yx!T×ùÃ -@Â L¥T m{ÿT
THE ETHIOPIAN
JOURNAL
OF
HEALTH
DEVELOPMENT
SPECIAL ISSUE
ON
SELF-CARE: A STUDY of
THREE COMMUNITIES IN ETHIOPIA
A Publication of the National Health Development Network-Ethiopia
By YAYEHYIRAD KITAW, MD DPH
Formerly, Associate Professor Department of Community
Health, Faculty of Medicine,
Addis Ababa University.
This publication was supported by a grant from WHO-Regional
Office for Africa (AFRO)
EDITORIAL BOARD
Editor-in-chief: Fisseha Haile-Meskal I
Asfaw Desta
Elias Gebre-Egziabher
Gabre-Emanuel Teka
Jemal Abdulkadir
Solomon Ayallew
Yayehyirad Kitaw
Zein Ahmed
EDITORIAL CONSULTANTS
Desta Shamebo
Gebre-Selassie Okubagzi
Getachew Tadesse
Nebiat Tafari
Tewabech Bishaw
Zewdie Wolde-Gebriel
The Editorial Office of the Ethiopian Journal of Health Development is the Department of Community
Health in the Faculty of Medicine Addis Ababa University, which is the Nucleus of the National Health
Development Network-Ethiopia.
CURRENT MEMBER INSTITUTIONS OF THE NATIONAL HEALTH
DEVELOPMENT NETWORK -ETHIOPIA
Central Statistical Office
College of Medical Sciences
Gondar, AAU
Department of Community Health
AAU
Ethiopian Management Institute
Council of Ministers
Ethiopian Nutrition Institute
Ministry of Health
Ethiopian Water Supply and Sewerage
Authority, National Water
Resources Commission
Health Research Council, Science and
Technology Commission
Health Sciences Center-Jimma
Ministry of Health
Institute of Pathobiology, MU
Medical Faculty, AAU
Ministry of Agriculture
Ministry of Health
Ministry of Information and
National Guidance
National Maternal and Child Health
Center Ministry of Health
Office of the National Committee
for Central Planning (formerly
Central Planning Supreme
Council)
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Health (formerly Central
Laboratory and Research Institute)
Ministry of Health
The Ethiopian Journal of Health Development
P.O. Box 32812, Addis Ababa, Ethiopia
Telephone: 15-77-01 or 15-86-54 Ext. 7
yx!T×ùÃ -@Â L¥T m{ÿT
THE ETHIOPIAN
JOURNAL
OF
HEALTH
DEVELOPMENT
SPECIAL ISSUE
ON
SELF-CARE: A STUDY of
THREE COMMUNITIES IN ETHIOPIA
A Publication of the National Health Development Network-Ethiopia
By YAYEHYIRAD KITAW, MD DPH
Formerly, Associate Professor Department of Community
Health, Faculty of Medicine,
Addis Ababa University.
This publication was supported by a grant from WHO-Regional
Office for Africa (AFRO)
SELF (LAY) CARE IN A DEVELOPING COUNTRY
A STUDY OF THREE COMMUNITIES IN ETHIOPIA
CONTENTS
EDITORIAL.................................................................... 9
Preface........................................................................... 13
Glossary..........................................................................16
I. INTRODUCTION
- Self-care in Ethiopia........................................................... 18
- Issues in self-care.............................................................. 20
- Definitions of self-care........................................................ 21
- Objectives of the study........................................................ 23
II. MATERIAL & METHODS....................................................... 23
- Study communities............................................................. 23
- Questionnaire.................................................................... 23
III. RESULTS............................................................................30
- Sickness.......................................................................... 30
- Action taken..................................................................... 30
- Self (lay) care....................................................................41
- Drug used in self (lay) care................................................... 44
IV. DISCUSSION
- Illness..............................................................................48
- Illness behaviour............ .................................................... 48
- Extent of use of self-care...................................................... 48
- Drug hoarding & and use...................................................... 53
- Traditional medicine............................................................ 54
V. CONCLUSION....................................................................... 54
- Bibliography...................................................................... 56
- Appendix 1- Questionnaire..................................................... 65
- Appendix 2 - Instructions....................................................... 68
-
INFORMATION FOR CONTRUTORS
I. The Ethiopian Journal of Health Development is a multi-disciplinary publication concerned with the broad field of
health development. The Journal publishes analytical, descriptive and methodological papers, as well as original
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EDITORIAL
SELF-CARIFOB HFA 2000
Biomedical research, no less than research in other fields, is conceived, designed and
conducted almost exclusively by professionals. In view of the time-consuming mastery of
knowledge and skills and costly technology that modern research demands it is difficult to
see reasonable alternatives to this established approach. The role of the lay public does not
extend beyond the giving of informed consent where the experiment utilizes human subjects
itself the result of a relatively recent reexamination of pertinent ethical issues and of public
pressure. Paradoxically this professional dominance applies even to areas such as self-care in
health although the concept of self-care includes not only an active share in the process of
care but extends to independent decision making by the patient in all aspects of his/her health
care. Possibly lay involvement in research in self-care may become a reality in the future with
the strengthening of its knowledge and skill bases. Even then professional Participation
would still be needed to assure application of scientific methods. At the same time research
conducted by professionals can be equally objective and provide valuable insights into a
component of health-care whose dimensions are still largely unknown. Identification and
development of, its beneficial aspects can contribute considerably to the attainment of HF
A/2000 whose tenets incorporate individual responsibility and participation in all aspects of
health development.
This special issue of the Ethiopian Journal of Health Development is devoted to the report on
self-care in three communities in Ethiopia by Yayehyirad Kitaw, a physician and
epidemiologist, for which he won the Jacques Parisot Foundation A ward for Social
Medicine.
Practising physicians had known that self-care was commonplace- and extended far into their
territory. But it had remained ill defined and without discernible attributes. However, despite
the, relevance of the subject, studies addressing self-care in this country even indirectly have
been few and restricted in scope up to the appearance of this report. Yayehyirad's study is
also preliminary and does not include parameters such as income and occupation and is
limited to illness episodes during a period of only two weeks. Nevertheless the information it
provides is substantial. Self-care is mainly used for minor illnesses though not confined to
that level; it appears; to be more common among females for reasons unknown and education
does not necessarily lead to pre fence for professional care although the nature of the illness
could be another determining factor .
Yayehyirad has commented on forces opposed to the development of self-care. Consideration
of conducive and deterimenal factors and forces is certainly pertinent and therefore
illustrative examples of alternative social environments in which self-care is thriving would
have been in order. It is to be hoped future studies on self-care in Ethiopia will include these
parameters to determine their respective roles in the area of self -care As far as professional
attitudes are concerned part of the problem, at least in developing countries, is at the interface
between tradition9l and modern medicine. In traditional medicine self-care and professional
care are more closely interwoven than in modern medicine. The tendency of the patient to
transfer the same attitude in his contact with modern medicine, often accidentally discovered
by the professional, generally elicits an unfavourabte response by the latter. In addition, easy
availability of potent drugs to patients through. irregular channels commonly appropriately
stored, with the possibilities of their misidentification, misuse and abuse, as indicated by
Yayehyirad's study, can hardly foster support for the concept of self-care on the part of the
providers of health care or even drug producers. But the attitude of the practitioners of
modem medicine is not one of outright hostility towards self-care. In the earlier part of this
century when modern medical practice was largely confined to a few expatriates the sick
came to them of their own volition. In fact the implicit belief by the populace in the healing
powers of Europeans in general was such that some of the foreigners exploited it to gain
ready laissez-passer and acceptance in the country. In the case of present day Ethiopian
practitioners the main factor in their attitude towards self-care is simple lack of information
rather than opposition to it.
In this study Yayehyirad has amply demonstrated that there is a great resource in the area of
self-care in health. Therefore, more extensive 'studies should be undertaken to unravel its
pattern and dimensions and the attitudes and behaviour associated with it so that its positive
potentials can be developed and infused into the efforts to attain the goal of HF A/2000.
PREFACE
The research proposal on which this report is based was submitted to AFRO to compete for the Jacques
Parisot Foundation Award which it had the good fortunes to win. The highlights (this study were presented in
my speech at the Thirteenth Plenary Meeting of the Thirty-Seven World Health Assembly on May 16. 1984
when I received the Jacques Parisot Foundation Medal.
Since then I had referral requests for copies from Africa, Europe and the USA. A grant from AFRO for
printing this report has made it possible to make it available for wider circulation. I believe the words of
appreciation I used in my speech to the general assembly are still appropriate.
"...One is always overjoyed by the recognition of his work however, humble the contribution might be. But
this joy becomes even greater for a public health physician when it is associated with the name of Jacques
Parisot.
The name of Procedure or Jacques Parisot is, I am sure, familiar to most of you here. All those who have
wol1ked in the broad field of public health and social medicine have heard of his innovative endeavours. As
a true public health man, he was seriously engaged in international work in health both in the Health
Committee of the League of Nations and id the World Health Organization whole Constitution he signed on
half of France. He was an outstanding organizer, not only in his faculty, of which he was dean for a number
of years. but also of the public health services of his region. He was an acclaimed teacher and researcher
with hundreds of papers to his name.
Te quote a 1964 WHO publication: "There is yet another aspect to the lire of this much-honoured man: that
of a social, almost political, philosopher. What will bI8Ippen to man in this rapidly developing society? What
are the problems of new towns and large blocks of flats ? What are the effects of automation? These are
among the questions that Jacques Parisot, has attempted to answer, highly topical questions which he has
approached with a sure step" (World Health, May.June 1964, P. 8). These, Ladies and Gentle men, are, I
submit, still highly topical questions. (I1tey are testimony to a great and visionary mind. My intervention
today will look at only one aspect of these topical questions. One aspect, but an aspect that I believe might be
decisive in the future of health development: self (lay) care.
I am overwhelmed, by the fact that I speak here today representing, in a way, African social medicine. Africa
is a young continent, with painful experiences but a bright future, which will have to be ensured through
strugg]e and sacrifice. I have no pretentions of representing this aspiration, this future. I only hope that some
glimp of this future will sparkle across what I am going to say today about self-care.
...If self-care is to have any meaning, it must be cooked at from I a larger sociopolitical perspective. It must
be seen as part of a whole complex of self-reliant development in health, which can only be part of a self.
reliant socio-economic development. For al] practical I purposes, this means that self-care must be judged
from the perspective of its possible contribution to solving the critical problem of under-developed countries
their liberation from imperialist fetters and their socioeconomic development. This perspective is very
important to the underdeveloped countries as their health (in fact disease) care system has, to date been a
poor imitation of the system in the developed capitalist countries.
(Before concluding my speech, Mr. president...1 would like to expressly gratitude to: the Jacques Parisot
Foundation which made this study possible: to the WHO Regional Office for Africa and in particular to its
Regional Director, Dr. Quenum, who closely followed and supported the development of this study; to the
Department of Community Health, Medical Faculty, Addis Ababa University, without whose general
intellectual support this study would not have been possible; to the Commission for the Organization of the
Party of the Working People of Ethiopia (COPWE) for allowing me to continue this research even though I
had moved to a different function; and last hut not least to my wife and children who not only gave the usual
familial support but participated actively and effectively in the compilation of the data and in computer
feeding.
Ladies and gentlemen, Professor Jacques Parisot, as I said at the beginning, was a great and visionary mind.
He had visions for the future development of health in what today are called under developed countries. But
as a man who has suffered through the atrocities of two world wars, he aspired and worked for peace. In this
troubled world or ours, I think it is befitting to conclude with his hopes and allow me to quote him in his own
language, He hoped:
"de voir quelques parcelles des ressources immenses affectees aux instruments de mort distraites au profit
des armes dispensatrices de vie, de I'oeuvre mondiale de notre -Organisation ( il parlait de. I'OMS) ...C'est la
un J reve, mes chers co}leagues" dit-il "mais le reve n 'est-il pas souvent 1 'expression des pensees qui nous
hantent, et cel1es-ci ne sont-elles pas les notres a tous?"
GLOSSARY
1. Awraja: A level of the administrative divisions of the country. Often taken as equivalent to province,
Ethiopia is divided into 14Administrative Regions (excluding Addis Ababa, the capital city, which has the
same status as an administrative region.) The 14 Administrative Regions are divided into 102 Awrajas which
in turn comprise over 500 Woredas ( districts) , the lowest administrative division of the country .
2. Drug Shop: A 'Pharmacy' where any kind of medicine is retailed. Differs from the Pharmacy proper in that
pharmacies are allowed to compound drugs while drug shop can only retail ready made drugs. Rural Drug
Shops on the other hand can only sell a limited number of drugs specified by law. Rural Drug Shops are
staffed by Health Assistants with very limited training.
3. Health Center: An establishment which provides preventive and curative se1'vices ( mostly ambulatory)
See Health Service.
4. Health Service: General Health Service means a net-work of Health Stations including Kebele
(Community) Health Service, where available. Health Centers and Hospitals (including specialized
hospitals). The structural organizations of Health Services is as follows:
.
- Kebele (Community) Health Service
- Health Station
- Health Centers
- Medium/Rural Hospitals
- Regional Hospitals
Central Referal Hospitals
5. Health Station: The smallest Health unit in the conventional health service structure. ( see Health Service )
6. Kebele: The smallest unit of mass organization in the country: i.e. Urban Dwellers Associations (Urban
Kebeles) and Peasant Associations ( Rural Kebeles) .
7. Mitch: local name for febrile illness, with i1ll defined etiology and symptoms, usually associated with
sudden onset.
8. Pharmacy: See Drug Shop
9. Rural Drug Shop: Seee Drug Shop
10. Tebel: Holy water, i.e. water from Church or from a spring, dedicated to a Sajnt or Angel used for curing
diseases.
11. Woreda: See Awraja
(Most of these definitions are based on reference 72) Self (lay) Care in a Developing Country:
A Study of Three Communities in Ethiopia
I. Introduction
The attainment of the social goal of "Health For All by the 2000", (HFA/2000~ assumes that people will take
the responsibilities for their health in the spirit of self determination and self reliance (106,107)*. The
promotion of self-care, as part of this movement has caught the imagination of many, (104). Self-care is
probably not only as old as mankind but also most widely used, (29, 30), however, because of the dominance
of the institutionalized biomedical bio-medical appr8ach, it has been a neglected field of study (30). The
Health Care Crisis'. in the West has led to a reveal of interest in self-care (57,59). Presently, the role of selfcare in the developed countries is being debated and a number of studies are being carried out (17, 18,
46,54)**.
Little is known about self-care in the developing countries some, for example Fendal (25), have hold the
view that the low level of sophistication of people in the Third World means that they would make use of
health services for minor complaints. On the other hand, the few studies that have been conducted indicate
hat self (lay) care with both modem and 1raditional1 drugs could be very important (9, 14, 56). Attempts to
promote self-care in the Third World are growing moth as part 0£ the Primary Health Care movement, and
therefore with the best of intentions (104), but also for less avowable intentions such as a greater market or
multlinationals (23)
Self-care in Ethiopia
As in many other countries, little has been recorded about self-care in Ethiopia. There are numerous
confirmations of its widespread practice and has a long historical tradition. The most vivid experssion we
know of is that of Ludolphus (quoted by Pankhurst 1961, (80)) who says that in 17 century Ethiopia "in most
Distempers every Person is his own Physician and used such herbs as he has learnt were useful from his
Parents.
We know that for certain diseases /eg. taeniasis. /treatment is almost completely an internal (home) affair.
For the other diseases, lay consultation is the rule before going to professionals in the indigenous or
"Western" system. This is, abundantly illustrated in Ethiopian literature in, which reference to health
problems and steps taken to alleviate these problems abound. [For a brief sum many of the Ethiopian
literature in Amharic up to 1974 in which the practice 0£ self (lay) care is illustrated, see (45)]. Almost
invariably the first action of the sick is to consult friends and/or neighbors. For example, a recent novel by a
famous Ethiopian author (39) makes action taken toward restoring one's health central to a self-studies, we
believe that these fictional works indicate the central role played by self (lay) care in the life of the people of
Ethiopia. A more recent study (9) in the Eastern part of Ethiopia has clearly documented the role and
importance of self (lay) care in this part of rural Ethiopia.
*The numbers refers to the bibliography at the end of the paper
**For bibliography on self-care 110.
Issues in Self-care
HF A/2000 through PHC has been adapted as a goal for the nations of the World at the Alma. Ata
conference {106). HFAJ/2000 arose, essentially, as an outcome of the medical care crisis in the imperialist
world ( i.e. the developed capitalist countries and their neo-colonial dependencies) * ( 34) .The achievements
of the socialist countries have been important factors in indicating ways for possible solutions for health
problems (86) , since it is clear that the conventional biomedical approach is not relevant ( 44, 66, 74, 85 ). If
the conventional approach were to be used the sheer magnitude, I of the financial outlay necessary will be
prohibitive (98), and thus a serious look at the age old practice in terms of mitigating high demand and the
attendant high cost of conventional {institutional) care is inevitable. Thus self-care was perceived by some
as a way of passing some of the financial and other burdens to the individual, however, it could, under a
different socio-political setting, also perceived as part of revolutionizing self-re1iant practice by the masses
in the process of molding their destiny. In this case self-care becomes part of a liberating process instead of
an extension of the control and exploitation mechanism of imperialism (For the relationship between
medicine and page see 76).
There is a lot of debate going on in the developed (capitalist) countries with respect to the motivation's, the
role and potentials of self-care and self help movements. The nature of the debate and the extent of
participation vary from country to country, {57) and reflect the specific concerns of the academic circles
involved and the crisis (health and other) situation in which monopoly capitalist countries find themselves in.
A lot of the issues are, therefore neither comprehensible nor of immediate relevance to workers in under
developed countries.
The issues in that present debate might he grouped into:
1. Why interest in self-care now? 2. The role and potential of self-care
A number of reasons could he advanced for the rise of interest in the self-care issue (30, 55, 59, 60, 61). The
shift in the pattern of disease towards more chronic illnesses (from 30% to 80% in 40-years), with the
attendant shift from cure to care, are often mentioned. The inadequacies (failure) of the 'official' health care
system with its maldistribution, increasing cost and the general issues of its effectiveness (16, 44, 66, 67) are
also important factors. From a more clinical perspective, changing life-styles and their impact on health have
also some bearing (59).
Se1f-care has also been considered as a "reflection of larger and more profound areas of social discontent
with the quality of life" (46,47) as part of the movement to liberate oneself from the stifling domination of
experts and bureaucrats. (6,44) In this context, some look at the self-care movement as being promoted by a
relatively small but strident minority seeking redress for grievances resulting from the handling by
professionals, or denial of access to professional care, or as an attempt to challenge the existing social control
of medicine. On the other hand, inspite of the protest of its advocates (47), the possibility that the selfcare/self-help movement might serve as a victim blaming mechanism and may be used to distract attention
from the more relevant structural (social-political) issues in health development has been stressed by others
(17, 54, 77).
Definitions of Self-care
Definitions of self-care could be very extensive or narrow, theoretical nr practical (essentially in terms of
research ability) (18, 36, 81), It has been defined as substitute (44), supplementary or additive to professional
care, (57) or as 8 discrete component in the health care delivery system. Some define it as a source rather
*For, sometimes questionable, attempts to see the PHC movement as part of the struggle for the New Economic Order, See 35.
than a form of lay medicine (24). Others (29) have defined it by the role play, thus singing out important
component 0£ the concept: self diagnosis, self-medication, self-treatment and, patient participation in
professional care. Simon et al (93) have listed and classified self-care activities related to acute cardiac
symptoms.
Ozias (79) defines self-care as "making decisions and taking actions which improve personal ph} social and
emotional health or reduce risk factors. Levin (59) in the same vein, defines it as "a process where by a lay
person can function effectively on his or her own behalf in health promotion and decision making, in disease
prevention, detection and treatment at the level of primary health resource in the health care system. Most of
these definitions suffer from individualistic bias and therefore la more community oriented definition has
been urged (71).
Self-care is increasingly used to denote health care activities including those by the family, neighbors, etc. in
short, all non-health professional resources (54). This is the approach adopted for the present study. Thus the
study reports upon rall health related activities (promotive preventive, curative) taken by the individual,
hisfamily, neighbors and other lay persons. Because of the nature of The faculty and the methodology
employed, this often hoils down to measures taken when a person is ill (see methods). In this study no
attempt at value judgement on the nature of the care, licit or illicit self medication ( 64) , is mace.
Some definitions of self care include a large variety of measures;- diet, special foods, first mid materials,
exercise, massage and medication (48, 81). Others, (64) limit themselves to self-medication by "modern"
drugs. In the present study simple modification of diet (drinking tea for cold, limiting food intake for
diarrhea, etc.) and limited modification of physical activities at home (bed rest, etc.) have not been included
as self-care thus, perhaps, increasing the no-care category .
Objective of the Study
It is often very difficult to distinguish self, (lay) care from the care of traditional healers, a field which still
awaits appropriate epidemiological exploration. The potential role of informed self-care as well as the
possible mishaps must be recognized (113) present study was undertaken as a first step in the elucidation the
nature, magnitude and role of self ( lay) care thus giving background information for the assessment of its
place in the drive for Health For All by the Year 2000". For a number of historical (70), socioeconomic and
political (72) reasons. Ethiopia presents unique opportunities £or such a study.
As very little is known' about self-care in Ethiopia and the differentiate on between lay care and "traditional
healer" service could prove difficult, this study is exploratory with strong emphasis on delineating the issues
and on methodological development and capability building for more extensive future studies. The following
questions are explored: What do people do when sick.? What are the characteristics of persons opting for sell
(lay) care? Why do they opt for self-care? How in relation to other options of care, is self (lay) care used?
What measures (drugs etc) do people use for self (lay) care? Is self (lay) care safe?
II. Material and Methods
As stated above this exploratory and essentially descriptive study employs the epidemiological ,approach
(50.51. 10,2); [(for recent development see (101)] .
Study Communities
Attempts were made to select areas that would yield information on as many factors ( ecological conditions)
as possible related to self-care and that could also be covered within the resources of the project. Practical
feasibility considerations* have led the author to concentrate ,on agglomerations. Three areas were chosen:
* A lot has been written on the shortcomings and hazards of population (survey) studies: for Ethiopia. see 69. 82. 114) .
a) A Kebele** (Higher 21, Kebele II) in Addis Ababa the capital city of Ethiopia [for further, eventhough a
bit dated, detail f on the Kebele see ( 26) ] .This Kebele is found in one of the densely populated areas of
Addis Ababa in close proximity to the University medical institution (Black Lion Hospital). It has a number
of health facilities (clinic and pharmacy /drug shops** and in terms of care could be considered typical for
most Kebeles in Addis Ababa.
The Kebele, was also chosen because of a study on health care among children conducted in 1972-73 which
serve as a background material ( 126) .
b) Zewai Town, This is the provincial capital for Haikotch and Butajira Awraja* and typical for such
administrative capitals. It has a health center, which serves part of the Awraja, a number of drug-shops and is
about 100 kms. from hospitals in the area. The town is also the head-quarter of the Rural Community Health
Teaching Project of the Department of Community Health, and therefore with a large amount of easily
accessible background material. The town has two Kebeles with quite distinct characteristics-Zewai 02 being
more urbanized than Zewai 01, which requires their separate treatment.
c) Adami Tulu [ for a description of a rural village see ( 7) ] is a semi-rural agglomeration 7 km from Zewai.
It has no government health facjlity but has two Rural Drug Shops. It is 7 km away from the nearest health
center (Zewai) and about 100 1km from the nearest hospital (Shashemene) .The Department of Community
Health has carried out surveys in the town a year before the present study and therefore background material
.
The population distribution in the study communities is given in Table 1. The total number of households
interviewed were: 525 in Adami Tulu, 344 in Zewai 01, 425 in Zewai 02 and 498 in Addis Ababa 21/11.
Table 2 gives the total number of housing unit, households and the number of people successfully.
interviewed i.e. those with complete forms-89% of the total. \The latter are the households included in the
analysis. No systematic attempt was made to find out if bias was introduced by non-respondents but there is
no apparent reason to believe so. There was no active resistance from interviewers except for two households
in Addis Ababa.
**See Glossarv
*See Glossory
Self (lay) care Ethiopia
TABLE 1: AGE SEX DISTRIBUTION OF THE STUDY POPULATION
COMMUITY
AGE AND SEX
0-11 months
1-14 months
15-44 years
45-64 years
65 T
TOTAL
ZEWAI 01
ZEWAI 02
No.
67
53
632
586
379
486
105
108
40
56
1,223
1,289
No
32
25
459
405
443
442
67
53
11
12
1,012
937
No
41
46
583
534
495
548
84
88
12
19
1,215
1,235
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
ADAMITULU
Grand TOTAL
%
5.5
4.1
51.4
45.5
31.0
37.7
8.6
8.4
3.3
4.3
48.7
51.3
2,512
%
3.1
2.7
45.4
43.2
43.8
47.2
6.6
5.7
1.1
1.3
51.9
48.1
1,949
ADDIS ABABA
21/1
No
%
36
2.4
28
1.7
633
42.9
664
41.5
691
46.8
784
49.0
91
6.2
98
6.1
25
1.7
27
1.7
1,476
48.0
1,601
52.0
%
3.4
3.7
48.0
43.2
40.7
44.4
6.9
7.1
1.0
1.5
49.6
50.4
2,450
3,077
In each place Kebele officials (elected) were approached to give their support for the study which they
readily did and interviewers were employed from the locality in Zewai and Admitulu. For Addis Ababa one
guide/cum interviewer was employed from the Medical school.
All households in the selected localities were included in the study. House numbers, given by the respective
Kebele offices, were used for identification and full coverage was insured by checking against information
on households available from the Kebele offices.
Self (lay) care, Ethiopia - 1984
TABLE 2: NUMBER OF HOUSEHOLDS & STUDY COVERAGE IN STUDY COMMUNITIES
LOCALITY
Total No. of
Housing Unit
No of Housing
Unit
No. of Households
interviewed
Response
Rate %
Kebele 21/11
Addis Ababa
ZEWAI
650
522
498
95
1,096
931
796
96
ADAMITULU
700
581
525
90
TOTAL
2,446
2,034
1,819
93
Questionnaires and an instruction manual were prepared by the author in consultation with a statistician and a
social scientist. Questionnaires, methodologies and instruments used for similar (socio-medical and health
services) studies in Ethiopia (I, 15,26,73,74,96, 114) were reviewed for this purpose. The questionnaire was
translated into Amharic and pre-tested on households in the Black Lion Hospital compound and the
necessary modifications were made.(see Appendix for questionnaire and instruction) .Based on previous
experiences ( 73, 82, 114) , the questionnaire was made as simple as possible, and the areas and the depth of
exploration limited to the minimum so as to reduce errors, non responses and bias.
Two 3rd year medical students were employed and then instructed on how to administer the questionnaire.
The students with the assistance of the guide mentioned above, carried out the interview in Addis Ababa.
They were closely supervised by the author during the interview period.
Eight interviewers were employed for the other communities five for Zewai and three for Adamitulu. The
inlterviewers having worked in the area as interviewers for the faculty before, were therefore familiar with
the area and had acquired experience in interviewing. They were given a two days instruction by the author
and the medical student interviewers, and were also very closely supervised by the two medical students for
two days and later supervision was carried out by the head of the Health Centre in Zewai. One of the medical
students went back for a one day supervision 'and did random counter checking in both places.
For the study, self-care was defined as "action taken to restore health or prevent disease by the person
himself or in case of children by the person directly responsible ( usually the mother) ." Lay care was defined
as "action taken to restore, health or prevent disease by non professional i.e., some one who is not a health
Worker {modern) or an established traditional healer," (see Appendix) .A close examination of the responses
given revealed that very few reported care -defined here. There was often difficulty in distingushing the
borderline at the point where self care ended and lay care started. Both are, therefore, treated together as self
(lay) care in the report.
Although the responses to the questionnaire were mostly of the closed type and precoded, some questions
were left open. The question on illness was filled-out using the respondents own words which were later
coded using the 1ay-reporting system (108 ) as modified for the Central Statistical Office, Household Health
Interview Survey (114)*
Some of the terminology used for health care in the quedtionnaire need explaining. Respondents were asked
whether they took any action when sick, and their responses were fitted into the categories which were given
to the interviewer who did not read the list to the respondents nor probe. Thus 'nothing' represented a patient
reporting to have taken no active measure to alleviate his health people did not consider slight changes in diet
or active step, and even discounted such measures as taking hot drinks, infusions, etc.
Professional care, was defined as care by any one who is recognized in the community as a 'healer' which
could be a traditional healer 0£ any sort Or a modern health worker practicing in an institutional setting or
privately. In the present setting, is 'was considered difficult for the lay 'person to distinguish between legal
and illicit practice of health professionals, and therefore deline1l.ting a transitional system as Dushkens &
Silkveer ,(9) have tried to do is, in our opinion, difficult from a questionnaire survey 'alone. Thus our
categories include only self ( lay) .traditional or modem care.
_____________
*The results of these surveys have ,been published recently. see 13
III. Results
Sickness
Table 3 summarizes the data on reported illness in the previous 14 days (two weeks). Between 87 (Zewai)
and 164 (Addis Ababa) persons per thousand people reported 10 have been sick in the previous 2 weeks. In
terms of sickness episodes, these were between 87 and 18:j per 1000. Cough and other respiratory symptoms
being the most frequently reported in all but Adamitulu, dominate the picture. Head and neck, diarrhea and
other gastro-intestinal symptom complexes vie for second place.
TABLE 3: KIND OF ILLNESS AS PERCENTAGE OF ILLNESS EPISODES AND NUMBER of PERSON
& SICKNESS EPISODES
ILLNESS and NUMBERS
Feb rile (mitch etc.)
Cough & other respiratory
Diarrhea and other respiratory
Head and Neck (Headache etc)
Veneral Diseases
Skin
Maternal
Other diseases
Injuries
Total numbers of episodes
Total number of persons
Number of sick persons per
100 inhabitants
ADAMITUL
U
No.
%
22
7.2
67
22.0
55
78
2
12
3
49
16
18.1
25.7
0.7
4.0
1.0
16.1
5.8
304
257
102
ZEWAI 01
ZEWAI 02
No.
14
11
6
66
69
4
45
9
%
4.2
34.9
No.
18
84
19.9
20.8
2.7
1.2
13.6
2.7
322
49
27
7
3
18
8
293
150
%
8.4
39.3
22.9
12.6
3.3
1.4
8.4
3.7
214
213
87
ADDIS
ABABA 21/11
No.
%
26
4.6
285
50.5
78
85
3
9
6
66
6
13.8
15.1
0.5
1.6
1.1
11.6
1.1
564
504
164
In most cases single illnesses (symptom-complexes) were reported as shown in Table 4. No person reported
more than 3 sickness episodes in the 14 days period. The age and sex, distribution of 'those reporting illness
is compared with that of the study population in Table 5. We note that women are over represented in the
illness group. The age group of less than one and over 45 years were over represented while those between
age groups I and 4 were under-represented. Intersetingly, the tinder representation of the age groups 15-44
especially for female is relatively small and becomes even smaller with rurality.
Self (lay) care, Ethiopia-1984
TABLE 4: NUMBER* OF DIEAS (SYMPTOM COMPLEXES REPORTED PER SICKPERSON
Number of Persons
Adamitulu
Zewai 01
Zewai 02
Addis Ababa 21/11
One
214
254
212
446
Two
38
35
1
53
Three
5
4
5
Total
257
295
213
504
*Includes episodes for which the kinds of illness was not specified.
Action Taken
Table 6 & 7 show the kind 0£ action taken by those reporting sickness in the last two weeks. Overall a large
proportion of those reporting illness (about 37% in Adamitulu, 13% in Zewai 02 and Addis Ababa, 30% in
Zewai 01) did not take any action. About 14% in Adamitulu, 23% in Zewai 01, '21% in Zewai 02 and 'a high
48% in Addis Ababa 21/11 had self (lay) care. Most of the sick, over 90%, limited themselves to action in
one system of care in the two weeks period. In all, combined actions constituted 7.5% , 14.6% , 0.5%, and
9% in Adamitulu, Zewai 01, Zewa:i 02 'and Addis Ababa, respectively. If we leave out change form no
action (nothing) to action or the inverse combinations. We find the following pattern.
Change from self (lay) care to
modern care
Change from traditional care
to modern care
Change from modern to self
(lay) care
Change from modern to
traditional care
Adamitulu
7
Zewai
-
Addis Ababa
47
1
-
2
1
7
7
-
1
2
Self (lay) Care, Ethiopia- 1984
TABLE 5: AGE & SEX DISTRIBUTION: TOTAJ... POPULATIONS AND THOSE REPORTING
ILLNESS (IN PERCENTAGE)
AGE GROUP
ADAMITULU
Sick Total
9.4
4.8
36.2
48.5
29.5
34.4
13.0
8.5
11.8
3.8
254
2,512
35.4
48.7
64.6
51.3
-1
1-14
15-44
45-64
65+
Total (number)
Male
Female
ZEWAI 01
Sick
Total
5.5
2.9
31.2
44.3
46.9
45.4
13.7
6.2
2.7
1.2
292
1,949
35.6
51.9
64.4
48.1
ZEWAI 02
Sick
Total
4.7
3.6
40.4
45.6
41.8
42.6
8.5
7.0
4.7
1.3
213
2,450
41.3
49.6
58.7
50.4
Addis A. 21/11
Sick
Total
5.2
2.1
32.0
42.2
42.7
47.9
15.3
6.1
4.8
1.7
503
3,077
37.8
48.0
62.2
52.0
Self (lay) Care, Ethiopia- 1984
Table 6: KIND OF ACTION TAKEN BY SICK PERSONS BY KIND OF SICKNESS (IN PERCENTAGE)
ACTION ILLNESS
Febrile (Mitch etc.)
Cough & Other
Respiratory
Diarrhae & Other GI
Head & Neck
(Headache etc)
Veneral Diseases
Skin
Maternal
Others
Injuries
Total
ADAMITULU
I
E
T
52.4
47.6 21
I
78.6
ZEWAI 01
E
T
21.4
14
47.0
53.0
66
64.0
36.0
114
43.4
56.6
83
74.5
25.5
235
43.2
57.8
100.0
50.0
66.7
71.4
41.9
51.0
56.8
42.2
50.0
33.3
58.1
28.6
49.0
44
64
2
10
3
31
14
255
39.7
61.1
57.1
43.3
50.0
53.8
60.3
38.9
42.9
100.0
56.7
50.0
53.8
58
54
7
3
30
8
288
8.9
40.0
85.7
44.4
25.0
33.7
91.1
60.0
14.3
100.0
56.6
75.0
66.3
49
25
53.2
63.2
25.0
25.0
42.0
16.7
64.2
46.8
36.8
100.00
75.0
75.0
58.0
83.3
35.8
62
68
3
8
4
50
508
6
I
11.1
ZEWAI 02
E
T
88.9
18
7
3
18
8
211
ADDIS ABABA 21/11
I
E
T
60.0
40.0
25
Self {lay) Care, Ethiopia -1984
TABLE 7: ACTION TAKEN BY SICK PERSONS BY SEX (IN PERECNTAGE)
ACTION
ADAMITULU
ZEWAI 01
ZEWAI 02
Nothing
M
33.7
F
37.4
M
29.8
F
29.3
M
10.2
F
14.6
ADDIS ABABA
21/11
M
F
13.2
13.1
Self (lay) Care
9.0
17.8
20.2
27.1
15.9
24.4
42.9
58.0
Professional Care
57.3
44.9
50.0
43.6
73.9
69.1
43.9
28.9
Total (number)
89
163
104
188
88
123
189
312
Table 7 shows the distribution of taken by sex. A8 in many other places (9,53), relatively more males resort
to external (professional) action while females tend to use more self (lay) care Or take no action at an. In
general, older 'age groups, those 65 and over in 'particular, tend to resort more to internal (i.e. action or self
(lay) care) action (Table 8). Education tends to reduce non action and reinforces self care (table 9) while the
role of religion was more difficult to asses because of the high preponderance (Table 10) of Orthodox
religion in the areas studied.
Self (lay) Care. Ethiopia -1984
TABLE 8: ACTION TAKEN BY SICK PERSONS BY AGE (IN PERCENTAGE)
AGE
(IN YEARS)
-1
ADAMITULU
I
E
T
60.9
39.1 23
ZEWAI 01
I
E
35.3
64.7
T
17
ZEWAI 02
I
E
20.0
80.0
T
10
Addis Ababa 21/11
I
E
46.1
53.9
T
26
1-14
47.8
52.2
92
57.2
42.9
91
29.1
70.9
86
64.8
35.2
159
15-44
48.0
52.0
75
49.6
50.4
137
35.6
64.4
87
67.9
32.1
215
45-64
48.5
51.5
35
67.5
32.5
40
50.0
50.0
18
63.3
36.4
77
65+
60.0
40.0
12
62.5
37.5
8
40.0
60.0
10
75.0
25.0
24
Total
50.6
49.4
253
53.9
46.1
293
33.6
66.4
211
65.5
34.5
501
I -Internal i.e. nothing or se1f (lay) care
E --External i.e. modern or traditional profe'58jonal care
T -.Total m numbers
Self (lay) Care, Ethiopia- 1984
TABLE 9: TYPE OF CARE BY LEVEL OF EDUCATION (IN PERCENTAGE)
EDUCATION
CARE
Nothing
ADAMITULU
I
L
E
40.5 26.7 36.4
ZEWAI 01
I
L
30.8 25.4
E
30.4
ZEWAI 02
I
L
20..8
13.6
E
7.2
Addis Ababa 21/11
I
L
E
15.7 16.9 10.2
Self (lay)
14.4
17.8
13.1
22.4
32.8
21.7
16.9
22.7
32.5
42.6
50
57.2
Professional
45.1
55.6
50.5
46.7
41.8
47.8
62.3
63.6
70.3
41.7
33.1
32.6
Total (number)
111
45
99
107
67
115
77
22
111
108
130
264
Table 10: TYPE OF CARE BY RELIGION
RELIGION
ADAMITULU
ZEWAI 01
ZEWAI 02
CARE
Nothing
OR
38.4
M
27.5
O
100
OR
30.0
M
23.1
O
-
OR
11.5
O
33.3
M
-
ADDIS ABABA
12/11
OR
M
O
13.7
13.7
7.1
Self (lay)
12.8
21.6
-
23.8
38.5
33.3
20.8
26.7
-
52.7
52.7
61.96
Professional
48.8
51.6
-
46.2
38.5
66.7
67.7
40.0
100
33.6
33.6
31.0
Total
203
51
1
277
13
3
192
15
4
387
387
42
Self (lay) Care
The reasons for the choice of self (lay ) care are given in Table 11. In all the study sites, the most frequent
reason for making use of self ( lay) care is the perception that the disease is minor. It is interesting to note
that, this reason becomes more, preponderant with urbanization. Poverty is the next most important mason.
Other reasons such as non-availability of, non-confidence in, etc. modern care 'were mentioned very rarely.
In fact only one person front Addis Ababa mentioned non-availabi11ty of modem health care as a reason.
Not even in Adami Tulu where nearest government service is 7 kms away, was non-availability of modern
health care given as a reason. Only 22 people thought modern care either does not work £or the kind of
disease they had or had failed.
Self (lay) care, Ethiopia -1984
TABLE 11: REASONS FOR SELF (LAY) CARE
REASONS
ADAMITULU
ZEWAI 01
ZEMAI 02
Disease in Minor
No
13
%
39.4
No
31
%
47.7
No
23
%
56.1
ADDIS ABABA
21/11
No
%
146
46.6
What I did is the
best
What does not
work
Modern failed
4
12.1
1
1.5
2
4.9
6
2.3
-
-
2
3.1
-
-
6
2.3
1
3.0
8
12.3
-
-
5
1.9
Modern not
available
Poverty
-
-
-
-
-
-
1
0.4
10
30.3
5
7.7
8
19.5
40
15.5
No time
1
3.0
3
4.6
3
7.3
12
4.7
Others
4
12.1
15
23.1
5
12.2
42
16.3
TOTAL
33
65
41
258
TABLE 12: SELF (LAY) CARE BY HOW USED
'"Table 12 shows how se1f (lay) care was used. As we have seen above most self (lay) care was uti1ized
alone, and very few made use of it before, after or con-currently with either modern
or traditional professional care.
Self (lay) Care, Ethiopia -1984
TABLE 12: SELF (LAY) CARE BY HOW USED ADMITULU ZEW AI 01 ZEW AI 02 Addis Ababa
21/11
HOW
ADAMITULU
ZEWAI 01
ZEMAI 02
No
27
%
84.4
No
55
%
82.
No
42
%
100
ADDIS ABABA
21/11
No
%
198
94.2
-
-
1
1.6
-
-
39
14.6
Concurrently with
other care
After other care
-
-
-
-
-
-
13
4.9
3
9.4
6
9.4
-
-
10
3.7
No answer
2
6.3
4
6.3
-
7
2.6
Total
32
Exclusively
(alone)
Before Other care
.
66
42
267
Drugs used in self (lay) care
A lot of self (lay) care (Table 13) was carried out by means of modem drugs, however, quite an important
proportion of the respondents used home made ( traditional) remedies. In this connection, an effort was
made to find out if respondents had drugs (traditional or modern) at home and if 80, what they thought they
should be used for.
TABLE 13: SELF (LAY) CARE BY NATURE OF CARE (IN PERCENT AGE )
Self (lay) care, Ethiopia-1984
Took Modern
Drugs
Took Home
(traditional)
Remendies
Other (Massage,
Advice, etc)
Total (Number)
Adamitulu Zewai 01
Zewai 02
14.4
22.2
40.5
Addis Ababa
21/11
65.6
82.9
76.4
59.5
28.5
5.7
1.4
-
5.9
35
72
42
256
TABLE 14: CHARACTERSTIC AND REPORED USE OF DRUGS
ADAMITULU ZEWAI 01
I. No of Drugs - Total
348
233
278
ADDIS
ABABA 21/11
379
No of Drugs per household
0.66
0.68
0.62
0.76
II. Traditional drugs-number (as %
of total)
Traditional drugs per household
173 (49.7%)
124 (53.2%)
119(42.8%) 54(14.2%)
0.33
0.36
0.26
0.11
Traditional drugs for specific use
66
51
39
39
Traditional drugs o specific use
107
73
80
15
III. Modern drugs (no) per
household
Modern drugs for non-human use
(173) 0.34
(109) 0.32
(159) 0.36
(325) 0.70
14
15
2
10
Modern drugs use unknown
13(8%)
11(12%)
16(10%)
58(18%)
Modern drugs determination
65(40)
28(30)
68(45)
36(11)
Modern drugs use not possible (%)
25(16)
14(15)
14(15)
67(21)
Modern drugs appropriate Use (%)
58 (36
41(44)
49(31)
154(49)
It would be noted that for a high proportion of the drugs kept at home, the nature 0£ the drug could not be as
certained by the interviewer because there was no proper labelling on the containers. The unla1bened drugs
and those £or non-human we are not included in Table 15, in which the opinion 0£ the respondents on the use
(indication) of the drugs kept at home was compared to :that indicated by the manufacturer as described in
Africa MIMS. For those drugs for which use could be ascertained from the 1abels, the respondents did not
know or were uncertain 0£ their use in 8, 12, 10 and 18 cases out of a hundred in Adamitulu, Zewai 01 Zewai
02, Addis Ababa respectively.
Self (lay) Care. Ethiopia -1981
TABLE 15: OPINION ON THE USE OF MODERN DURG (FOR HUMAN USE>
COMPARED TO THAT INDICATED BY MANUFACTURERS
OPINION DRUG
(ACTING ON)
Alimentary
Cardiovacular
Analgesic/Antipyretic
ENT
Ophtalmic
Geniotourinary
Infection
Vitamin and other
Nutritional
Antiallergic
Respiratory
Dermatologic
Total
ADAMITULU
ZEWAI 01
ZEWAI 02
ADDIS ABABA 21/11
2
4
5
2
5x
12xx
-
12
4
3
2
20
2
4
1
1
1
5
2
5x
1
4xx
1
18
1
3
1
6
2
-
3
3
6
3
3x
1
11xx
3
8
1
1
5
14
12
2
3
4
4
1
4
11
26
2
2
12x
1
2
32xx
6
25
12
16
19
12
4
15
4
1
13xxx
6
25
1
10
58
1
11xxx
1
14
8
2
41
1
1
16xx
2
1
24
5
1
49
1
3
58xxx
6
4
67
4
39
4
154
IV. DISCUSSION
Illness
The perception of illness by a person in a household was used as the starting point for inquiry on actions
taken. The findings (Table 3) in general are similar to report from studies in Ethiopia and elsewhere with the
attendant possibilities of under reporting and general incomparability of surveys. (3, 9, 27, 32, 78, 90, 99.
114).
Illness Behaviour
The proportion of no action; respondents (table 7) is much higher than that reported or more rural
communities in other parts of Ethiopia (9) and those reported from other parts of the world. (19, 53, 81, 114).
In general, people in the study communities seem to report less illness, and resort more to internal action.
Eexent of use of self-care
Se1f-care is extensively used all over the world. The distortion caused by the dominating position held by the
biomedical approach has led to its neglect in the endemic world which, however, did not mean that it was
abandoned by the people. As Doyal (20) has pointed out, access 0£ most people to institutionalized medicine,
even in the present day developed countries, is a twentieth century phenomenon. Earlier, "most healing and
care was undertaken... on an informal or semi-formal basis, often by women..." But the neglect by academics
and health professionals has meant that little has been documented on the nature, extent and varieties of
se1f-care. (81,105).
Recent reports from the developed countries clearly show its extensive use. In Dennlark, 90'% of all the cases
reported to a general practitioner have practiced some self-care previously ( 83) .In Britain the percentage
goes up to 95% (24), and in England, 75% of symptoms are handled by se1f-care (62). Fry (,1972) has shown
that only 20% of symptom experiences result in medical contact and that 75% of all symptoms in United
Kingdom .and the US.A. are cared for without seeking professional advice. Kohn and White (51) have
shown, in their international collective study, that self care is widely used.
The same phenomena could be discerned from the studies 10 under developed countries. The following
percentage of self care ( se1f-medication ) have been reported from Latin America ( 52): urban Honduras
64.3%; Cali, Colombia, 59.9% ; Ecuador, 50.1% ; Asia: rural Malaysia 28%; Taiwan.930/0 (48) India 25.42% and Nepal about 20% (81 ); Eritrea: Studies in Ghana (55.9%, (4 ) rural Cameroon- (19.2% ), (78);
Nigerian University students (88%) se1f.medication) (95) ; Nigerian children (31) and Ken1a. (37% did
nothing, 35% self-medication) (90).
Thus self care is extensively used all over the world, however, it is difficult to make any corparative analysis
since the definition of self-care, the recall period, the questions asked and the general study conditions have
not been standard. It has been estimated in one study the under-reporting of self-care could be high (90), and
thus the percentage differences observed among different groups and in different countries might not reflect
actual variations in use or non use self-care. However, one well standardized international comparative study
(51) has shown that, at least for nonprescription drugs, high variation could be observed in different socioeconomic settings.
If "nothing" and self '(lay) care are combined, the findings from the present study (Table 6 and 7) generally
correspond to findings elsewhere, specially in developing countries. It might be more instructive to compare
these findings with that of Busbkens and Slikkerveer ( 9) in another part of Ethiopia. They report a low non
action (1.6% only) 35.0% internal-action (approximately self (lay) care in this study) and a relatively high
.(63.4%) of external action patients ( corresponding to our "professional care " category). Over 50% of the
latter reported the use of traditional practitioners. Because of differences in definitions and methodology,
conclusions from these comparisons are difficult to make hut clearly point Out areas that will need exploring
in future studies.
Self (lay) care is used under very different circumstances. It is often used as a first and last resort (as a
substitute) (8) when the person believes that the ailment is not serious or when he considers that he knows
enough to handle even a possibly serious condition or, in the cases of many underdeveloped countries, when
other (modern) care is not available, self-care could be used as a supplement of professional (modern or
traditional) care (18), since patients have been known to use self-care concurrently with doctors care even when hospitalized (5). In certain cases, self-care is used to supplement and/or continue professional care
with the knowledge of end instructions from a professional. This has been the case, for a long time, for
chronic communicable disease such as 1.uberCulOlis and leprosy specially in underdeveloped countries (43),
It- has been recommended for dailysis (41) or for monitoring the evolution of some chronic diseases eg.
diabets (38)and for the care of the elderly* (42). Recently, a lot of studies have been carried out on self (lay)
use of oral rehydration therapy (see for example 22,94).
Self-care is also used prior to seeking professional Care, either as an attempt at self-care that fails or as a first
measure (suffering reduction or minimization of life-threatening conditions) before seeking external help.
That se1f-care could be the first and an important component of the care system even or life threatening
condition such as ischemic heart disease is shown by the study of Simon et al (93). It is difficult to conclude
from the persons study how self-care is used as compared with modern institutional care, The possibility for
substitution of self-care for modern health services is high given the distance (physical, socio-economic and
cultural ) of the modern health services (112). The fact that a large proportion (47%) of the sick in Adamitulu
did "nothing" about their problems could be surmised as indicating a large amount of unmet needs even
though none mentioned non-avaliablity of health care as a reason for using sell. care. On the other hand, the
high rate of active self Care (49.5% ) in the Addis Ababa Kebele seems to indicate a substitution effect at
least £or the more urbanized communities i.e., Addis Ababa and Zewai 02. In the few combinations noted,
self-care is used to supplement (intact, perhaps, t,) replace a failing) modern care. This is supported by the
fact that the most frequent reason given for sell-care is that the respondent considered the case minor. (Table
11).
DRUG HOARDINC & USE
Drug, hoarding (Table 13) is apparently quite low in our study communities. The highest, 0.8 item per
household in, Addis Ababa, one of the most urban communities in 'Ethiopia, is very low when compared to
those reported from Britain, 10.3 per houses hold (21; over 10 in Isreal (28); 9.2, in Demnark (10) and 22.5
for the US.A (49) .In these studies, all or almost all households had least one, drug while in our study quite a
large proportion had no drugs.
*Recently (1984) WHO has published "Self (heakh) Care and the Oldler People" -A Manual £or Public Policy and Programme Development
IRD/ADR, 1980/2001.
Unfortunately there are not many studies on drug hoarding in the third world (8). In communities, in South
Africa, Buchanan (8) found that urban whites had 8.8 drugs per household i.e., close to what has bee}}
observed in the developed capitalist countries while urban ,blacks and Indians were not far behind with 5.6
and 3.4, respectively. Rural blacks had 0.8 drug per household with 51.5% of the families with no education.
The limited scope (64 rural families) and the probability that Buchanan (8) did not include traditional drugs
in what he termed 'medication' makes any Conclusion hazardous, but the striking closeness of the finding
between rural black and our communities draws attention.
The issues of drug hoarding will not be considered here but the importance of drugs in the health care system
in general (11) and the possibilities of "drugging the third world" (92) in spite of the self-serving protests
(84) of representatives of the multi-national drug companies must be appreciated.
More interesting from the self (lay) care aspect is the knowledge on the use of the drugs hoarded (Table 15)
and the related issue of safety of self (lay) care (89) disturbing to note that for a high number of modern
drugs, 40% in Adamitulu, 'there were no lables ( or the labels were illegible) on the container. In 8 to 180; of
the drugs, the respondent did not know the use of the drug they had at home. Even more disturbing is that in
15%-121% the cases the use reported by the respondents was incorrrect (inappropriate ). Thus, in all the
communities, only for less than 50% of the drugs could correct use be ascertained importance of this is clear
since we know that, some of the drugs in question are very potent (antibiotics. cardiovascular, etc.
drugs/eventhough a lot of the drugs have been kept for a long time in the households and their potency is
suspect.
TRADITIONAL MEDlClNE
Only few people reported the of traditional practitioners and it is known ( 40) that patients do not often
volunteer easily information concerning the use of such practitioners. We know, on the other hand, that some
traditional practitioners have very busy' practices {9, 33, 40, 97) .The fact that few mental illnesses, an area
almost exclusively reserved to certain types of traditional healers, are reported and the high use of traditional
therapies such as Table* in the household, indicate the possibility of under reporting.
The method of data collection did not include individual, long lasting preventive/curative measures such as
amulets etc. that are worn on the individual. Thus this aspect of the use of traditional practitioner, which
could be quite extensive (9, 88, 97, 115) is not reported in the present study.
In contrast, most people used traditional drugs for self (lay) care (Table ( 13) and a large number of
traditional drugs are available in the markets in the study area. They are used for prevention (some being held
or exibited in the household for years ) "or for curative purposes. Those used for curative purposes could be
for various kinds of symptom-compexes.ln fact most drugs are for ubiquitous use, the often heard answer lor
use being "for all conditions."
It is important to note {Table 13) that the use of traditional remedies decreases with urbanity. Thus 83% of
the se1f (lay) care in Adamitulu, the most rural 0£ the study communities, is with traditional drugs while only
29% for Kebele 21/11 in Addis Ababa, the most urban.. It is clear that the use and knowledge erosion
phenomenon that has been documented elsewhere is also starting in Ethiopia. This has important implications
for future action.
*See Glossary
V. CONCLUSION
The study clearly shows the high use of se1f i(lay) care. Although its effectiveness ha~ yet to be established,
there are no grounds to believe (2, 14, 83) that it would fare less favourably than F1exenerian instutionalized
medicine. The study also shows that there are grounds for suspecting possible hazards from self (lay) care.
at least for those carried out with modem drugs. The extent of this danger and its nature (an extension of
iatrogenesis?) remains to be determined.
We have seen that self (lay) care has become a center of interest for academics of the developed capitalists
countries in recent years. For them it is, at best, seen as a means of regaining the sell-reliant and independent
( autonomous ) health, activity that has been alienated by capitalist development of which medicalization of
health is only one aspect. Eventhough some erosion during the recent neo-colonialist past should be
anticipated, the issue in Ethiopia is quite different. The issue is not how to spread sell-care or make in
acceptable but how to support and sustain it by bringing it into the main stream of human progress without
unduly medicalizing it. The solution does not, certainly, lie in rejecting (as certain disaffected bourgeois
intellectuals advocate) technological development. [See the penetrating critic of Dlich by Navaro (74) and
also Berliner's (4)]. Neither does it lie in the wholesale mimicry of the pattern of health (disease) services
developed in the West. The Primary Health Care approach with its amphasis on viewing health development
as part of the \"hole development process, on sell-reliance, community involvement, etc. clearly points to the
ways and means of trascending this apparent dilemma. Sell (lay) care has certainly great tentials as a strategy
in a consequent PHC approach.
Under these conditions, it is bound to be part of a community's self-reliant practice with very low probability
of degenerating into a reactionary practice (victim blaming, obscuration of structural issue, etc.) designed to
prolong an exploitative situation.
This study is only exploratory and therefore raises more question than it has answered for. The whole issue of
how people perceive health, disease and health related action must be thoroughly received. What is the place
of self (lay) care in this? What are its strong points, its weaknesses and how can it be incorporated in the
development of a relevant, effective and efficient health care system? How can it be integrated in a relevant
health-care plan ? What is its place in the Community Health Services (Yekabele Tena Ageleglot) being
developed on the basis of the PHC approach? The role of health education (37, 85, 111) in effectively
integrating self care in health development is undeniable but how could it be made part of a general
development education, related to the activity of (at least) the Community Health Agent?
These and a number of other questions will have to be answered if, as should be, self-care is to be integrated
into a planned health development. The', questionnaire developed for the present study, improved on the
basis of the experience gained, could serve as a tool for a more representative study. A more elaborate
instrument will have to be designed to elucidate the questions of the very low report on traditional
practitioner use and also on effectiveness and safety of damages. Income as a variable, not' included in this
study, to avoid possible draw backs due to the sensitivity of the issue, may have to be included.
Effort should be made to avoid, any undue medicalization of self-care. Health workes & health policy
makers, often very biomedically oriented, should be made aware of the issues of self (lay) care; But: of
course, the most important measure is to include self (lay) care in the development plan of the country. All
those concerned should seriously consider the issue in further elaborating the Ten Years Perspective Plan.
The data on self-care should be strengthened for this purpose. Further studies using, for example, the Central
Statistical Office, National Sample Household Survey Frame should be carried out so as to gain a more
clearer picture for policy & planning.
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APPENDIX 1
Jacques Parisot Foundation Award Study
Self (lay) Care in Ethiopia
Questionnaire
( see Instructions )
1. Address:- House Number _______________________ Kebele __________________
Woreda (Keftegna) ____________________
Awraja (Town) _______________________ Keflehager__________________
2. Religion __________________ 3. Education __________________
4. Composition of the Household
Age in year
Male
0-11
1-14
15-44
45-64
65+
Total
Female
5. Has anybody (in the household) been sick in the last 14 days
No.
(b)
Name
(c)
age
(d)
Sickness or
injury
(e)
What was
done
(f)
Nature
of Care
(g)
It self (lay) are why?
(h)
how?
6. Do you have any medication (drug) at home now? No..... Yes..... If yes! show me a) write where and how
the drug is kept.
(A) Name of Drug
(c) Use
(d) For Whom
(e) Source
(F) When
APPENDIX 2
JACQUES ,PARISOT FOUNDATION AWARD STUDY SELF (LAY) CARE IN ETHIOPIA
INSTRUCTION FOR FILLING THE QUESTIONNAIRE ,
INTRODUCTION
Little is known about self (lay) care in Ethiopia. We suspect that a lot of health care (essentially care for the
sick in the context of this study) is carried out by the patients themselves, household members, neighbors,
etc. It is important to know the nature and magnitudes of this so that we can have" a fair idea of the role it
could play in the attempt to achieve the social goal of "Health For All by the Year 2000."
The Jacques Parisot Foundation has selected this study for support in view of its importance.
The objectives of the study are to:
-Describe the nature, magnitude and role of self (lay) care in selected rural and urban communities.
-Elucidate the relationship between traditional) medicine (traditional practitioner use ) and self-care.
Elucidate the, relationship between western (modern) medicine and self-care (including self-use and hoarding
of modern drugs).
-Draw recommendations for policy on the place and role of sell (lay) care in the strategies for the
achievement of the social goal of "Health For All By the Year 2000."
This questionnaire is being used to seek answers for some of the objectives listed above. It is essential that it
is filled correctly and completely. Your role as an interviewer is therefore crucial to the successful outcome
of the study.
Please fill the questionnaire carefully, clearly, lisibly. Check that each item is appropirately filled. Follow the
instructions given here faithfully. reread them whenever indoubt during the interviews. Do not hesitate to
check ,with the supervisor ,whenever you have doubts.
In this study, self-care means action taken to restore health or prevent disease by the person himself or in
case of children by the directly responsible person ( usually the mother) .Lay care means Action taken to
restore health or prevent disease by non-professional i.e. any health worker (modern) or an established
traditional healer.
INSTRUCTIONS
A. INTRODUCING YOURSELF TO THE HOUSE.HOLD
-Most of you are well known in the communities you will be working in but it is always useful to start the
interview with polite introduction greetings.
-Make the objective of your interview clear from the outlet. The following formula might be used. "I am
conducting this interview for a study which is trying to find out what people do when they are sick. or need
health care for other reasons. The findings from this study will be used for planning. Therefore your
collaboration in answering these questions will be helpful to the whole community and to Ethiopia."
B. RESPONDANT
-The respondant should be the head of the household. Make
sure that the wife ( in cases where the head is male) is avail.
able to supplement. The availability of the whole family
would be useful. Avoid, tactfully, any interference by neigh.
hours, etc.
C. FILLING QUESTIONNAIRE
-All items must be filled. Put (-) for no answer and DK for don't know. There should not be any empty space
at the end of the interview.
QUESTION 1 -ADDRESS
Fill completly
QUESTION 2- RELIGION OF THE HEAD OF THE HOUSEHOLD
Use, the following: O = Orthodox, M =Muslim P = Protestant, C = Catholic.For others write in full using
respondentsterminology.
QUESTION 3- EDUCATION OF THE HEAD OF THE HOUSEHOLD
Use the following: I = Illiterate, R = Read only, R/W = Read & Write, E = Elementary, S = Secondary , =
Higher .
QUESTION 4 -COMPOSITION OF THE HOUSEHOLD
Write the number of people in the appropriate cell.
-Age is at the last birthday: in months 1Ipto one year. In completed years after one year.
QUESTION 5 -ILLNESS DURING THE I.AST 14 DAYS
-Make sure the respondent understands the period ( time frame) of reference. Use days e.g. , Monday to
holidays to clearly demarcate the time period Sickness includes injuries.
a) Give a number to 'each member of the household who is reported sick from 1 to
b) Sex M = Male, F = Female.
c) Age = In completed months up to one year. In completed years above one year.
d) Illness or injury: As given by respondent. Use the patients terminology. (The attached; list
might help you in summerizing the responses Annex
- If more than one episode or disease, record separtely. eg. 1. mitch, 2. fracture of the right arm.
- If different symptoms or the same disease or episode, record together as one episode e.g. 1. mitch:
headache, fever, is of appetite
e) What was done for the sickness or injury?
N -Nothing S = Took measures myself (for children upto 10 years, this means the mother or father. For older
children distingush clearly between self and mother or father.F -Measures taken by member of the family. L
= Measures taken by consulting other lay persons (neighbours, etc.) i.e. persons outside the family but who
do not usually or as a profession do health work. T = Consulted traditional healer ( i.e. persons who
are engaged in practice of traditional medicine: Wogesha, faith healer, tebele, etc. ) M = Went to modern
health service. If a combination of measures were taken indicate as such e.g. S,T&M. 1) Nature of care 'if
any What was the outcome of the consultation or what kind of treatment ( with what) did you get? Put il1; the
respondent words. e.g. took drug, tablets, some manipulation (massage...) only advice g) If Self (S) or lay (F
and/or L) care, why did you do it? i.e. Why didn't you use or limit you self to traditional or modern care? Put
in the respondents words. E.G. The sickness/injury was minor; what I did is the best for the kind of sickness
or injury; modern medicine does not work for this sickness/injury; modem failed; as supplement ( safe guard)
to other treatment modern not available. etc.
h) How was self or lay care usOO?
-Exclusively i.e. alone =
-alone
-Before other measures = before
-Concurrently with measures -= Co.
-After other measures =After
If combinations, put as such e.g. Before & Co. or Before 1; Mter.
QUESTION 6 DRUGS AT HOME
a) Write where the drug is put (exposed or not, accessible to children or not) and whether
kept clearly or not.
b) Name of drug: Write the name of drug in full.
-If modern write the name on the lable.
-If traditional or modern without lable, write name as given by respondant.
-If name is unknown put UK.
c) Use of the drug as given by the respondent in own terms. If more than one use, put all down separate by as
a) for fever
b ) stomach ache, etc.
d) For whom is the drug used for?
A = Adults only
B = For both adult and Children
C = For children only
e) Where form the family got the medication ( drug) ?
L = Relative, neighbor or any other lay person
M = Bought in drug shop or pharmacy by the family
T = Traditional practitioner
D = Bought in drug shop or pharmacy by the family
H = Given at hospital, health center or health station
Other = Specify
f) When did you obtain the drug or since when do you have it?
Put the date ( month, year) if possible. Otherwise put approximate time elapsed since obtained. (e.g. three
months, one year, etc.)
g) Quantity used during treatment i.e. how much of it do you use for treatment per day
and for how many days? put so Much per day x number or days e.g. 6 tablets x 5 (dropped after pretest).
ANNEXES
Socio-demographic and health information on:
1 .Ethiopia
2. Kirkos Kebele ( which includes Kebele 21/11) Addis Ababa
3. Zewai town
4. Adamitulu
have been summerized as background material for this study
but have not been included to limit the bulk of the report
to a reasonable size.
..