professional status to the various categories of tradi tional healers.Such legislation will systematise practice of tra ditional healing and in so doing, set certain standards which will benefit both traditional healers and their clients.

For nurse adm inistrators
Nurse administrators should provide as much information as they can to their subordinates about how transcultural beliefs affect patient care.This information can be provided in staff development programmes.All employees should be constantly updated with information about traditional practice.

Fo r research
The findings of this study suggest that further research is needed on a variety of topics, but especially on: • medicines used by traditional healers • the future of traditional healers • studies which compare the attitudes of nurses and traditional healers towards integration

Lim itations of the study
The research was limited to the population of only three dis tricts of one province (North West Province).As populations differ from one province to another, the results were not repre sentative.South Africa is called "the rainbow nation" because of the diversity of its population, and so any scientific study of this kind has to be replicated and qualified with further re search in other regions of South Africa.The ideas, opinions and views indicated by respondents could not be linked to the ideas, opinions and views of nurses in other provinces.

Final conclusions
The study has provided much useful information about atti tudes to the issue of integrating traditional healers into the primary health care system.The research shows that the atti tudes of respondents to the possibility of integration was, on the whole, extremely positive -subject to certain qualifications on the part of the respondents, which emerged very clearly.This indicates and the integration of traditional healers into the primary health care system of South Africa is a viable project that should be implemented from the highest level of govern ment.Kriel (1989:211)

writes:
It is hoped that the insights obtained will also have a soberirtg effect on impatient outsiders who have dealings with Afri cans.Let them consider that the ancient traditions, whatever may be said against them and whatever the futility o f con structing a future on them, did indeed afford deep emotional security.

Region Districts Questionnaires distributed Number returned completed Number returned incomplete
graphical data on the attitude of community heath nurses were made from censuses, vital statistics, periodic sample surveys, television, radio, and paper news.
There is a majority of Tswana community health nurses, 65(67.7%)who are providing pri mary health care in the Odi region (Odi, Brits and Moretele) in North West Province.This indicates that the nurses in Odi Table 2 : Ethnic groups in Odi region (O di, Brits and M oretele districts) (N = 96)

Table 3 :
Attitude of com m unity health nurses Attitu des of comm unity health nurses The roles of traditional heal ers are displayed in the following table.As it will be noticed in table 4 traditional healers have an important role to play.