Map of Tanzania.
Satimia FT, McBride SR, Leppard B. Prevalence of Skin Disease in Rural Tanzania and Factors Influencing the Choice of Health Care, Modern or Traditional. Arch Dermatol. 1998;134(11):1363-1366. doi:10.1001/archderm.134.11.1363
To determine the prevalence of skin disease in a rural Tanzanian community and to investigate the health-seeking behavior of this community.
The study was in 3 parts: (1) 120 heads of households were interviewed to determine the factors that influence the families' health-seeking behavior; (2) the 800 members of these families were examined for evidence of skin disease; and (3) a focus group discussion was held with influential members of the community to get a broader view of health-seeking behavior.
A rural village in the southwestern area of Tanzania. Individuals were interviewed and examined in their own homes.
A total of 34.7% of 800 villagers had one or more skin diseases, the most common of which were tinea capitis, tinea corporis, scabies, acne, and eczema. Modern and traditional health facilities were equally used, but heads of the households older than 55 years who had never been to school and individuals who were not Christians favored traditional medicine. It was cheaper to go to a traditional healer, but modern medicine was thought to be more scientific.
Skin disease was a problem in this village and was perceived to be a problem by both individuals and the community. There is a need to assess the clinical and diagnostic skills of both modern and traditional health practitioners and to instigate a preventive health education program to eradicate the common infections and infestations.
EIGHT HUNDRED individuals living in a rural village in Tanzania were examined for skin disease. One hundred twenty heads of household were interviewed using a questionnaire to determine their health-seeking behavior in relation to skin disease, and a focus group discussion with influential members of the village was held to obtain a broader perspective of the community's behavior and attitude toward skin disease.
The prevalence of skin disease was 34.7%, with most of the diseases being both treatable and preventable. Approximately equal numbers of heads of household chose modern or traditional health care for their families' dermatological needs. Factors influencing this choice of treatment included the age, religion, and level of education of the head of the household (Table 1).
Tanzania is similar to other sub-Saharan African countries in that it has very few dermatologists, so there is limited medical expertise in the diagnosis and treatment of skin disease. Dispensaries and health centers are not manned by doctors but by clinical officers and assistant clinical officers who have very little training in dermatology. Skin disease is common in rural communities1 and can have a profound effect on both the individual and the community.2
Traditional healers are found everywhere in Africa and form the backbone of rural medical practice.3 (See Table 1 for definitions of terms used throughout the article. Many of them are interested in skin disease,4 and many plants and herbs have been found to be effective in the treatment of skin disease,5 but little is known about how these remedies are used by traditional healers in Tanzania.
Chapwa Village is situated in Tunduma Ward, Mbozi District, Mbeya Region, in the Southern Highlands of Tanzania (Figure 1). The village is 18 km from Tunduma Town on the main Tunduma-Mbeya road and is well linked with other parts of Mbeya Region. It has a population of 3500 (1988 census). The main tribes are Nyumwanga, Nyika, Ndali, and Nyakyusa, each of which have different cultural characteristics. The main religion is Christianity, with several different denominations having churches in the village. Most of the houses are built with bricks; some have iron-sheet roofing, but the majority are roofed with grass.
The average temperature is between 18°C and 25°C. There are 2 seasons: the dry season, from July to October, and the wet season, from November to June. The water supply is inadequate, with many people depending on ponds and shallow wells for domestic use. The main activities of the villagers are farming (maize, beans, and ground nuts) and cattle rearing. The village has 1 primary school, but no modern health facility. The nearest health center is 18 km away in Tunduma Town. However, there are several traditional healers and 4 traditional birth attendants within the village itself.
Skin disease is among the 10 most common diseases registered at Tunduma Health Centre, and the number of patients attending there with skin disease has increased over the last 3 years. There are no figures for patients attending traditional healers and no community-based data.
This study was undertaken to determine the prevalence and nature of skin disease within a rural Tanzanian community and to investigate the health-seeking behavior of this community and the factors that determine the choice of health care system within the community. It was performed with a view to developing an appropriate and effective dermatological service for the area in the future, possibly in liaison with the local traditional healers.
Chapwa Village was randomly selected from 7 villages in Tunduma Ward by a multicluster sampling method. The sample size was determined using a method described by Kirkwood.6 Twelve "10-cell leaders" were randomly selected, and their households provided the study population, ie, all heads of households and all members of these households. Children younger than 3 months were excluded for cultural reasons. The study was in 3 parts:
Part 1. One hundred twenty heads of households were interviewed by a research assistant using a well-structured questionnaire written in Kiswahili. Questions were asked about age, sex, marital status, level of education, occupation, knowledge about skin disease, and the factors that would influence their choice of health care for skin disease in themselves and their families.
Part 2. All members of these households older than 3 months were examined by a single researcher (F.T.S.) who had completed 1 year of dermatology training at the Regional Dermatology Training Centre, Kilimanjaro Christian Medical Centre, Moshi. Examination of the skin was performed in the individual's home after informed consent was obtained. Confidentiality and privacy were maintained as far as was possible. Individuals who were found to have skin disease were treated on the spot.
Part 3. A meeting was held with highly regarded members of the community to gain a broader perspective of the attitudes and health-seeking behavior of the villagers with regard to skin disease. The meeting was chaired by the main researcher (F.T.S.), and notes were taken by a research assistant. Participants included the village chairman, the village secretary, the village agricultural officer, 2 primary school teachers, 4 traditional birth attendants, 3 traditional healers, 4 ten-cell leaders, 2 religious leaders, and 3 other influential people in the community. Topics discussed included knowledge and superstitions about skin diseases, the types of skin diseases best treated by traditional healers, the availability of medicinal plants, and the factors that influence whether people go to traditional healers or to a modern health care facility for treatment of skin diseases.
A total of 800 people were examined for the presence of skin disease; 50% of them were younger than 15 years, and there were approximately equal numbers of males and females (Table 2). The prevalence of skin disease in this community was 34.7%, with males and females equally affected. Fifty percent of all skin disease affected children younger than 15 years (Table 2). The 5 most common diseases overall were tinea capitis, scabies, acne, eczema, and tinea corporis (Table 3), but the pattern of skin diseases was different in different age groups:
All patients with scabies were symptomatic, but more than half the patients with acne did not perceive it as a problem (Table 3).
Among the 120 heads of households interviewed, there were twice as many males as females, and most were older than 25 years. Almost half of the heads of households (47.5%) said that if they, or a member of their family, had a skin problem they would go to a modern health facility, and 43.3% said that they would go to a traditional healer. A few said that they would not do anything (5%) or that they would treat themselves (4.2%). Seventy percent of the heads of households older than 55 years said that they would use a traditional healer, whereas 78% of those between 15 and 34 years of age would go to a modern health facility. This difference is statistically highly significant (P<.001). Seventy-one percent of non-Christian heads of households prefer traditional medicine, compared with 37% of Christians; again, this is a statistically significant difference (P<.05). Eighty-one and a half percent of the heads of households who cannot read or write prefer traditional medicine, and 69% of those who had at least a primary school education prefer modern medicine (P <.001, Table 4). When asked for reasons for their choice, they said that the 2 most important ones were science and cost. Eighty-three percent of those who mentioned cost said that it was cheaper to go to a traditional healer, and 60% of those citing science said that modern medicine was more scientific and therefore likely to be more effective. Of those choosing to go to a modern health facility, 88% said they did so because it was more scientific (Table 5).
The information gained from the community meeting showed that skin disease was perceived to be a problem in the village. The diseases known to be treated by traditional healers were tinea capitis, eczema, and scabies. The plants used for treating these conditions were all easily available in and around the village.
In Tanzania, traditional medicine is part of the culture, although it is not as well organized as in India7 or China.8 Its practices are based on beliefs that were in existence thousands of years before the development and spread of modern scientific medicine.9 People are comfortable with practices that are in harmony with their culture and are reassured when advice is given in an unhurried manner by someone who seems to understand.10 Traditional healers are found all over Tanzania. They are accessible, affordable, culturally appropriate, and acceptable. They explain illness in terms that are familiar because they are part of the local belief system.11 In contrast, modern health service providers hold views on health that italicasize disease; the focus is on the physical body in an attempt to be "objective and scientific."12
The health situation has improved in many developing countries owing to the training of personnel at the primary health care level and to the introduction of essential drug kits.13 But modern drugs are expensive and the supply may be irregular.14 In Abidjan, Cote d'Ivoire, 14% to 17% of urban households changed from modern to traditional medicine when the franc was devalued15; these figures were probably even higher in rural areas. Traditional medicine is generally cheaper than modern medicine.16 The World Health Organization estimates that 80% of the population of most developing countries rely on traditional forms of health care as their primary source of health care.17
We were surprised to find that fewer than 50% of the heads of households in Chapwa Village said that they would go to a traditional healer as their first choice for treatment of skin disease. This greater than expected use of modern health facilities may be because they (1) consider skin disease a particular group of diseases that need modern medicine, (2) were reluctant to admit to using a traditional healer to personnel from a modern medical system for fear of seeming backward, or (3) were simply trying to please us. It is particularly surprising in view of the fact that the nearest health center (for modern health care) is 18 km away and that there are several traditional healers living and working in the village.
The main factors that seemed to influence the choice of health care were age and education. Heads of households who were older than 55 years and those who had not been to school mainly used traditional healers. Such findings are not surprising, since these people would have been brought up with traditional medicine and had no opportunity to learn about alternatives. Christians were more likely to use modern health care, presumably because of the possible association of traditional medicine with witch doctors. There are several Christian churches in the village, and local pastors may have a considerable influence on behavior. The cost of treatment is an important reason why people choose traditional medicine and scientific knowledge a reason for choosing modern health care.
Skin disease was a problem in Chapwa Village, and, indeed, it was perceived as a problem by the village elders; 34.7% of the population had one or more skin diseases, mainly the common infections and infestations. These diseases are both preventable and curable, so it seems that neither the traditional nor the modern health practitioners are having much impact on them. Benzyl benzoate, compound benzoic acid ointment (6% benzoic acid and 3% salicylic acid in emulsifying ointment [Whitfield ointment]), and griseofulvin, if used properly, would eradicate scabies, tinea corporis, and tinea capitis, and these drugs are meant to be available in the government drug kits. It would be interesting to compare the drugs of the traditional healers with those of the modern practitioners.
Because it is now obligatory in Tanzania for all children to attend primary school, the future heads of household will be relatively well educated and therefore more likely to seek their health care from modern health care facilities rather than from traditional healers. Since traditional medicines have been found to be useful in other countries, it would be a pity if that indigenous knowledge of herbs and plants were lost in Tanzania. Perhaps now would be a good time to integrate both traditional and modern health care systems, as has been done in rural Uganda.18 It seems only a matter of common sense to combine the 2 to optimize skin care so that people can benefit from locally available, cheap medicines rather than buying expensive, imported pharmaceutical products. In this way, some of Tanzania's many indigenous species will be preserved and perpetuated.
Because of our findings, there are plans (1) to instigate a preventative health education program in the community, (2) to assess the diagnostic and treatment skills of both modern and traditional medical practitioners in relation to skin disease and sexually transmitted diseases, and (3) to explore the possibility of integrating traditional and modern facilities in the treatment of skin disease.
Accepted for publication April 10, 1998.
Reprints: Barbara Leppard, DM, FRCP, Regional Dermatology Training Centre, KCMC, Private Bag, Moshi, Tanzania.