LITERATURE REVIEW
INTRODUCTION
Our focus in this chapter is to critically examine relevant literature that would assist in explaining the research problem and furthermore recognize the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps.
Precisely, the chapter will be considered in two sub-headings:
Conceptual Framework
Theoretical Framework
Chapter Summary
2.1 CONCEPTUAL FRAMEWORK
Traditional Medicine: An Overview
Prior to the advent of Modern Medicine in most Sub-Saharan African countries, traditional medical practices which include the use of herbs/plants and other products from plants and animal parts as well as spiritual procedures, were the main remedies for nearly all kinds of ailments (Mahomoodally, 2013). Despite the increase in the use of Modern Medicine in African countries at the threshold of the 21st century, the use of Traditional Medicine is also witnessing huge patronage as more Africans continue to rely on it for their health care needs. Adjei (2013: 2) corroborates this view in his words:
…another factor that validates the relevance of herbal medicine is that herbs remain the foundation for a large amount of commercial medications used today for treatment of heart disease, blood pressure regulation, pain remedies, asthma and other health problems…For instance, Artemisinin which is extracted from the Chinese herbal wormwood plant Artemisia annua is the basis of more effective antimalarial drugs… Herbal medicines are being used increasingly as dietary supplements to fight or prevent common maladies like cancer, heart disease and depression. The public and herbal medicine community is extolling the miraculous medical benefits of the ginkgo biloba, St. John‘s wort, moringa, sunflower seed, black cohosh and many other herbs…In spite of all these prospects, herbal medicine remains poorly integrated into the current health care structure of Ghana.
The term ―healthcare‖ varies in meaning depending on the context it is used. Conventionally, it is an important determinant in promoting the general physical and mental health and well-being of people (WHO, 2010). Health can therefore be conceived to mean a state of complete physical, mental, and social well-being and not just the absence of disease and sickness or frailty (WHO, 1946). In political terms, health (wellbeing) of a people can be conceptualised in terms of what governments do and neglect to do about the world of medical care (Marmor, 2013). Sociologically, three major perspectives offer different types of explanations, but together they provide us with a more comprehensive understanding of health care. First, while Functionalism emphasises that good health and effective medical care are essential for a society‘s ability to function; the Political Economy of Health emphasises the extent of inequality in accessing the quality of health and health-care delivery for citizens of a given society or economy (Weitz, 2013). The political economy explains how social and economic variables that impede the ease of access to modern medical services which in turn pushes people to utilise traditional medical alternatives (Gandu, 1992). The Symbolic Inter-actionist Approach emphasises that health and illness are social constructions. For the purpose of this study, health care refers to the maintenance or restoration of physical health, mental health and social well-being. This can be achieved through prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairment in human beings. Utilisation is seen as the act of making use of health care services provided by TMP or self-applied for therapeutic or healing purposes Traditional Medicine is used to describe a variety of indigenous health care practices employed by people including the prevalence of a wider belief system that encompasses the triune nature of man that may come in the form of physical expression and, could manifest in mental as well as spiritual forms (Hucks and Tracy, 2013). In general terms, both at the diagnostic and treatment levels, the operational platform of Traditional Medicine tends to focus on the whole condition of the individual patient or health seeker, rather than on the particular ailment or disease in question (WHO, 2002). This in part explains why Bratman (1997) and Patwardhan (2005) suggest that unlike modern medical health care practice, Traditional Medicine whose central focus is more on healing does not fall within the realm of bio-medicine. Their position is attested by Bodeker (2005) that in North America and Western Europe, Traditional Medicine is referred to as Complementary and Alternative Medicine (CAM). Informed that Traditional Medicine is therapeutically conceived to be the sum total of health practices, measures, ingredients and procedures given to present generations from years past which has enabled human beings of all cultures to fight disease, to lessen pains due to ill health and to provide treatment (WHO, 1978). Traditional Medical system is a health care practice since man‘s civilization protecting and restoring human health before the coming of Modern Medicine. Plants of Medicinal values are the main drivers of Traditional Medicine and also the earliest known-healthcare products to mankind. In view of the diverse nature of Traditional Medicine as an all encompassing therapeutically health care system; several definitions and conceptions have been advanced by scholars. While Helwig (2005:374) classifies ―Traditional Medicine as a holistic discipline involving indigenous herbalism and indigenous spirituality, typically involving diviners, midwives, bone setters and herbalist. Abdullahi (2011:1) refers to traditional medicine as ―ethno-medicine, folk medicine, native healing, and alternative medicine. He considers it as the oldest form of health care system that has stood the test of time. His use of the term ―folk medicine connotes health practices arising from superstition and cultural beliefs, while ―ethno-medicine stands for the health practice by a specific indigenous people.
Diversity in the classification and definition of Traditional Medicine indicates that developments have taken place without a clear standard body of medical thought and practice to the system. This implies the need for a standard and accepted definition that would serve as a working tool for the various definitions of Traditional Medicine (Aamir, 2014). Bognar (1998:76) is of the view that Traditional Medicine is an ―alternative treatment because it represents continued hope in quest for survival‖. However, whether alternative or complementary, Traditional Medicine, or Ayush, all refer to a variety of medical practices that can be bound together in what Patwardhan (2005:31) describes as ―logic of reductio-ad-absurdum, defined by criteria of absence from the mainframe of what has come to be known as modern medicine‖. In a similar vein, Dawkins (2003:58) submits that "there is no alternative medicine; there is only medicine that works and medicine that does not work". To agree to this assertion, is to infer that if any medicine is to be an alternative to another, Modern Medicine would be more appropriate because it is an off-shoot of Traditional Medicine. According to Stepan (1985:281), ―Traditional Medicine is interpreted in a broad sense to include inter alia medicine, practices of alternative medicine and practices of traditional healers‖ because of its diverse dimensions WHO (1976:3) formulates a more all-embracing definition of Traditional Medicine as: ―The sum total of all knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observations handed down from generation to generation, whether verbally or in writing‖. The foregoing definition by the WHO suggests that some concepts and practices of Traditional Medicine obtainable from Africa have been taken into account. Therefore, this study sees Traditional Medicine as encompassing the diverse health approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercise applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illnesses in humans.
Any person endowed with the knowledge and skills to provide the health needs of a community but has not attended any form of formal modern training can be referred to as a traditional healer. As part of their services, traditional healers prescribe medicines that are prepared using animal parts, herbs, water, alcohol, roots, leaves and tree barks available in their immediate natural environment. These services are covered in the World Health Organisation (1976:4) definition which states that a traditional healer is:
A person who is recognized by the community in which he lives as competent to provide health care by using vegetable, animal and mineral substances and certain other methods based on social, cultural and religious background as well as on the knowledge, attitudes and beliefs that are prevalent in the community regarding physical, mental and social well-being and the causation of disease and disability.
The foregoing definition incorporates certain components of traditional healers yet some aspects of it have tended to be non-specific in nature. For instance, its inclusion of ‗witch-doctors‘, diviners, seers, or spiritualists would seem to suggest that scientific research into such areas of Traditional Medicine would be very difficult or almost impossible because those are not amenable to any of the human senses, hence they cannot be scientifically studied and recorded (Sofowora, 2008). In the African context and African reality, ‗witch-doctors‘, diviners, seers, or spiritualists are part and parcel of integral components of the practice of Traditional Medicine. Diagnosis in Traditional Medicine involves a systematic quest for answers to the genesis of a particular ailment to determine who or what cause it, and why (Ngubane, 1977). The answers come from the cosmological beliefs of the people (Onwuanibe, 1979). Diagnosis is reached either through spiritual revelations, physical observation past, personal or family history. In circumstances where divination is needed, diagnosis may come in the form of combination of observation, patient self diagnosis, understanding the direction of a small metal ring movement which is hung on a thread. In addition, cowries direction points, broken pieces of metals and wood thrown randomly on the ground or mat fall, observe the marks left on sand by an animal entice with food and unfamiliar footprints. Interpretation and understanding of signs or words made by possessed persons in trance, and water gazing in which the diviner communicates with the right spirit whose image he sees reflected in a pot, calabash or water (Iddrisu, 2017). The preparation and administration of Traditional Medicine is based on indigenous methods whereby treatment is prescribed, usually consisting of herbal remedies that are considered to have healing abilities and spiritual effects (Onwuanibe, 1979). The art and science of traditional medical practices in Africa include ritual sacrifice to mollify the ancestors, ritual and magical strengthening of people and possessions, steaming, purification (like ritual washing, or the use of emetics or purgatives), sniffing of substances, cults or cultic practices, wearing of charms, and body piercing among others (Truter, 2007). Scarifications, blood-letting, circumcision and cupping or drawing of blood are the commonest surgical procedures performed by African traditional healers and these are sometimes performed in the presence of other people. The letting of blood is sometimes used as a way of casting out the illness. If the cause of the sickness is perceived to be bewitchment, a number of cultic practices or rituals may be performed in order to cast out the spell including the inducing of vomiting, enemas, blood-letting, whistling or elaborate rituals such as animal sacrifices. In Traditional African Medicine, the main objective of ocultic practices and or rituals is to reinstate stability and harmony in terms of the beliefs and values of an established culture. These rituals lessen patients‘ worry and serve to alleviate feelings of guilt. End of the rituals often has a calming effect on the patient. A large part of the African traditional healer‘s practice is also devoted to counseling individuals (Truter, 2007).
Karim, Zigubu-Page, Arendse (1994:12) indicate that a variety of treatment methods are used in the administration of herbal medications including:
sucking of hot medicated liquid from fingertips, inhalation of powdered medicine in its dry form as snuff, rubbing of powdered medication into incisions, steaming or use of a vapour-bath, use of enemas for stomach complaints, use of fomenting treatment for aching feet, burning of incense which is said to appease the ancestors, use of an amulet manufactured from animal skin to ward off evil spirits.
These culture-bound conditions of spirit possession, sorcery, ancestral wrath, neglect of cultural rites or practices and defilement (Truter, 2007) are thought not to respond to modern medicine and must be treated by traditional healers. In some cases, patients have been reported to use Traditional Medicine simultaneously with Modern Modern (Abdullahi, 2011). Wolffers (1990:14) states that ―the wisdom behind combining modern and alternative approaches rest on the fact that the patients are seeking for what they need from the right source, and only absence or unaffordable desired of medical facilities can frustrate the choice‖. Combining modern and alternative approaches in some African countries popularly referred to as ―shopping treatment‖ (Freeman and Motsei, 1992:1185) is the interchangeable, consecutive or even concurrent use of both for the same ailment. Boonzaier (1985:237) states that patients attempt to get ―the best of both worlds‖ and are absolutely happy to exchange freely between traditional and modern treatment. This wavering between the two systems of health care for treatment makes it difficult to determine the more effective one. Nevertheless, it would be of interest to know some of the health conditions that make patients to use the two types of treatments simultaneously in the succeeding parts of the chapter
The Role of TRM in Primary Health Care
Interest in traditional systems of medicine and, in particular, herbal medicines, has increased substantially in the 21st century. TRM assumes greater importance in the primary health care of individuals and communities in many developing countries and has been popularly recognised (Hoareau and DaSilva, 1999; Bodeker and Kronenberg, 2002; Pal and Shukla, 2003; Elujoba et al, 2005; Van Andel and Havinga, 2008; Alves and Rosa, 2007; Tilburt and Kaptchuk, 2008; Payyappallimana, 2010; Sen et al, 2011; Van Andel et al, 2012).
WHO in seven decades ago acknowledged health as “a state of complete physical, mental and social well-being and not merely absence of disease or infirmity” (WHO, 1948). According to Vandebroek (2013), this definition communicates well to the inclusive nature of TRM that extends beyond the physical body into a broader social/emotional, cultural and spiritual context of health and well-being. “The importance of traditional medicine in global health care is reflected by the three A’s, viz., Affordability, Availability and Accessibility” (Vandebroek, 2013). This is especially true in rural areas lacking biomedical health care, but also in immigrant communities in large urban centres (Pieroni and Vandebroek, 2007) and urban slums, regardless the increased availability of biomedicine and practice in urban areas.
There has also been an increased international trade in herbal medicines (van Andel et al, 2012; Van Andel, and Havinga, 2008) and a significant world market worth an estimated $83 billion in 2008 (WHO, 2011b). In his introductory remarks of General Guidelines for Methodologies on Research and Evaluation of TRM, the acting Coordinator of TRM, DrXiaorui Zhang, reiterated that use of TRM has expanded globally and has gained popularity during the last decade. “It has not only continued to be used for primary health care of the poor in developing countries, but has also been used in countries where conventional medicine is predominant in the national health care system” (WHO, 2000a). TRM practice has been a significant part of the history of medicine in Ghana. The contribution of TRM to health care in Ghana is tremendous as more and more Ghanaians, especially the poor, underserved and the excluded that are presumably unable to afford orthodox medical care wholly rely on traditional medical practices. Indeed, upsurge utilisation rate of TRM is portrayed by the emergence and rapid growth in the number of herbal outlets, herbal clinics and hospitals (Bloom and Standing, 2001; van der Geest and Whyte, 1988) in the sub-Saharan Africa and elsewhere. Herbal medicine according to Ayitey-Smith (1989) has been, and still in use to treat and manage all kinds of ailments. A lot of these medicinal plants have been documented, with sharp focus on those for cold, chronic catarrh, migraine, malaria, hypertension, diabetes, bronchial asthma, jaundice, bruises, fever, sexual and reproductive health issues, menstrual irregularities, skin disorders. Now, preparations that control the spread of AIDS and its attendant opportunistic and melancholic infections presented on people living with HIV and other complex ailments have been developed by herbal medical practitioners (Peltzer et al, 2006; Osei-Edwards, 2003; Gyasi et al, 2013). A study by UNAIDS shows that about two-thirds of HIV/AIDS patients in developing countries use TRMs to obtain symptomatic relief and manage opportunistic infections (UNAIDS, 2003). The medicines used by the practitioners to treat AIDS patients are rightly available locally (WHO, 2001). The large number of traditional medical practitioners and their locations in every town or village in the continent could be exploited to handle AIDS care needs. Their familiarity with patients and also the communities in which they operate serve as added advantage to relief the AIDS patients. The WHO (2001) has declared that the traditional herbal practitioners are normally acknowledged and trusted in their communities; they could therefore be used as counselors and health educators to cure the spread of HIV and AIDS in Africa.
TRM practitioners use plant parts such as leaves, stems, roots, seeds, fruits, flowers, tree barks, etc, and other mineral substances which have been found to have essential medicinal properties to cure diseases. These plant parts are made into various forms: fresh, dried, cut-in-pieces, powder, ointment, oil extract, liquid, lotion, etc. to treat ailments (Mensah and Gyasi, 2012). This has been taking place for so many years before the orthodox medicine found its way to the continent of Africa. Scientifically, the herbs or the medicinal plants in use have proved to be efficacious for the treatment of the various endemic ailments (Addae-Mensah, 1992). In fact, medicinal plants with anti-viral and anti-bacterial properties are available in Africa (Ayitey-Smith, 1989) and there are prospects for the developments of these medicinal plants into new chemotherapeutic agents. The prevalence of malaria, HIV/AIDS and other infectious diseases and now non-communicable diseases has been escalating at an alarming rate in the sub-Saharan African (WHO, 2008; 2011; KofiTsekpo, 2006). However, the malaria endemic countries in Africa have herbs for treating the fever. According to Buor (2003), the malaria parasite has developed resistance to all the anti-malaria drugs and there is the need to develop herbal substitutes not only for the side effects but also for the expensiveness. What is now left is to research into these herbs for their use as anti-malaria drugs.
Use of Traditional treatment
World Health Organization (WHO) estimates that about 80% of people living in Africa use traditional medicines for the management of their prevailing diseases (WHO, 2013; Marshall, 1998). Although recent advances in molecular biology and physiological chemistry have greatly enhanced the understanding and treatment of diseases, a large segment of the population still depends on traditional treatment as the preferred form of health care (Iwu & Gbodossou, 2000; Fratkin, 1996). Studies have shown that this high use of traditional treatments may be due to accessibility, affordability, availability and acceptability of traditional traditional treatments by majority of the population in developing countries (Tamuno, 2011; Akerele, Blass, Singh, Chowdhury, Kulshreshtha, Kamboj, & Bishaw 1993).
Traditional healers such as herbalists, midwives and spiritual healers constitute the main source of assistance for at least 80-90% of rural population with health problems in developing countries (WHO, 2002). The herbalists are an important national health care resource in South Africa and they are potentially valuable partners in the delivery of health care (Kubukeli, 1999). The use of traditional treatments however, is on the increase even in developed countries because of the belief that herbal remedies are safe because of their natural origin and have little or no side effects (Jacobsson, Jönsson, Gerdén, & Hägg,, 2009).
The increasing widespread use of traditional traditional treatment has prompted the World Health Organization to promotes the use of traditional treatment for health care by; supporting and integrating traditional treatment into national health systems in combination with national policy and regulation for products, practices and providers to ensure safety and quality; ensure the use of safe, effective and quality products and practices, based on available evidence; acknowledge traditional treatment as part of primary health care, to increase access to care and preserve knowledge and resources; and ensure patient safety by upgrading the skills and knowledge of herbalist (Akerele, 1987; WHO, 2005; WHO, 2008).
Traditional medicine is a vital part of health care in Nigeria. Nigeria has a rich and diverse range of flora that has been used by various ethnic communities for treatment of different diseases (Kokwaro, 2009; Gachathi, 2007). Indeed, more than 250 plants are used by various ethnic communities in Nigeria as purgatives, laxatives and emetics to treat a range of diseases (Maina, Kagira, Achila, Karanja, & Ngotho, 2013). Ethnobotanical surveys in Nigeria indicate that traditional medicine is widely practiced in the country by the different communities (Jacob, Farah, & Ekaya, 2004; Kareru et al., 2007; Njoroge & Bussmann, 2007).
In Nigeria, at least 90% of the population has used traditional treatment at least once for various health conditions (Njoroge & Kibunga, 2007). A survey conducted in Thika district, Nigeria showed that 97.45% of that population preferred to treat or manage diarrhea conditions with traditional treatment rather than conventional medicine while 52.5% first seek treatment for diarrhea from herbalists before going to the hospital (Njoroge & Kibunga, 2007). The Samburu people who inhabit the northern part of Nigeria make use of a wide range of ethno-medicinal resources comprising of about
120 plant species which are used to treat many diseases including malaria, gonorrhea, hepatitis and polio (Fratkin, 1996). Similar elaborate and rich pharmacopoeia systems have also been documented for other Nigerian communities such as the Maasai, Gusii, Luo, Abaluyia and the Kikuyu people (Gachathi, 2007; Kiringe, 2006; Sindiga, 1995).
The conventional system provides for only 30 per cent of the population, implying that more than two-thirds of Nigerians depend on traditional medicine for their primary health care needs (NCAPD, 2008). The importance of traditional treatments in Nigeria is evidenced by the fact that traditional herbalist far outnumber conventional providers. Given the estimated 40,000 herbalist and assuming a population of 38 million Nigerians, there is a herbalist-patient ratio of 1 to 950 (Maina et al., 2013).
The dependence on medicinal plants is due to lack of access to modern medical services. Although the majority of Nigerians (80 per cent) live within 5 kilometers of a health facility, medical services are not always available. Many facilities lack drugs, basic services and amenities and the cost of medicine is high. In addition, there are shortages of health professionals and the ratio of doctors to the population remains low at 15 per 100,000 (NCAPD, 2008).
Conventional Health System in Nigeria
Since Nigeria attained her independence in 1963, there has been massive growth and development of health care systems at various levels. The increased population and the demand for health care have outstripped the ability of the government to provide effective health services (Oyaya and Rifkin, 2003). However the government through the Ministry of Health (MOH) is committed to ensuring that accessible, affordable and effective health services which will promote the well-being, improve and sustains the health status of the Nigerian population is made available (MPHS-GOK, 2008; KSPAS- GOK, 2010)
Disease, ignorance, and illiteracy have been found to be the major obstacles in Nigeria. The Government of Nigeria (GoK) has supported Ministry of Health (MOH) to combat disease, but maintaining financial of MOH has undergone a lot of difficulties (KNHA, 2005). Financing and management of Health services has been a major problem in the MOH. Maintaining growing population without resources, GoK finds it challenging. Despite the reforms in the Ministry of Health that were introduced in Nigeria, people still source for health care services elsewhere (Nyamongo, 2002) and a huge population has been using traditional treatment (Lambert et al., 2011; Kiringe, 2006).
The poor constitute slightly more than half the population of Nigeria and three- quarters of the poor live in rural with Gucha district having 74% of its population living below poverty line of one US dollar per day (Chuma et al., 2009). The inaccessibility of modern medicine to Nigerian‟s population because of escalating costs has necessitated a search for alternative ways of managing illnesses (Sindiga, 1995).
In the past, modern science had considered methods of traditional knowledge as primitive and during the colonial era traditional medical practices were often declared as illegal by the colonial authorities. Consequently doctors and health personnel have in most cases continued to shun traditional practitioners despite their contribution to meeting the basic health needs of the population, especially the rural people in developing countries (WHO, 2005).
Many practitioners of conventional medicine view the increasing recognition of traditional health systems as a failure by modern medicine to satisfy the health care needs of society while some even feel threatened by a system that they view as unscientific and beyond rational categorization (Sofowora, 1996).
Analysis of various national policies related to public health and medicinal plants usage highlighted some issues for example failure to meet basic health conditions due mainly to the following factors: inadequate decentralization of health services; isolation of some rural communities; and persistence of traditional beliefs regarding pathology. This has led to underutilization of available services in health centers and high cost of services provided by hospitals in relation to the income of the rural population. In addition to recommending measures to raise consumer awareness, the guidelines suggest that governments establish standards of practice, treatment and training for complementary medicine (WHO, 2005). They also encourage collaborations between conventional and traditional care providers to improve results and help reform the health sector in developing nations (Akerele, 1992).
Traditional treatment Practice
Human beings have engaged in the development of detailed botanical pharmacopoeia through trial and error with a view to combat illnesses that were often specific to their localities. The practice of traditional treatment in Nigeria unlike Asia has largely been considered primitive by the elite (Kigen, Ronoh, Kipkore, & Rotich, 2013).
The high dependence on traditional treatment in most African populations is partly attributed to traditional beliefs and lack of reliable modern health care (Sindiga, 1995). The decision to engage with a particular medical channel is influenced by a variety of socio-economic variables, sex, age, gender, religion, the type of illness, access to services and perceived quality of services (Tipping & Segall, 1995).
Traditional treatment is commonly chosen by people to treat common diseases and chronic diseases. Many Nigerians believe in the potency of traditional treatment, even when they can access modern medicine (Kigen et al., 2013). In many cases they would choose to combine both herbal and modern medicine, especially if they are afflicted with chronic ailments such as HIV/AIDS, hypertension, infertility, cancer and diabetes (Kigen et al., 2013). According to a study done in Taiwan, it was established that patients used traditional treatment for muscular and joint problem for lung or respiratory complain while others to promote wellness and quality of life (Daly, Tai, Deng, & Chien, 2009).
Source Of Knowledge On Traditional Treatment Use
In most Nigerian communities, perhaps due to cultural reasons, the practice was considered a family affair and the practitioner would prefer to transfer the talent to one close relative (Kigen et al., 2013). Similarly, the herbalist reported that knowledge about traditional treatment is passed down from parents, relatives and friends and may not necessarily require any formal education (Enwere, 2009).
Family expectations of receiving treatment from herbalist are one of the reasons for continuous dependence on traditional treatment. In addition the influence of relatives, friends and neighbors on health-care seeking behavior for traditional treatments has been reported globally in adults and children, 51.4% in the United States (Bennett & Brown, 2000) and 60%-86% in developing countries (Danesi & Adetunji, 1994; Oshikoya et al., 2008; Lanski et al., 2003). Moreover, studies have shown that media such as newspapers advertisements, television and radio, play an important role in creating awareness (Bennett & Brown, 2000).
Attitude towards Traditional treatment
Traditional treatment has been used for centuries and it is claimed to have gained acceptance because of its effectiveness. Studies have shown that the attitudes of patients have a strong association with the utilization of traditional treatment. A study done in South Africa among Academic and Administrative University staff indicates that patients‟ have positive attitude towards traditional treatment, with better clinical care and positive outcome after treatment using traditional treatment (van Staden & Joubert 2014).
Studies carried out so far indicate that this increase in use of herbal remedies for management of health conditions could be as a result of people perceiving them as natural and therefore safe, increase in cost of contemporary medicine and increase in advertisement of herbal remedies. In a study carried out in Murang'a District, Nigeria among people with diabetes mellitus showed that there was association between the perceptions people have on herbal remedies and use of traditional treatment (Mwangi, 2003).
Similarly, in Ethiopia, a study done to evaluate the perception and practices of modern and traditional health practitioners about traditional medicine indicated that there is a perception that the conventional health system is inadequate to diagnose and treat certain diseases like evil eyes, epilepsy and gonorrhea (Gatachew, et al., 2002).
Phyto-medicine products
Over the past decade, interest in drugs derived from plants has greatly increased. It is estimated that about 25% of all modern medicines are directly or indirectly derived from plants (Cragg & Newman, 2001). The potential of plants as source of conventional drugs exists for example reserpine, an alkaloid was the first anti- hypertensive drug that was isolated from the roots of Rauwolfia serpentine (Apocynaceae) in 1952 (Pandey, Debnath, Gupta, & Chikara, 2011). Safety and effectiveness of some of the medicinal plants have been evaluated leading to new antimalarial drugs developed from the discovery and isolation of artemisinin from Artemisia annua L., a plant used in China for almost 2000 years (WHO, 2008).
It is clear that there is a lot of potential in Nigerian traditional treatment judging from the published laboratory results from the screening of the plant extracts that have been analyzed in various institutions. The following Nigerian medicinal plants; Albizia gummifera, Boscia salicifolia,, Rhus natalensis, Vernonia lasiopus, Rhamnus prinoides, Pentas longiflora and Ficus sur among others, have shown antiplasmodial activity hence effective in malaria treatment (Gathirwa et al., 2007; Rukunga et al., 2007; Muthaura et al., 2007; Muregi et al., 2003). Similarly, the aqueous extract of Carissa edulis, Prunus Africana and Melia azedarach have demonstrated the potential anti-viral activities at non-cytotoxic concentrations (Tolo et al., 2008). Other studies have shown that water extracts of Warburgia ugandensis have antifungal activity against Candida albicans (Olila et al., 2001) and also antileishmanial activity (Ngure et al., 2009). Similary, pentacyclic triterpenes isolated from Acacia mellifera have demonstrated antimicrobial activity (Mutai et al., 2009) among other Nigerian medicinal plants.
However, there is need to document the information from herbalists in order to provide a database for future research and potential for development of new drugs. Information obtained from ethno-medicine is now being put on a scientific basis and is therefore important to investigate the knowledge, attitudes and practice on utilization.
Economic Considerations In The Use Of TM
Average household income in most of Sub-Saharan Africa (SSA) is extremely low compared to that of other developing and developed economies. For example, the per capita income for Nigeria is estimated at $560 as against $37740, $43560, $38950, $15840 and $4770 for UK, USA, Japan, Korea and South Africa, respectively. There is a significant level of poverty in SSA and, especially, Nigeria. Per capita consumption expenditure is less than USD1.00 per day [Wolfenson 20024]. The level of poverty has excluded a significant proportion of the population, especially in the rural locales, from accessing modern health care facilities even when it is available. Poor access to OM is also compounded by very low public expenditure on health, amounting to about USD14.00 per person per year. The inadequacy of public health infrastructure is one of the major reasons for poor quality of service in public health institutions. Consequently, the infant mortality for the region is reported to be 55% higher and life expectancy about 11 years lower than the rest of the world's low-income developing countries. Maternal mortality is double that of other low- and middle-income developing countries [World Bank 1994]. Private healthcare facilities are comparatively more efficient in terms of quality of service but charge fees that are far beyond the level the average farming household could afford. Many rural and farming households would therefore be without any form of healthcare facility without the TM [Mafimisebi 2007]. The combination of high level of poverty, inadequate public health infrastructure and high cost of private health care services has confined the larger proportion of both the urban and especially the rural populace to patronizing TM [Okunlola 2007 and Mafimisebi 2007].
The most common ailment affecting the people is malaria which has been reported as leading to drastic reduction in agricultural productivity [Alaba 2009 and Jimoh 2005]. According to the WHO [WHO 1992], malaria is now resistant to Chloroquine therapy. The recommended Atesunate Combination Therapy (ACT) is hardly ever offered free in most public healthcare facilities. The average cost of malaria treatment based on ACT is estimated to be about N1,500 (USD 10.00) inclusive of cost of laboratory tests. This is a princely sum for the average Nigerian in the rural areas which are characterized with low household incomes [Mafimisebi 2007 and Mafimisebi 2008]. A TM therapy for the same ailment will cost on the average N200 or could even be procured for free, if the person could collect the medicinal plants and prepare the medicament personally. When the ailments are complicated such as internal organs mal-functioning, mental illness or barrenness, the cost implications are far beyond the income capacity of the average citizen. In such instances, TM is the only option available for obtaining some remedy at affordable costs. Hence, a large proportion of Nigerians, especially those living in rural areas, continues to patronize TM [National Bureau of Statistics 2006]. TM continues to grow because traditional healers are considered successful in curing a large number of illnesses [Fasola 2006].
In summary, the reasons adduced for the rise in the uptake of TM in Nigeria are:
1. Inadequate modern medical practitioners. The ratio of TM practitioners to the total population is estimated at 1:250 while that of OM practitioners is 1:26,000 [Federal Ministry of Health 1995-Conserve Africa 1995].
2. High and rising proportion of fake and adulterated synthetic drugs which makes a lot of people to crave for natural products [Akuyili 2004].
3. The resistance of some pathogenic organisms to synthetic drugs (e.g. Plasmodium falciparum to chloroquine).
4. Facilities are inaccessible for much of the population. In some urban areas the average waiting time at a hospital or clinic can be as much as eight hours.
5. The staff are poorly trained and ill-motivated.
6. Many staff members, believing they hold superior knowledge, treat patients inconsiderately.
7. Patients are frequently not told the nature and causes of their illnesses.
8. There are inadequate technical services leading to poor quality care.
9. The treatment costs too much, even in public hospitals and clinics.
10. Governments spend a large proportion of the per capita GNP on OM.
11. Treatment is divorced from the patient's culture, family and community.
12. The treatment only addresses a patient's biological manifestation of the illness and does not attempt to heal spiritual aspects of illness.
Arising from increased use, the practice of TM is now being modernized and popularized in Nigeria culminating in increasing number of herbal homes and growing confidence in TM. A crop of educated practitioners now exploits plants for large-scale production of TM products. The hitherto unregulated activity is now being checked to maintain standard by government agencies to eliminate quacks. There is increasing number of NAFDAC-certified TM products being sold to the public [Oguntade 2009]. To complement this effort, State Governments have also come up with Traditional Medicine Councils to oversee the affairs of practitioners. These steps are serving to instill the confidence in many Nigerians to patronize TM. If the present trend in patronage continues, Nigeria may soon be ranking favourably with China, India and Korea in terms of the proportion of her GDP accruing from TM. The constraints to achieving this are the low level of herbal knowledge transfers to the succeeding generation of Nigerians and rapid bio-diversity loss arising from scientifically unsustainable methods of harvesting medicinal plants [Alves 2007].
2.2 THEORETICAL FRAMEWORK
The theory used for this study is the theory of Planned behavior theory.
Theory of planned behavior (TPB)
The theory of planned behavior (TPB) is a psychological theory that links beliefs to behavior. The theory maintains that three core components, namely, attitude, subjective norms, and perceived behavioral control, together shape an individual's behavioral intentions. In turn, a tenet of TPB is that behavioral intention is the most proximal determinant of human social behavior.
The Theory of Planned Behaviour (TPB) is an extension of the Theory of Reasoned Action (TRA) (Fishbein & Ajzen 1975, Ajzen & Fishbein 1980). Both models are based on the premise that individuals make logical, reasoned decisions to engage in specific behaviours by evaluating the information available to them. The performance of a behaviour is determined by the individual’s intention to engage in it (influenced by the value the individual places on the behaviour, the ease with which it can be performed and the views of significant others) and the perception that the behaviour is within his/her control.
The TPB is also a widely applied behavioral model. It helps us understand how the behavior of people can change. The model assumes that behavior is planned; hence, it predicts deliberate behavior (Ajzen, 1991). The TPB is the descendant of a similar model known as the TRA (Ajzen & Fishbein, 1975). The succession was due to the discovery that behavior is not completely voluntary and cannot always be controlled; therefore, perceived behavioral control was added to the model, and with this addition, the theory was renamed the TPB. According to the TPB, any action a person takes is guided by three types of considerations: behavioral beliefs (beliefs about the probable consequences of the practiced behavior), normative beliefs (beliefs about the normative expectations of other people), and control beliefs (beliefs about the presence of factors that may enable or obstruct the performance of the behavior). Behavioral beliefs normally result in a favorable or unfavorable attitude toward a specific behavior, normative beliefs result in perceived social pressure or subjective norms, and control beliefs trigger perceived behavioral control. Usually, the greater the favorable behavior, subjective norm, and perceived control, the stronger the person’s intention to perform the behavior in question.
The relevance of this theory to the study, showcased that in the wake of lock down pioneered by Covid -19, The pandemic has put marriages under significant pressure as couples struggle to navigate financial hardships, lack of privacy, stress over medical concerns, and family and professional worries.
2.3 CHAPTER SUMMARY
In this review, the researcher has sampled the opinions and views of several authors and scholars on the use of traditional treatment, conventional health system in Nigeria, traditional treatment practice, source of knowledge on traditional treatment use, attitude towards traditional treatment, and economic considerations in the use of TM etc. The works of scholars who conducted empirical studies have been reviewed also.