ASTUDYOFTHERELATIONBETWEENHEALTHATTITUDES,VALUESANDBELIEFSANDHELP‐SEEKINGBEHAVIOURWITHSPECIALREFERENCETOAREPRESENTATIVESAMPLEOFBLACKPATIENTSATTENDINGAGENERAL

HOSPITALby

BASILJOSEPHPILLAY

submittedinpartialfulfilmentoftherequirementsforthedegreeof

DOCTOROFPHILOSOPHY

intheSub‐DepartmentofMedicallyAppliedPsychology,FacultyofMedicine,UniversityofNatal

1993

ii

ABSTRACT

Thereisstrongevidencesupportingtheviewthatbeliefsandattitudesinfluencehealth

behaviour.Furthermore,culturalandsocialbeliefsalsohavebeenshowntoinfluencethe

wayhealthcarefacilitiesareused.Althoughwesternmedicineplaysadominantroleinthe

masscontrolofdisease,traditionalorfolkmedicinecontinuestoplayanimportantrolein

thehealthcareofblackcommunities.Theytherefore,possessuniqueattitudes,valuesand

beliefsabouthealthandillnesswhichintegrallyinfluencetheirhealthbehaviour.

Thisstudyaimsthereforeto:understandphenomenologicallytheurbanAfrican’s

perceptionofillness,diseaseandhealth;identifyattitudesthatdirectlyinfluencehealth

behaviour:identify“triggerfactors”thatprecipitatehealthactionandisolatefactorsthat

contributeto“negative”healthbehaviour.

Thesampleinthisstudyconsistedof3groupsofurbanAfricanswhowere20yearsand

older.Group1comprisedfirsttimeattenderstoamedicaloutpatientsdepartmentGroup2

andGroup3weresamplegroupsdrawnfromtheUmlaziTownshipandtheKwaMashu

Townshiprespectively.TheHealthandIllnessBatteryinthelanguageoftheparticipants

wereadministeredbytrainedinterviewers.

Thisstudyhasdemonstratedthefollowing:urbanAfricanshaveapersonalconceptionof

illness,healthanddiseasethatinfluencestheirmannerofhelp‐seeking;therearecertain

attitudesandbeliefsthatdirectlyinfluencebothpositiveandnegativehealthbehaviour;.

thereareseveralhealthbeliefswhichinteractinacomplexwayandmayleadtomedical

help‐seeking.Healthactionwasfoundtobeinfluencedbysignificantindividualsinthe

subject'senvironment;demographicvariables,suchas,age,sex,educationandurbanisation

stronglyinfluencethehealthandillnessbeliefs;theseresultsvalidatedsomeofthe

iii

fundamentalaspectsofthecommonwesternhealthandillnessmodels;theuseofservices

andfacilitiesaredeterminedbythelocation,accessibilityandthequalityofservices;

financialcosts,time,transport,lackofcommunitysupports,negativelyaffectedhelp‐

seeking;symptomshavebeenidentifiedasa“triggerfactor”ofhelp‐seeking.Individualsuse

otherformsoftreatmentsindependentofmedicaltreatments.Amodelofhelp‐seekingfor

urbanAfricansisproposed.

iv

PREFACE

Thisstudyrepresentsoriginalworkbytheauthorandhasnotbeensubmittedinanyformto

anotherUniversity.Whereusewasmadeoftheworkofothersithasbeenduly

acknowledgedinthetext.

ThisresearchdescribedinthisthesiswascarriedoutatKingEdwardVIIIHospital,Durban,

SouthAfricaandintheSub‐DepartmentofMedicallyAppliedPsychology,Departmentof

Psychiatry,FacultyofMedicine,UniversityofNatal,underthesupervisionofProfessorL

Schlebusch.

Inthisresearchthestatisticalplanningandanalysis,andrecommendationsarisingfrom

theseanalyses,havebeendonewiththesupportoftheInstituteforBiostatisticsofthe

MedicalResearchCouncil.ThisresearchwasalsopartiallyfundedbyaMedicalResearch

CouncilPostGraduateScholarship.

v

ACKNOWLEDGEMENTS

Iamindebtedtomanypeoplewhohavegreatlyassistedmyresearchandsupportedme

duringthepreparationofthisthesis.

ImustespeciallythankmypromoterProfessorL.Schlebusch,ProfessorandHeadofthe

Sub‐DepartmentofMedicallyAppliedPsychology,FacultyofMedicine,UniversityofNatal,

whoseadviceandcontinuedsupportIhavegreatlybenefitedfrom.

TheotherswhoImustmentionare:

ProfessorW.H.Wessels,ProfessorandHeadofPsychiatry,FacultyofMedicine,University

ofNatal.

DrA.J.Lasich,DeputyHeadofPsychiatry,FacultyofMedicine,UniversityofNatal.

DrM.Nair,PrincipalPsychiatristandHeadofPsychiatry,KingEdwardVIIIHospital.

DrJ.Ndlovu,Psychiatristinprivatepractice.

DrT.Mayekiso,SeniorLecturerandClinicalPsychologist,DepartmentofPsychology,

UniversityofTranskei,Transkei.

vi

MsR.Eiselen,SeniorLecturerandStatistician,DepartmentofStatistics,UniversityofSouth

Africa.

DrP.J.BeckerandMsE.Gouws,InstituteforBiostatisticsoftheMedicalResearchCouncil,

Durban.

ThesuperintendentsofKingEdwardVIIIHospitalforpermissiontoconductthisresearchin

thehospital.

MrB.Rortarg,TownPlanner,ScottWilsonKirkpatrickAssociates,Durban.

MrE.N.Iyer,TownPlanningTechnician,PaulMitkula&Associates,Durban.

DrL.Khan,SeniorLecturer,DepartmentofLandSurveying,UniversityofNatal.

MsL.RichmanandMrD.R.Sawyer,CentralStatisticalService,Durban,Departmentof

HomeAffairs.

NazereneJob,DianneJob,SelvumJ.Abel,RobinAbel,JenniferS.Madhan,JennetS.Hansen,

GeraldJPillay,NirmalaPillayandMarkNaidoo

Mymumandlatedadfortheirsupportandencouragement

Mywife,Cecilia,andchildren,Loren‐JosephandCassandraSuminthra,Iamalwaysgrateful

fortheirpatience,encouragementandsacrificesinorderformetocompletethisresearch.

vii

TABLEOFCONTENTS

CHAPTER1

INTRODUCTION ...................................................................................................................... 1

CHAPTER2

PSYCHOLOGYANDHEALTH .................................................................................................... 8

2.1PSYCHOLOGICALCONCEPTSINHEALTHANDILLNESS ....................................... 12

2.1.1 HEALTH,ILLNESS,ANDDISEASE......................................................... 12

2.1.2 SOMESPECIFICTYPESOFHEALTHBEHAVIOUR................................. 14

2.1.2.1PreventativeBehaviour ......................................................... 14

2.1.2.2HealthProtectiveBehaviour.................................................. 15

2.1.2.3IllnessBehaviour .................................................................... 15

2.1.2.4SickRoleBehaviour................................................................ 16

2.2HEALTHBELIEFS,ATTITUDESANDVALUES......................................................... 17

2.3MODELSOFHEALTH‐RELATEDBEHAVIOUR ....................................................... 18

2.3.1 THEHEALTHBELIEFMODEL............................................................... 18

2.3.2 KASLANDCOBB'SMODEL ................................................................. 20

2.3.3 SUCHMAN'SMODEL ......................................................................... 21

2.3.4 FABREGA'SMODEL ............................................................................ 23

2.3.5 MECHANIC'SMODEL.......................................................................... 24

viii

2.3.6 ANDERSEN'SMODEL.......................................................................... 26

2.3.7 SOCIALLEARNINGTHEORY ................................................................ 26

2.4CRITICALISSUESINHEALTHBEHAVIOUR............................................................ 29

2.4.1 PERSONALANDDEMOGRAPHIC........................................................ 29

2.4.2 HEALTHBELIEFS ................................................................................. 31

2.5SOCIALSUPPORTANDHEALTH........................................................................... 32

2.6SYMPTOMSANDSYMPTOMPERCEPTION.......................................................... 33

2.7LIFEEVENTS,STRESSANDILLNESS ..................................................................... 34

CHAPTER3

HEALTHINSOUTHAFRICA..................................................................................................... 40

3.1CULTURALINFLUENCESONHEALTH................................................................... 44

3.2AETIOLOGYOFILLNESSINTHEAFRICANWORLDVIEW ..................................... 47

3.2.1 EnvironmentalImbalance.................................................................. 47

3.2.2 SorceryandIllness ............................................................................. 48

3.2.3 AncestorsandIllness ......................................................................... 49

3.2.4 Umnyama andIllness......................................................................... 51

3.3ILLNESS,SICK‐ROLEANDHELP‐SEEKINGBEHAVIOUR........................................ 52

3.4TRADITIONALTREATMENTS ............................................................................... 54

CHAPTER4

METHOD ............................................................................................................................... 57

4.1SUBJECTS ............................................................................................................ 57

4.1.1 GeneralHospitalGroup ..................................................................... 60

4.1.1 CommunityGroups............................................................................ 61

4.2METHODOFDATACOLLECTION......................................................................... 62

4.2.1 HospitalGroup................................................................................... 62

ix

4.2.2 CommunityGroup ............................................................................. 63

4.3MATERIALS.......................................................................................................... 64

4.3.1 HealthandIllnessQuestionnaire(HIQ) ............................................. 65

4.3.2 HealthBeliefQuestionnaire(HBQ) .................................................... 66

4.3.2.1ConstructionofQuestionnaire .............................................. 67

4.3.3 SocialSupportQuestionnaire(SSQ)................................................... 67

4.3.3.1ConstructionofQuestionnaire .............................................. 68

4.3.4 SymptomInventory(SI) ..................................................................... 69

4.3.5 LifeExperienceSurvey(LES) .............................................................. 70

4.4TRANSLATIONOFQUESTIONNAIRES .................................................................. 70

4.5PILOTSTUDY ....................................................................................................... 72

CHAPTER5

RESULTS................................................................................................................................. 73

5.1DEMOGRAPHICDATA ......................................................................................... 73

5.2TIMEANDTRANSPORTCOSTSOFHOSPITALPATIENTS ..................................... 83

5.3HELPSEEKINGBEHAVIOUROFHOSPITALPATIENTS .......................................... 83

5.3.1 ChoiceofDaytoAttend..................................................................... 84

5.3.2 Patient'sFirstSuspicionsofIllnessandAttendance.......................... 84

5.3.3 PatientsReasonsfornotAttendingEarlier........................................ 87

5.3.4 Feelingsorexperiencesthatsuggestedtothepatientsthat

theywereIll ....................................................................................... 87

5.3.5 IllnessDisclosure................................................................................ 89

5.4SERVICES ............................................................................................................. 90

5.4.1 Choiceofdoctor,hospitalandpharmacybythecommunity

groups. ............................................................................................... 90

5.5SUBJECTSPERCEPTIONSOFTREATMENT ........................................................... 95

5.6RELIGIOUSANDCULTURALBELIEFS.................................................................... 99

5.7HEALTHANDILLNESSBELIEFS(QUALITATIVERESPONSES) ............................... 105

x

5.7.2 Whatdoesitmeantobesick?.......................................................... 106

5.7.3 Whatdoesitmeantobeill?............................................................. 107

5.7.4 Whatdoesitmeantobewell? ........................................................ 107

5.8ILLNESSBEHAVIOUR ...................................................................................................... 113

5.9HEALTHANDILLNESSBELIEFS ........................................................................... 114

5.10SOCIALSUPPORT............................................................................................. 134

5.10.1 Comparisonsofgroupsonaccessibilityandproximity..................... 139

5.11SYMPTOMPERCEPTIONS................................................................................. 145

5.12SUBJECTSRATINGOFSEVERITYOFSYMPTOMS............................................. 149

5.13EXPERIENCESTRESSORSANDLIFECHANGES .................................................. 151

CHAPTER6

DISCUSSION.......................................................................................................................... 163

6.1HELPSEEKINGBEHAVIOUROFHOSPITALSUBJECTS ......................................... 167

6.2USEOFSERVICESBYCOMMUNITYGROUPS...................................................... 171

6.3HEALTHANDILLNESSBELIEFS(QUALITATIVE)................................................... 178

6.4THEHEALTHANDILLNESSBELIEF(QUANTITATIVE) .......................................... 180

6.5SOCIALSUPPORTANDHEALTH.......................................................................... 188

6.6SYMPTOMPERCEPTIONS................................................................................... 192

6.7STRESSANDHELPSEEKINGBEHAVIOUR ........................................................... 193

6.8ACOMPARISONOFTHERESULTSWITHOTHERHEALTHANDILLNESS

MODELS ........................................................................................................ 195

6.9TOWARDSAMODELOFHEALTHANDILLNESS................................................. 197

6.10SUMMARYANDCONCLUSION......................................................................... 201

REFERENCES ......................................................................................................................... 207

xi

APPENDIX ............................................................................................................................. 231

xii

LISTOFTABLES

TABLEI

DISTRIBUTIONOFSAMPLEBYSEX ........................................................................................ 57

TABLEII

SAMPLESELECTIONFORHOSPITALGROUP .......................................................................... 63

TABLEIII

AGEDISTRIBUTIONOFGROUPS ............................................................................................ 75

TABLEIV

ETHNICDISTRIBUTION........................................................................................................... 76

TABLEV

EDUCATIONALLEVELOFGROUP........................................................................................... 76

TABLEVI

YEARDISTRIBUTIONOFURBANLIVING................................................................................. 77

TABLEVII

DESTINATIONSOFHOSPITALSUBJECTS ................................................................................ 80

TABLEVIII

xiii

SUBJECTSOCCUPATIONS....................................................................................................... 81

TABLEIX

ILLNESSPRECIPITATIONANDATTENDANCETOHOSPITAL ................................................... 85

TABLEX

LOCATIONOFDOCTOR.......................................................................................................... 90

TABLEXI

REASONSFORCHOOSINGADOCTOR ................................................................................... 91

TABLEXII

CHOICEOFHOSPITAL ............................................................................................................ 92

TABLEXIII

REASONSFORCHOOSINGAHOSPITAL ................................................................................. 93

TABLEXIV

CHOICEOFPHARMACY.......................................................................................................... 94

TABLEXV

REASONSFORCHOOSINGAPHARMACY............................................................................... 94

TABLEXVI

SUBJECTSPERCEPTIONSOFTREATMENT.............................................................................. 95

TABLEXVII

TREATMENTFACTORSSUBJECTSWEREPLEASEDABOUT..................................................... 96

TABLEXVIII

TREATMENTFACTORSSUBJECTSWERENOTPLEASEDABOUT............................................. 96

xiv

TABLEXVIX

SOURCESOFMEDICATION .................................................................................................... 97

TABLEXX

SUBJECTSPERCEPTIONSOFWESTERNMEDICINES............................................................... 98

TABLEXXI

REASONSFORTAKINGVITAMINS.......................................................................................... 99

TABLEXXII

RELIGIOUSANDCULTURALBELIEFS ..................................................................................... 100

TABLEXXIII

USEOFTRADITIONALHEALERS. ........................................................................................... 101

TABLEXXIV

TREATMENTGIVEN.............................................................................................................. 101

TABLEXXV

FREQUENCYOFVISITSTOTRADITIONALHEALERS............................................................... 102

TABLEXXVI

SUBJECTSPERCEPTIONSOFTHEEFFECTIVENESSOFTRADITIONAL

TREATMENT.......................................................................................................................... 103

TABLEXXVII

CONTINUATIONOFTRADITIONALTREATMENT................................................................... 103

TABLEXXVIII

PRAYERASATREATMENTFORILLNESS ............................................................................... 104

xv

TABLEXXIX

CONSULTATIONOFHERBALISTS........................................................................................... 104

TABLEXXX

USEOFTRADITIONALOR“LAY”SUBSTANCES...................................................................... 105

TABLEXXXI

MEANINGOFBEINGILL........................................................................................................ 108

TABLEXXXII

MEANINGOFBEINGWELL ................................................................................................... 109

TABLEXXXIII

INDICATORSOFBEINGWELL............................................................................................... 110

TABLEXXXIV

INDICATORSOFBEINGILL .................................................................................................... 111

TABLEXXXV

REASONSPEOPLEGETSICK/ILL ........................................................................................... 112

TABLEXXXVI

ILLNESSBEHAVIOUROFSUBJECTS ....................................................................................... 114

TABLEXXXVII

COMPARISONSOFGROUPSRESPONSESONHBQITEMS(IN%) ........................................ 115

TABLEXXXVIII

MEANSANDSTANDARDDEVIATIONSOFEACHHBQITEMFORGROUP ............................. 127

TABLEXXXIX

xvi

FACTORANALYSISOFTHEHBQ(COMBINED) ...................................................................... 128

TABLEXL

MEANFACTORSCORESONTHENINEFACTORSRELATINGTOHEALTHBELIEF ................... 133

TABLEXLI

COMPARISONSOFSSQITEMSBETWEENGROUPS(in%) .................................................... 135

TABLEXLIV

MEANSANDSTANDARDDEVIATIONSOFSSQITEMSBYGROUPS ...................................... 139

TABLEXLII

ANOVAOFACCESSIBILITYANDPROXIMITY ......................................................................... 140

TABLEXLIII

DUNCAN'SMULTIPLERANGETEST....................................................................................... 141

TABLEXLV

FACTORANALYSISOFTHESSQ(COMBINED) ....................................................................... 142

TABLEXLVI

MANOVAONFACTOR1OFSSQ........................................................................................... 144

TABLEXLVII

MANOVAONFACTOR2OFSSQ........................................................................................... 145

TABLEXLVIII

EXPERIENCEOFSYMPTOMSBYEACHSUBJECTBYGROUP.................................................. 146

TABLEXLIX

MEANANDSTANDARDDEVIATIONOFSEVERITYOFSYMPTOMS ...................................... 149

xvii

TABLEL

EXPERIENCEOFSTRESSORPERGROUP................................................................................ 152

TABLELI

EXTENTOFIMPACTPERGROUP........................................................................................... 156

TABLELII

MANOVAOFTOTALLIFEEXPERIENCESBETWEENGROUPS................................................ 160

TABLELIII

DUNCAN'SMULTIPLERANGETEST....................................................................................... 160

TABLELIV

MANOVAOFNEGATIVELIFEEXPERIENCESBETWEENGROUPS.......................................... 161

TABLELV

DUNCAN'SMULTIPLERANGETESTONNEGATIVELIFEEXPERIENCES.................................. 161

TABLELVI

MANOVAONPOSITIVELIFEEXPERIENCESBETWEENGROUPS........................................... 161

TABLELVII

DUNCAN'SMULTIPLERANGETESTONPOSITIVELIFEEXPERIENCES ................................... 162

xviii

LISTOFFIGURES

Figure1 Conventionalstress‐vulnerabilitymodel ....................................................... 37

Figure2 Elaboratestressmodel .................................................................................. 39

Figure3 TheAfricanconceptofillness........................................................................ 45

Figure4 Sampledistribution ....................................................................................... 58

Figure5 Male‐femaledistributionofthesample........................................................ 59

Figure6 Agedistributionofgroups ............................................................................. 74

Figure7 Educationlevelofgroups .............................................................................. 78

Figure8 Numberofyearslivinginanurbanarea ....................................................... 79

Figure9 Occupationofsubjects .................................................................................. 82

Figure10 Illnessprecipitationandattendancetothehospital ..................................... 86

Figure11 Reasonsfornotattendingthehospitalearlier .............................................. 88

Figure12 ModelofAfricanhelpseekingbehaviour..................................................... 198

xix

GLOSSARY

χ2 ChiSquare

ANC AfricanNationalCongress

ANOVA AnalysisofVariance

CAT ComputerisedAxialTomography

df DegreesofFreedom

Dx Disease

ECG Electrocardiogram

EEG Electroencephalogram

HBM HealthBeliefModel

HBQ HealthBeliefQuestionnaire

HIB HealthandIllnessBattery

HIQ HealthandIllnessQuestionnaire

IFP InkathaFreedomParty

Km Kilometre

LES LifeExperienceSurvey

MANOVA MultivariateAnalysisofVariance

MEDUNSA TheMedicalUniversityofSouthernAfrica

Mn Mean

MRC MedicalResearchCouncil

NAMDA NationalMedicalandDentalAssociation

NEHAWU NationalEducation,HealthandAlliedWorkersUnion

p pvalue

PASA PsychologicalAssociationofSouthAfrica

SD StandardDeviation

xx

SI SymptomInventory

SSQ SocialSupportQuestionnaire

USA UnitedStatesofAmerica

Rx Treatment

Zuluwordsusedinthisthesisareexplainedinthetext.

Boththeterms"black"and"African"willappearinthisthesisandrefertoBlackSouth

Africans."Black"isusedininstances,suchas,"blackgroups"or"blackcommunity"and

"African"isusedmainlyinreferencestothetraditionalAfricanworld‐viewandtoaspects

ofAfricancosmology,asin,"Africanmedicine","Africanillness"and"Africanhealers".

1

CHAPTER1

INTRODUCTION

ThehealthsystemofSouthAfricahasreceivedheightenedattentionbothlocally(Daily

News,9March1990;NationalMedicalandDentalAssociation[NAMDA],1987),and

internationally(AnderssonandMarks,1988;Zwi,MarksandAndersson,1988),largely

becauseithasbeenstronglyinfluencedbythepoliticalsysteminthecountrybasedon

racialseparation.ThehealthserviceshereareacombinationofbothFirstandThirdWorld

medicalpractice.Thesolutionssuggestedwithregardtotheunificationofhealth

departmentsandtheimprovementofthehealthsystemhavemainlydealtwithissues

suchaspoliticalchange,thesharingofpoliticalandeconomicpowerandtheequalization

ofeducation,housing,employmentandwages.Allthesechangeshavedirect

consequencesforthehealthcare(Price,1988)andwouldhavetheeffectofequalizing

healthcarefacilitiesandovercomingpresentobstaclestoeffectivecare,suchas,the

affordabilityofhealthcareandthemaldistributionofhealthworkersandfacilities.

Butthereisanother,lessobvious,obstaclethatendemicallyaffectsthecareandhealing

processwhichcannotbeignoredinthepresentconcerntoimprovethehealthsystem.

ForthemajorityoftheSouthAfricanpopulation,whoareblackandsociallydisinherited,

thepracticeofwesternmedicineis“alien”inmanyways.Thisgrosslyneglectedareahas

todowithanaspectofthepsychologicaldimensionofhealthandisthesubjectofthis

study.Inordertoobtainmaximumutilisationandbenefitofthehealthsystemitisof

2

primeimportancetounderstandtheblackpatient'svieworpsychologicalperceptionof

healthandillness.Althoughwesternmedicineplaysadominantroleinthemasscontrolof

disease,traditionalorfolkmedicinecontinuestoplayanimportantroleinthehealthcare

ofblackcommunitieshereandintherestofAfrica.Individuals,inblackcommunities,

therefore,possessuniqueattitudes,valuesandbeliefsabouthealthandillnesswhich

integrallyinfluencetheirhealthbehaviour.Healthbehaviour,accordingtoStone(1979),is

agenerictermusedtoreferto“allmolarbehaviourthatisguidedbyhealthpurposesor

reinforcedbyhealthoutcomes”(p.24).KaslandCobb(1966a,1966b)suggestthathealth

behaviourcanbedifferentiatedintopreventativehealthbehaviour(actionstakento

preventillness),illnessbehaviour(actionstakenaftersymptomsareexperienced)andsick

rolebehaviour(actionsafterdiagnosis).[Thesecategoriesofhealthbehaviourwillbedealt

withingreaterdepthinChapterTwo].

Thereisstrongevidencesupportingtheviewthatbeliefsandattitudesinfluencehealth

behaviour.Forexample,Lewisetal.(1976)andMechanic(1976a,1976b,1976c)have

shownthathealthcarefacilitiesaredirectlyaffectedbyfactorssuchasdominantbelief

aboutillnessandthestigmaassociatedwithseekinghelp.Theclinicaldiagnosisofillnessis

notalwaysrelatedtothepatient'ssubjectiveresponsetotheirsymptomsand“feeling

better”maybeassociatedwitheventswhicharequiteindependentofprofessional

treatment(Knowles,1977).[TheseaspectsareexploredfurtherinChapterTwounder

“Beliefs,AttitudesandValues”].

Thewayindividualsinterprettheirsymptomsofanillnessisanessentialstepinthe

processofseekinghelpandofthehealingprocessitself.Frequently,theseinterpretations

haveledtomanysymptomseitherbeingignoredorgoinguntreated(Mechanic,1978;

Pennebaker,1982;RoghmanandHaggerty,1972).Bishop'sstudy(1984)oflayresponses

toillness(refertoChapterTwo,sub‐section“Health,IllnessandDisease”fordefinitionof

illness)illustratedtheproblemofserioussymptomsgoingunnoticedbecausetheyfellout

ofthepurviewofthepatient'sinterpretationastowhatwasgoingon.[Thisaspectof

symptominterpretationisdealtwithinChapterTwounder“SymptomInterpretationand

HealthBehaviour”].

3

Furthermore,culturalandsocialbeliefsalsohavebeenshowntoinfluencethewayhealth

carefacilitiesareused.Ngubane(1977),indiscussingmodelsofillnessamongZulus,noted

thedistinctionmadeinZulusocietybetweenillnessesthatareuniversalandtreatable

biomedically(umkhuhlane)andthosewhichmayrequireritualisedandindigenous

methodsofhealing(ukufa Kwabantu‐“diseaseoftheAfricanpeople”).Thisdistinction

between“African”and“non‐African”illnessesisoftenalludedto(CheetamandCheetam,

1976;Edwardsetal.1983;Wessels,1984a).However,asMills(1983,1985)indicates,

someillnessessuchastuberculosismaybeunderstoodpurelybiomedicallyinsome

contextsandashavingAfricanelementsinothers.Ngubane(1977)observedthatthe

conceptsofecologyarecentraltotheZuluideaofhealth.Explanationsofillhealthmay

oftenlieininterpretationsofenvironmentalimbalancescreatedbysorcery(ubuthakathi)

ordisturbancesinthesocialorder.[Theseaspectsandtheroleofculturearetreatedmore

fullyinChapterThree].

Itappearsthatagreatdealofthehealthcareoccursquiteindependentlyofthe

formalisedhealthcaresystem(ChristmanandKleinman,1983).AccordingtoMills(1985),

thereisarangeofnon‐formalandsocio‐culturalresourcesforillnessmanagement

availableincommunities.Popularhealthcare(givenbyfamily,friendandothermembers

ofthecommunity)andfolkmedicine(whichincludetheformalisedculturalexperienceof

healing,faithhealers,traditionalhealersandpriests),arestillconsideredmoresignificant

thantheformalisedwesternhealthservices.

Theattitudesthatpeopleholdabouthealthareclearlyimportanttohealthcareitself.

Someresearchershaveevenarguedfordifferingmodesofservicesbasedondifferent

viewsofillness(Millon,1982).Changesintheattitudesofhealthandillnesswill,inturn,

haveadirecteffectonthehealingprocessitself.Oneexampleisthe“germtheoryof

illness”whichdirectlyledtochangesintheattitudestotheuseofsterilemedical

procedures,improvementofsanitationandpersonalhygiene(Clymeretal.,1984).

[Cultural,popularandfolkmedicinesarediscussedinChapterThreetogetherwithcertain

otherrelatedissues].

4

Althoughthereisanabundanceofresearchintothisaspectofhealthcareworld‐wide,

verylittlehasbeendoneinAfricancommunities,andthisdearthofresearched

informationistrueforSouthAfricaaswell.Inthisstudy,therefore,thefocusisonthe

relationbetweenhealthattitudes,valuesandbeliefsandaspecificareaofhealth

behaviour,namely,“helpseekingbehaviour”or“healthaction”inurbanAfricans.The

attemptisalsomadetogainanunderstandingofurbanAfricanbeliefs,attitudesand

valuesabouthealthandillnessandtoseehowthesebeliefs,attitudesandvalues

influencetheirhealthbehaviouraswellastheuseofhealthcarefacilities.Inaddition,

relatedurbanAfricanhealthandillnessissues,suchas,symptomsandsymptom

interpretation,theinfluencesofculturalandsocialbeliefsontheuseofhealthcare

facilities,theroleofpopularhealthcareandfolkmedicine,theroleofsocialsupportin

theseekingofmedicalhelpandtheeffectsoflifechangesorstressesonhelp‐seekingare

alsoinvestigated.Inthisconnection,theexistinghealthandillnessmodelsarecompared

andanAfricanmodelforhelp‐seekingbehaviourisproposed.

AstudyofthiskindhasdirectrelevanceforboththeSouthAfricancontextandother

“ThirdWorld”countries.Itwillassistinthedevelopmentofhealtheducation

programmes;planningofhealthfacilities;thetimeouspromotionofhealthaction;the

controlofdiseaseandtheraisingofthehealthstatusofthepopulation.However,itisits

contributiontomedicalpsychologythatistheimmediateobjective.Ihavebeenespecially

interestedinitsdirectbenefitforclinicalpsychologists,especiallythoselikemyselfwho

workinageneralhospitalsettinglikethepioneeringSub‐DepartmentofMedicallyApplied

PsychologyunitattheKingEdwardVIIIHospitalinDurban,SouthAfrica.

Insummary,thisstudyaimsto:

1 understandphenomenologicallytheurbanAfrican’sperceptionofillness,

diseaseandhealth;

2 identifyattitudesthatdirectlyinfluencehealthbehaviour;

5

3 studytherelationshipbetweenthekeyattitudesthatinfluencehealth

behaviour,andotherrelevantenvironmental,socialandpsychological

factors;

4 identify“triggerfactors”thatprecipitatehealthaction;

5 isolatefactorsthatcontributeto“negative”healthbehaviour;

6 assessthevalidityofexistingmodelsofhealthandillnessforthesample

studied;and

7 understandtheprocessunderlyingtheassociationofsymptomstodisease

andtheinterpretationsgiventosymptoms(i.e.theunderstandingof

illness).

Inordertoachievetheaboveaims,thefollowinghypotheseswillbetestedina

representativesampleofurbanAfricansdrawnfrombothaclinicalandgeneral

population:

1 thatthesubject'spersonalconceptionofillnessstronglyinfluencesthe

mannerorwayofseekinghelp;

2 thatcertainattitudesdirectlyinfluencepositiveand/ornegativehealth

behaviour;

3 thatcertaineventsinthesubject'senvironmentcontributetotheseeking

ofhelp;and

Trigger factors refer to factors, such as, circumstances, events, cognitions or sensations.

6

4 thathealthactionisinfluencedbysignificantindividualsinthesubject's

environment.

Thisthesisisorganisedinthefollowingway.InChaptersTwoandThreenecessary

backgroundinformationandareviewofthepertinentliteratureispresented.Chapter

Twoalsoprovidesabriefhistoryofpsychologyanditsinvolvementinhealthandillnessas

wellasadescriptionofvarioustermsanddefinitionsthathaveemergedfromthis

relationship.Alsoprovidedinthischapteraredefinitionsofthepsychologicalconceptsin

healthandillnessthatwillbeusedthroughoutthisthesis.Toprovidesomeperspectiveon

health‐relatedbehaviourareviewofsomeofthemorepopulartheoreticalmodelsof

health‐relatedbehaviourfollows.Finally,areviewofsomeofthecriticalissuesinhealth

behaviourareprovided.

ChapterThreedealswithissuesspecifictotheSouthAfricancontext.Theseincludeissues

suchashealthinSouthAfrica,culturalinfluencesonhealthwithspecialreferencetothe

aetiologyofillnessintheAfricanworld‐viewandtraditionaltreatments.

InChapterFourthemethodologyofthisstudyispresented.Adescriptionofthesubjects,

theselectionofthesampleandthematerialsusedinthestudyarethendescribed.Other

issues,suchas,thechoiceofthequestionnairesused,thevalidationofthequestionnaire

andproblemsexperiencedtogetherwithavailablemeasurementsfollow.

TheresultsandtheanalysisofthedataappearinChapterFive.Theresultsarepresented

mostlyintabularand,wherevernecessary,ingraphicalform(Briscoe,1990),intheorder

itwasobtainedfromtheHealthandIllnessBattery(HIB)sothattheyareeasily

comprehensibleandallowforeasycomparison.Theresultssectionsummarisesthedata

collectedandtheirstatisticalanalysis.

InChapterSix,thediscussionsection,themainfindingsareexaminedandinterpreted.

Finally,themainconclusionsandthetheoreticalimplicationsofthestudyarepresented.

See chapter four “Method of Data Collection” for a description of the HIB.

7

8

CHAPTER2

PSYCHOLOGYANDHEALTH

Althoughthehistoryofpsychologymaybetracedtotheperiodofearlycivilisation(Kimble

andSchlesinger,1985a,1985b),asascientificdisciplineitcoversaperiodjustovera

century(Brennan,1986).Likemanyoftheothersciences,psychologyoriginatedin

philosophyandemergedasaseparatedisciplineinthelatenineteenthcentury.Itwas

initiallyconcernedwithsensationsandperceptionsbutthereaftermovedtothestudyof

humanbehaviourandbecamemore“applied”.Oneofthefirstappliedsub‐specialities

wasclinicalpsychology.Althoughthebeginningofclinicalpsychologyismarkedbythe

foundingofthefirstAmericanpsychologicalclinicin1896byWitmer,itwasonlyinthe

1940'sthatitbecomeawellorganizedandrecognizedacademicdiscipline.Intheearly

1970'sfurtherspecializationtookplacewithinpsychologywithpsychologistsbecoming

moreinvolvedinareasofhealthandillness.Thisinvolvement,however,shouldnotbe

construedasatotallynewphenomenonbutratherasare‐newedinterest.

Thecombinedroleofpriestandhealer,philosopher,scholarandteacher,howeveris

mucholderandremainsaphenomenonstillcommonintraditionalsocietiesandinthe

practiceoftraditionalmedicine(Schlebusch,1990).

Psychologists'interestinhealthandillnesshasledtonewchallengesandopportunities

andhascontributedtoatransformationoftheirtraditionalrole.Howardetal.(1986)

notedthat53.2percentofnewpsychologydoctoratesin1984wereinthehealthservice

providersubfields.Theseauthorsalsopointoutthatnotonlyhastherebeenadramatic

riseintheemploymentofpsychologistsinthehealthservice,butthattherehasalsobeen

arelateddeclineintheiracademicandresearchroles.Furtherevidenceforthisoverall

rateofgrowthofpsychologicalinterestintheareaofhealthistheincreasedemployment

9

ofpsychologistsinmedicalandhealthcarepositions;theriseinmembershiptobodies

suchasTheAmericanPsychologicalAssociationinthedivisionsofHealthPsychologyand

Neuropsychology;theincreaseintheamountofliteraturepublishedintheareaandthe

riseinthenumberofpsychologistsemployedatmedicalschools(GentryandMatarazzo,

1981;Millon,1982;Sweet,etal.1991).SimilarchangeshaveoccurredintheUnited

Kingdomaswell(Nicholas,1983).

InSouthAfricanasimilartrendistakingplace.Therehasbeenthedevelopmentofclinical

psychologicalservicesingeneralhospitals(Schlebusch,1983a,1983b;Schlebusch,1987;

Schlebusch,PillayandLouw,1989;Pillay,SchlebuschandLouw,1992);thetrainingof

internsinclinicalpsychologyatgeneralhospitals(Schlebusch,1983b,1989);the

establishmentofteachingprogrammesatmedicalschoolsinmedicalpsychology,clinical

healthpsychologyandbehaviouralmedicine(Schlebusch,1989);thedevelopmentof

employmentopportunitiesintheseareasandplannedfuturedevelopmentinacademic

hospitals(Schlebusch,1987;1989).However,thesedevelopmentsvaryconsiderably

withinthecountry(Schlebusch,1989,1990).Insomeprovinces,forexample,Natal,a

fairlywellestablishedserviceexistsinhospitals,suchas,KingEdwardVIIIHospital(alarge

teachinghospitalattachedtotheUniversityofNatalMedicalSchool)andAddington

Hospital.TheNatalUniversity'sMedicalFacultywasthefirstSouthAfricanmedicalschool

toestablishadepartmentofaMedicallyAppliedPsychologywiththeappointmentofa

fullprofessorshipinthisfield(SchlebuschandWessels,1986).ElsewhereinSouthAfrica,

clinicalpsychologyattheteachinghospitalsoperateswithintheDepartmentsof

Psychiatrywithprincipalpsychologistsasclinicalheads.AnexceptionisTheMedical

UniversityofSouthernAfrica(MEDUNSA)inGarankuwa,whichhastwodepartmentsof

psychology.Oneofthesedepartmentsteachesgeneralpsychologyandtheothertrains

clinicalpsychologists.Morerecently,thePsychologicalAssociationofSouthAfrica(PASA)

feltitnecessarytodevelopaDivisionofHealthPsychology.

Notonlyarepsychologistsfromallsub‐disciplines(e.g.clinical,social,academic,etc)

showingagreaterinterestinhealthandillness,others,suchas,socialworkers,

occupationaltherapists,psychiatristandmedicalpractitionersarealsoshowingagrowing

10

interestinpsychologicalprinciplesandconceptsfortheirwork.Theiremphasesand

practicesnaturallyvary.Theattemptbytheseinterandintra‐disciplinestodefinetheir

workhasledtoaplethoraoftermsanddefinitions;Forexample,“healthpsychology”,

“clinicalhealthpsychology”,“medicalpsychology”,“behaviouralmedicine”,“psychological

medicine”,“psychosomaticmedicine”,“behaviouralhealth”and“healthbehaviour”.The

similaritiesanddistinctionsbetweenthesetermsarenotalwaysclearandattimesthey

areinappropriatelyused.Broadlyspeaking,theseareascanbedividedintothosethat

arediscipline‐specificandthosethataremulti‐disciplinary(Schlebusch,1990).Areassuch

aspsychosomaticmedicine,psychologicalmedicineandconsultation‐liaisonpsychiatryare

allsub‐specialitiesofpsychiatryandusuallyinvolveprofessionalstrainedinmedicineand/

orpsychiatry.Clinicalpsychology,rehabilitationpsychology,healthcarepsychology,

generalhospitalpsychology,neuropsychologyandhealthpsychologyarespecifictothe

disciplineofpsychologyandinvolveprofessionalstrainedinpsychology.Otherareassuch

asbehaviouralmedicine,behaviouralhealthandhealthbehaviouraremultidisciplinary.

Someareasarebroadlydefinedwhileothersaremuchmorespecific.Forexample,health 

psychology,whichisdisciplinespecific,isdefinedas:

theaggregateofthespecificeducational,scientificandprofessional

contributionsofthedisciplineofpsychologytothepromotionand

maintenanceofhealth,thepreventionandtreatmentofillness,the

identificationofetiologicanddiagnosticcorrelatesofhealth,illnessand

relateddysfunction,andtheanalysisandimprovementofthehealthcare

systemandhealthpolicyformation(Matarazzo,1982,p.4).

Itisevidentfromthisdefinitionthathealthpsychologyembracesanyactivityof

psychologyrelatingtoanyaspectofhealth,illness,healthcaresystemorhealthpolicy

formation.Clinicalhealthpsychology,ontheotherhand,ismorespecific,accentuating

thesignificantrelationshipbetweenclinicalpsychologyandhealthpsychology

(Schlebusch,1990).

11

Insomeinstances,healthpsychologyissometimeserroneouslyusedtoreferto

behaviouralmedicine.Thisisgrosslyinaccuratesincebehavioural medicine accordingto

SchwartzandWeiss(1978)isdefinedasthe

interdisciplinaryfieldconcernedwithdevelopmentandintegrationof

behaviouralandbiomedicalscience,knowledgeandtechniquesrelevantto

theunderstandingofphysicalhealthandillnessandtheapplicationofthis

knowledgeandthesetechniquestoprevention,diagnoses,treatmentand

rehabilitation(citedinGochman,1988).

Essentially,behaviouralmedicineisthe‘interface’ofthebehaviouralandbiomedical

sciences.

Anemerginginterdisciplinaryfieldwhichisstillintheprocessofestablishingitsidentity

andwhichisparticularlyrelevantforthisstudy,is  health behaviour.Amoreconcise

definitionthanthatusedearlier(Stone,1979)isthatofGochman(1982)whodefines

healthbehaviouras

thosepersonalattributessuchasbeliefs,expectations,motives,values,

perceptionsandothercognitiveelements:personalitycharacteristics,

includingaffectiveandemotionalstatesandtraits;andovertbehaviour

patterns,actionsandhabitsthatrelatetohealthmaintenance,tohealth

restorationandtohealthimprovement(p.169).

AccordingtoGochman(1982)theword“behaviour”referstosomethingthatpeopledoor

avoiddoingandisnotnecessarilyconsciouslyorvoluntarilydone.Thisdefinitionexcludes

treatment,reflectionsofbodilystates,clinicalimprovementsorphysicalrecoveryor

healthstatus.Aperson'sperceptionsofhis/herhealthstatusorofimprovement,recovery

orotherchangesinhealthstatusarealsoregardedashealthbehaviours.Thisdefinition

alsoincludes“notonlydirectlyobservable,overtactionsbutalsothosementalevents,

feelingsandfeelingstatesthatareobservedormeasuredindirectly”(Gochman,1982).In

addition,accordingtothisdefinitiontheseattributesareunderstoodtobeinfluencedby

familystructure,thepeergroupandsocialfactors,andsocial,institutionalandcultural

determinants.

12

Healthbehaviour,therefore,isnotsynonymouswithbehaviouralmedicinealthough

someaspectsarecommontoboth.AccordingtoGochman(1988)thebasicparadigm

proposedforbehaviouralmedicineisthemedicalmodel,whereashealthbehaviouris

definedindependentofpathology,diagnosisandtreatmentofspecificdisordersbut

includesconcernforgeneralhealthmaintenanceandwellbeing.Itdoesnotautomatically

beginwithinamedicalframeworkoritsassumptions.Healthbehaviourdoes,however,

encompassrelatedconceptssuchas“preventative”and“protective“illnessandsick‐role

behaviour.

2.1PSYCHOLOGICALCONCEPTSINHEALTHANDILLNESS

2.1.1 HEALTH,ILLNESS,ANDDISEASE

Althoughverywidelyused,theconceptshealth, illness and disease areverydifficultto

definesincetheyhavebeeninterpretedquitedifferentlyamonglaypeopleandscholars

(Schlebusch,1990).Inspiteofthevaryingusesoftheseterms,Diaz‐Guerrero(1984),in

searchforauniversalconceptionofhealth,studiedtheresponsesofsubjectsinasample

drawnfromthirtydifferentculturesandfoundthatthereissomecross‐cultural

agreementthathealthischaracterizedas“good”,“potent”and“active”.

“Health”isfrequentlyconsideredtobeanormalcondition,implyinganabsenceof

disease,symptomatologyorlaboratoryabnormalities.Suchaviewwhichaccentuatesthe

absenceofbiomedicalsymptomatologyconstitutesanegativeconceptofhealth.

Schlebusch(1990)suggests,incontrast,amorepositiveconceptofhealthinwhich

psychosocialvariablesplayacentralrole.Thesevariablesinter aliaincludeeducation,

socialclass,diet,income,socialandoccupationalenvironment,life‐style,interpersonal

relationships,personalhabits,accesstohealthcareandoccupationalfunctioning.Sucha

positiveconceptofhealth,hebelieves,willfacilitateamorecomprehensiveapproachto

thedeliveryofhealth,unlikethetraditionalmedicalmodelanditsconceptofdisease

13

whichtendstofocusondiagnosisandthecureofdiseasetotheneglectofpreventionof

diseaseandmaintenanceofgoodhealth.

Even“disease,”whichhasbeennarrowlydefinedas“amedicalhypothesisthatimplies

particularpathologicalprocessesunderlyingaspecificsyndrome”(Mechanic,1978,p.25),

isnowincreasinglyusedtorefertobehaviouralandsocialprocessesforwhichnosuch

specificitycanbedemonstrated(Schlebusch,1990).Oftentheterms“illness”and

“disease”areusedinterchangeably.Onewayofdistinguishing“disease”from“illness”is

toregardtheformerasa“condition”,andthelatterasa“behaviour”.However,asalready

mentioned,thetermsareusedinterchangeablybecauseofthepsychologicalinterplay

betweenthem(Schlebusch,1990).Inessence,diseaseischaracterizedbystructuralor

physiological,functionalandbiochemicalchangesandreferstoabiologicalprocess.Its

basiccharacteristicsremainthesameregardlessofwhenorwherethediseaseoccurs

(Schlebusch,1989).

“Illness”,ontheotherhand,impliesasubjective,psychologicalandsocialexperience

whichisthereforeopentointerpretationbybothpatientsandthesocietytheylivein.In

fact,illnessmayoccurintheabsenceofdisease.Incontrast,therearetimeswhendisease

maybepresentbutthepatientmaynotfeelill.Thisissometimesreferredtoasthe

“preclinicalphaseofdisease”(Braunstein,1981).AccordingtoCott(1986),illnessoften

remainssubsequenttooptimalmedicaltreatmentand,therefore,constitutesasignificant

health‐careproblem.Inaddition,illnessbringsaspecificmeaningtoapatient'slifeand

crystallizesspecialmeaningthatconstitutesandexpressesitselfasawayoflife(Kleinman,

1986).Itisbecauseoftheseidiosyncraticelementsandtheorientationtowardsproblems

ofexistenceandcopingthatpromptedHunt(1988)tosuggestthatthemeasurementof

illnessmustbedirectedtowardsthepatient'sviewpoint.

Gochman(1988)pointsoutsixelementsthatcontributetothecomplexityanddifficultyin

definingtheseconcepts.Thefirstelementheattributestothe“simultaneousexistenceof

layandprofessionalorscientificdefinitions.”Althoughtheyoverlaptherearealso

differenceswhichhaveimportantlifeordeathrelevanceintheareahealth.Thesecond

14

elementisthe“existenceofmultipleprofessionalorscientificdefinitions.”Forinstance,

themedicaldefinitionsemphasizethepresenceorabsenceofpathologywhile

psychologicaldefinitionsemphasizeperceptions,feelingsofwellbeingandequilibrium.

Thethirdelementisthe“pluraldefinitionswithineachprofession(p.8).”.The

acknowledgementthatatleastthreedimensions,namely,thebiomedical,personaland

socio‐culturalmustbetakenintoaccount,constitutesthefourthelementofdifficultyin

definition.Thefifthelementaffirmsthat,becauseoftheimportanceofthesethree

dimensions,therearevaryingdegreesofjuxtaposition,conflictandequilibriumamong

themedical,personalandsocialperspectives.Thelastelementreferstothesimultaneous

existenceofseveraldifferenthealthpracticesystems;theseinclude“scientific”medicine,

religiousor“traditional”medicine,publichealthpracticeandfolkmedicine.

2.1.2 SOMESPECIFICTYPESOFHEALTHBEHAVIOUR

KaslandCobb(1966a,1966b);Mechanic(1978,1986);Suchman(1972)andParsons

(1951)havemadecertaincriticaldistinctionsbetweenthevarioustypesofhealth

behaviours.Thesedistinctionsindefinitionsofhealth‐relatedbehaviourarediscussed

below.

15

2.1.2.1PreventativeBehaviour AccordingtoKaslandCobb(1966a),preventativebehaviourreferstotheactionsof

individualswhobelievetheyarewell(i.e.notexperiencinganysignsorsymptomsof

illness)inordertoremainwell.Suchaviewconfineshealthbehaviourtopreventative

activitiesandinclude,butisnotlimitedto,“everyday”nonmedicalbehaviourssuchas,

durationofsleep,eatinghabits,weightmanagement,physicalandrecreationalactivity,

non‐consumptionofalcoholandnon‐smoking(BellocandBreslow,1972).Primary

preventivemedicalbehavioursincludebehaviourssuchasimmunizationagainstinfectious

diseases,whilesecondarypreventivemedicalbehaviourswillincludeperiodicmedical

examinationsandscreeningformedicalproblems.Thesemeasuresdonotnecessarily

preventdiseasebutcontributetoitsearlydetection(Gochman,1988).

2.1.2.2HealthProtectiveBehaviour

Healthprotectivebehaviourreferstotheactionsofindividualsthataugmentprimaryand

secondarypreventativebehavioursandaredirectedtowardsprotectingtheirhealth,

whethermedicallyapprovedornot(HarrisandGutten,1979).Examplesofhealth

protectivebehavioursarepraying,repairinghouseholdimplements,consuminglarge

dosesofvitamins,takinglaxatives,emetics,enemasandcoldshowers.Thecommon

rationaleofthesebehavioursisthattheyprotectandmaintainhealth(Feuerstein,Labbe

andKuzcmierczyk,1986).

2.1.2.3IllnessBehaviour

Theactionsofindividualstoascertaintheirstateofhealth,thatis,whentheyarenotsure

thattheyarewelloraretroubledbyfeelingsorsensationsthattheybelievemaybesigns

orsymptomsofanillnessareregardedasillnessbehaviour(KaslandCobb,1966a).

Examplesofillnessbehavioursareresponsestophysicalsymptomatology,seekingexpert

16

helpandadvice(eitherfromhealthcareprofessionalsorlayandfolktherapists),seeking

theopinionsoffriendsandrelatives,aswellasdelayingactiontoseeifthesignsor

symptomsremit(Gochman,1988).AccordingtoMechanic(1978),illnessbehaviourhas

severaldeterminantsincludingtheperceptionandseverityofsymptoms,theirdisruptive

andpersistentnature,individualneeds,theavailabilityofalternativeinterpretationsand

treatment,aswellascostsintimeandmoneyincurredbytheindividual.Theseare

discussedingreaterdetailwhenMechanic's(1976a)modelofillnessbehaviourisgiven

fullertreatmentbelow.

Illnessbehaviouralsoinvolveshelp‐seekingbehaviour(Mechanic,1986)andmanifests

whenpatients'decidetodosomethingabouttheirsymptomsordistress.Help‐seeking

behaviourincludesnotonlytheconsultingofamedicaldoctorbutalsothesolicitingof

generalhelpfromcommunityadvisers,tribalauthorities,traditionalfaithhealers,the

sangoma(diviner)orministersofreligion.

Itis,therefore,importanttobearinmindthatthepatient'sbehaviourinpreventingand

dealingwithillnesscanbeviewedinthecontextofthepatient'sownrepresentationof

theillness,whichisbasedlargelyontheexperienceofcertainconcretesymptoms.The

self‐understandingofthesesymptomsandthenatureofthepatient'sownrepresentation

oftheillnessisnaturallyopentosocio‐culturalinterpretationaswell.However,thisself‐

understandingofillnessactsasaregulatingsystemtoguidecopingbehaviourandtoset

goalsthroughwhichcopingisevaluated(Laventhalletal.1980)andispowerfullypresent

evenduringtheformalscientificprocessofhealing.Thepsychologicalimplicationsofthis

areobvious.

2.1.2.4SickRoleBehaviour

Sickrolebehaviourreferstothoseactionsadoptedbyindividualswhohavealreadybeen

designatedsick,eitherbyothersorthemselves,inordertogetwell(KaslandCobb,

1966b;Parsons,1951).Examplesofsuchbehavioursarecompliancewithaprescribed

17

medicalregimen,limitationofactivityandactionsrelatedtorecoveryandrehabilitation.

Sicknessiscloselyalliedtosickrolebehaviourasitgenerallyreferstosociallysanctioned

waysthatinferillness;itisnotnecessarilyimpliedbyillnessordiseaseandcanbe

observedintheabsenceofeither(Hunt,1988).Itinvolvesvariousbehavioursincluding

labelling,communicatingdistress,seekingmedicaladvice,absencefromworkandstaying

inbed.(Schlebusch,1990).

2.2HEALTHBELIEFS,ATTITUDESANDVALUES

Thesocio‐culturalattitudes,valuesandbeliefsofapersonguideandinfluencehisorher

perceiving,filtering,interpreting,understandingandpredictingofnews,informationand

daytodayevents.Hermeneuticalunderstanding,inotherwords,maybeinfluencedby

bothcognitiveandnon‐cognitiveprocessessuchasperceptionsandvalues.Similarly,as

mentionedearlierintheintroduction,theattitudes,valuesandbeliefsofindividuals

abouthealthandillnessinfluencestheirhealthbehaviouraswell.

‘Attitude’ismostcentralinsocialpsychology.Anattitudemaybedefinedasa

“predispositiontofeel,thinkandacttowardssomeobject,person,grouporeventina

moreorlessfavourableorunfavourableway”(Richardson,1980,p.299).Accordingtothis

definitionattitudesaremadeupofthreecomponents—cognitive,affectiveand

behavioural.Beliefsconstitutethecognitive  component;attitudesformtheaffective 

componentandtheactionsconstitutethebehavioural component.Eachofthethree

componentsmayvaryinintensityandcomplexity.

Attitudesderivefromunderlyingvalues.Avaluemaybedefinedasabasicattitude

towardscertainbroadmodesofconduct,suchas,courage,honesty,friendshiporcertain

statesofexistence,forexample,equality,salvationandfreedom.Valuesarethusakinto

attitudesbuttheyrefertotheendsandnotthemeans.

18

2.3MODELSOFHEALTH‐RELATEDBEHAVIOUR

Overthepastfourdecades,severaltheoreticalmodelshavebeenproposedinanattempt

toexplainoraccountforhealthbehaviours.Cummingsetal.(1980)haveidentified

fourteenmodelswhichtheyregardas“mostnotableintermsofpredictiveabilityand

frequencyofcitation”(p.124).Areviewofallfourteenmodelsareneitherwithinthe

scopeofthisstudyornecessaryforitsobjectives.Thefollowingsectionwillbriefly

highlightafewofthemorefrequentlyusedmodels.

Amodel(orparadigm)isasystemofbeliefsaboutthestructureandworkingsofreality.

Kuhn(1962)pointedoutthatmodelsdefinethelegitimateproblemsandmethodsofa

researchfieldforsucceedinggenerationsofpractitioners.Amodel,heheld,guidesand

limitsobservation.Asamodelisusedanomaliesemergewhenexplanationsdonotquite

fitrealityandtheorieslosetheirexplanatoryvalue.Anomaliesemergewhenthe

legitimacyofexplanationleadstothesearchfornewwaysofexplanation.Thereisoftena

periodofcompetingmodelsuntilonedominatestoachievewidespreadlegitimacy,

sufficientlyenoughtobecometheprevailingparadigm.Itistheemergenceofanomalies

thatforceonetoseekalternatemodels.

Forourpurposesweseemodelsascomplexhypothesesthatattempttoexplainhealth

andillnessbehaviours.Allofthemodelsdiscussedbelow,exceptsociallearning,were

specificallydevelopedashealthmodels.

2.3.1 THEHEALTHBELIEFMODEL

TheHealthBeliefModel(HBM)wasdevelopedintheearly1950sbyagroupofsocial

psychologists(Hochbaum,1958;Rosenstock,1974)inthePublicHealthServiceofthe

UnitedStatesofAmericainordertounderstandwhypeoplefailedtoaccept“disease

preventativesandscreeningtestsforearlydetectionofasymptomaticdiseases”

(Rosenstock,1974,p.328.).Itwaslaterusedtounderstandsickrolebehaviours,illness

19

behavioursandcompliancewithprescribedmedicaltreatment(Wallstonand

Wallston,1984).Thecomponentsofthemodelemergedoutofwellestablished

psychologicalandbehaviouraltheoriesthathypothesizethatbehaviourdependsmainly

ontwovariables:thevalueplacedbytheindividualonagoal(ie.desiretoavoidillnessor

togetwell)andtheindividual’sbeliefthatagivenactionwillachievethegoal(thata

specifichealthactionwillpreventoramelioratetheillness).TheHBMconsistsofthe

followingdimensions:

(1)perceived susceptibility whichreferstoanindividual’ssubjective

perceptionoftheriskofcontractinganillness;

(2)perceived severity—thisreferstothefeelingsconcerningthe

seriousnessofcontractinganillness;

(3)perceived benefits refertothebeliefsregardingtheeffectivenessofthe

variousactionsavailableinreducingthethreatofdisease;and,

(4)perceived barriers—thesearethepotentialnegativeaspectsofa

particularhealthactionwhichmayactasimpedimentstoundertakingthe

recommendedhealthbehaviour.These‘barriers’includesideeffects,pain,

inconvenienceandtime‐consumption.

TheHBMassumesthatthereisa“cuetoaction”thatmaytriggerofthedecision‐making

processandmaybeeitherinternal(ie.symptoms)orexternal(eg.mediaand

interpersonalinfluences).Thismodelacceptsthatdiversedemographical,socio‐

psychologicalandstructuralvariablesmayaffecttheindividual’sperceptionand,asa

result,influencehealth‐relatedbehaviour(JanzandBecker,1984).

Althoughthismodeliswidelyacceptedbyhealthresearchers,ithaselicitedcriticismsas

well.Haefer(1974)describedtheHBMas“aconfusingmelangeofinconsistent(thoughby

nomeansdisconfirming)resultsobtainedunderwidelyvaryingconditionsandsusceptible

tonounivocalinterpretation”.Atpresenttherearesomanyvariablesthathavebeen

identifiedthatthetheorybecomesuntestableandunabletobefalsified,animportant

criterionforthevalidationofatheorysayWallstonandWallston(1984)followingKarl

20

Popper's(1959)‘falsificationprinciple.’Inaddition,essentialelementsidentifiedbythis

model,suchas,demographic,structuralandattitudes,donotalwayspredictasexpected.

Thelackofspecificationofrelationshipamongthevariablesresultsinrelativepredictions

ratherthanquantitativeones(Stone,1979).Anotherproblemisthelackofconsistent

operationalizationofvariableswhichresultindifferentmeasuresbeingusedindifferent

studies.Whilethisvariationmayenhancetheadaptabilityofthemodel,itmakes

comparisonsbetweendifferentstudiesdifficult,ifnotimpossible.

2.3.2 KASLANDCOBB'SMODEL

KaslandCobb(1966)haveformulatedtwomodels,onefor“health”andanotherfor

“illness”behaviours.ThesemodelssharesomesimilaritywiththeHBM.Thevariation,

accordingtotheirmodel,isthepossibilityofanindividualundertakingaspecificbehaviour

inthepresenceofparticularsymptoms.Furthermore,thesemodelstakeparticular

cognizanceoffactors,suchas,pain,discomfort,psychologicaldistress,personaltolerance

forpain,disability,copingmechanismsandsocio‐demographiccharacteristics.

Thismodelofhealthbehaviourshypothesizesthatbehaviouroccurringintheabsenceof

symptomsisinfluencedbythethreatofdiseaseandbeliefsconcerningthevalueofhealth

action.Socialcharacteristicsandknowledgeareseenasinfluencingboththeperceived

threatandhealthaction.Otherfactorsthatinfluencebehaviourincludethepast

utilizationofmedicalservices,thecostofhealthaction,thecostofinactionandthe

probabilityofthehealthactionresultinginthedesiredoutcome.

Themodelonillnessandsickrolebehaviourshypothesizesthatbehaviourundertakenin

thepresenceofsymptomsisinfluenceddirectlybytheindividual'sperceptionofthe

threatofthediseaseandthebeliefconcerninghealthaction.Painanddiscomfortare

seenasinfluencinganindividual'sperceptionsaswellasdirectlyinfluencingbehaviour.

Socialcharacteristics,personaltoleranceforpain,disability,andcopingmechanismsare

assumedtoaffectbehaviourindirectly.The‘threat’componentincludestheperceived

21

importanceofhealth,perceivedsusceptibilitytoillnessandseverityoftheconsequences.

The‘value’componentincludestheprobabilityofactionleadingtoadesiredoutcomeand

thedifferentialratioofthecostofactiontothecostofnottakingaction.

2.3.3 SUCHMAN'SMODEL

Thismodel(Suchman,1965a,1965b)resultsfromtheeffortstoadoptasociological

perspectivetounderstandanindividual'sdecisionswithrespecttotheutilizationof

health‐services.Healthbehavioursareexaminedwithintheirsocialandculturalcontexts

andhypothesizedlinksaremadebetweenspecifiedhealthorientationsorbehavioursand

socialrelationshipsorgroupstructures.Centraltothismodelarethesocialpatternsof

illnessbehaviour.Therearefourprincipalfactorsinfluencingillnessbehaviour:

1.Content—whichinvolvesaseriesofconceptsfacilitatingdescriptionsofalternative

behavioursandtheiroutcomes.Forexample,

(a)shopping—theseekingofmedicalcarefromdifferentproviders;

(b)fragmentation of care—receivingmedicalcarefromdifferentproviders

atthesamesource;

(c) procrastination—delayinseekingcaresubsequenttotheobservation

ofsymptoms;

(d) self‐medication—self‐initiateduseoftherapies;and,

(e) discontinuity—interruptionsinthetreatmentorprocessofcare.

2.Sequence—thisfactorisdividedintofivetransitionalstages:

(a)symptomexperience;

(b)theassumptionofasickrole;

(c)medical‐carecontact;

(d)dependent‐patientrole;and,

(e)recoveryorrehabilitation.

Initially,thedimensionofthesymptomexperiencealertstheindividualthatsomethingis

wrong.First,thepainordiscomfortorabnormalityisexperienced;secondly,thephysical

22

sensationsorsymptomsareinterpretedanddefinedonthebasisoftheirdegreeof

interferencewithusualsocialfunctioning(cognitivedimension);andfinally,theanxiety

andfearassociatedwiththeillnessemerge(emotionaldimension).

Although,accordingtothismodel,theindividualwillmovefromthesymptomexperience

totheassumptionofthesickrole,heorshemaydecideonalternatives,suchas,denying

thepresenceofillnessordelayingtheseekingofmedicalhelp.Duringtheassumptionof

thesickrole,theindividualwillattempttoreducethesymptomsbyself‐initiatedtherapies

ortreatmentswhilesimultaneouslyconsultingfamilyandfriendsforadviceand

information.Followingtheconsultationofadoctortoassistwiththeorganicand

psychosocialneeds(medical‐carecontactstage),theindividualentersintoarelationship

whichinvolvestheacceptanceofaprescribedregimen(dependent‐patientrolestage).

Duringthemedicalcontactstage,however,thepatientmayneitherbelievethediagnosis

noraccepttherecommendedtreatmentandmayturntoothersourcesforhelp.Further,

variousfactors,suchas,physical,administrative,social,psychologicalaswellasthequality

ofthedoctor‐patientrelationships,mayinterferewithprescribedtreatmentduringthe

dependent‐patientstage.Inthefinalstage(recoveryandrehabilitation)theindividual

givesupthepatientrole.

3.Spacing referstothesocialcohesionofthegrouptowhichtheindividualisamember;

thatis,thecommunity,friendshipandfamilylevelsoftheindividual’ssocialwell‐being.

Thedegreeofsocialorganisationischaracterisedbythelevelofingroupattractionand

exgroupexclusionasmeasuredby“ethnicexclusivity”onthecommunitylevel,“friendship

solidarity”onthesocialleveland“orientationtofamilytraditionandauthority”onthe

familylevel.Thesethreedimensionsarecombinedinanindexofcosmopolitan‐parochial

socialstructure,whereparochialismisdefinedbyhighexclusivity,highfriendshipgroup

solidarityandhighorientationtotraditionandauthority.Thehealthorientationofthe

individualisseenasacontinuum,varyingfromthescientific(objective,professionaland

impersonal)tothepopular(subjective,layandpersonal)basedonthe“knowledgeabout

disease,”“scepticismofmedicalcare”and“dependencyinillness.”Popularhealth

orientationischaracterisedbythefollowingdimensions:cognitive(lowknowledgeabout

23

disease),affective(highscepticismofmedicalcare)andbehavioural(highdependency

duringillness).

4.Variabilityreferstothevariationsinbehaviourduringthefivestagesofillness.These

variationsaffecttheprogressionfromonestagetothenext.

WhileSuchman'sstudy(1965a)seemstosupportarelationshipbetweensocialsupport,

healthorientationandvariationsinresponsetoillness,otherstudies(Reederand

Berkanovic,1973;Geertsenetal.,1975;Farge,1978)wereunabletoreplicatethese

findings.

2.3.4 FABREGA'SMODEL

Fabrega's(1973)modelusesananthropologicalapproachtounderstandingillness

behaviour.Thismodelsuggestninestagesofinformationprocessingwhichleadthe

individualtoadecisiontoactinacertainway.Itassumesthattherearefoursystems

involvedintheinformationprocessing.Theseare(a)thebiological system whichfocuses

onchemicalandphysiologicalprocesses;(b)thesocial systemwhichaffectsrelationships

withotherindividuals,groupsandinstitutions;(c)thephenomenological systemwhichis

concernedwiththeindividual'sstateofawarenessandself‐definition.;and(d)the

memory systemwhichincludesearlyillnessexperiences,medicalattitudesandbeliefs.

Thesesystemsareopenedandinter‐joined.

Thefirsttwostagesofthismodeldealwiththerecognitionandevaluationofsymptoms.

Instageonetheindividualcomestorealizethepresenceofillnessorchangestakingplace

andactstoalleviatetheperceivedillness.Atthenextstagethenegativecomponentsof

theillnessareevaluatedonthebasisofpresentandpastexperiences.Thisevaluation

leadstoanegativevaluebeingattachedtotheconditionreflectingthedanger,disability,

discomfort,socialstigmaandthepsychosocialdisruptionsassociatedwiththeillness.In

thethirdstage,avarietyofmutuallyexclusivetreatmentalternativesareconsidered.

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These‘plans’arelearnedresponsesbasedonpastexperienceswithillnessrangingfrom

theuseofhomeremediesandpatentmedicinestolayreferralsinordertoobtainmedical

careorhealing.Stagesfourtosevenrelatetotheindividualsevaluationofdifferent

treatmentplans.Theseincludealternativesthatwillreducethe“disvalue”,thebenefits

andutilityofeachaction,aswellaspersonalandeconomiccostsoftheaction.Thisleads

totheeighthstagewhichistheselectionofatreatmentplan.Intheninthstage,further

processingandupdatingtakeplaceasaresultofthetreatmentplanselectedinstage

eight.Theillnessmayberelabelledandarecyclingofthestagesmayoccur.

2.3.5 MECHANIC'SMODEL

Mechanic'smodel(1978)focusesonhelp‐seekingbehaviourandshowsthevariationwith

whichdifferentpeopleperceive,evaluateandreact(ornotreact)tosymptoms.The

emphasisisonwhatoccursbeforeanindividualseesahealth‐careprovider.Mechanic

(1978)identifiestenvariablesthatinfluence“help‐seeking.”Theseare:

1 “thevisibility,recognizabilityorperceptualsalienceofdeviantsignsand

symptoms;

2 theextenttowhichsymptomsareperceivedasserious(thatis,the

person'sestimateofpresentandfuturedanger);

3 theextenttowhichthesymptomsdisruptfamily,work,andothersocial

activities;

4 thefrequencyoftheappearanceofthedeviantsignsorsymptoms,—their

persistenceandrecurrence;

5 thetolerancethresholdofthosewhoareexposedtoandevaluatethe

deviantsignsandsymptoms;

6 availableinformation,knowledge,andculturalassumptionsand

understandingoftheevaluator;

7 basicneedsthatleadtodenial;

8 needscompetingwithillnessresponses;

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9 competingpossibleinterpretationsthatcanbeassignedtothesymptoms

oncetheyarerecognized;and,

10. theavailabilityoftreatmentresources,physicalproximityandpsychological

andmonetarycostsoftakingaction(including,physicaldistance,costsof

time,moneyandeffort,aswellas,costsofstigma,socialdistanceand

feelingsofhumiliation)”(p.268‐269).

Variables2,3,9and10closelyresemblethebasicelementsoftheHBM.Inaddition,

Mechanic(1978)distinguishesbetween“otherdefined”and“self‐defined”illness.Both

thesituationsinvolvelayreferralsystems.Thedifferenceoccursinthe“other‐defined”

category,wherethedefinitionofillnessoriginatesfromothersintheenvironmentandthe

sickpersonseemstoresisttheevaluationandmayhavetobebroughtfortreatment

involuntarily,forexample,inthecasesofpsychosis,illnessofchildrenandincasesof

adultdenialofillness.

2.3.6 ANDERSEN'SMODEL

Thisisabehaviouralmodel(AdayandAndersen,1974)thathasbeenusedwidelyfor

assessingmedicalutilisation.Accordingtothismodel,healthutilisationisdependent

uponthreecomponents:

1 thepredispositionofthefamilytousehealthservices;

2 theabilitytosecureservices;and,

3 theneedforservices.

Thefirstcomponentincludesinformation,suchas,age,sex,maritalstatus,education,

occupation,andhealthbeliefsandattitudesaboutmedicalcare,physiciansanddisease

(eg.familiesthatbelieveintheefficacyofmedicaltreatmentwillseekcaresoonerand

moreoften).Thesecondcomponentreferstotheconditionsthat“enable”theuseof

healthservicesorwhichmakesthemavailable,theseinclude,familyresourcessuchas

26

incomeandmedicalaidorcommunityresourcessuchastheavailabilityofhealthservices

andhealthpersonnel,traveltimesandwaitingtimes.Whenthesetwocomponentsare

present,twofactors,(namely,thevariationinperceptionofillnessandthemannerof

responsetoillness),willdeterminewhetherhealthservicesareused.Perceivedneedis

measuredbybothsubjectiveperceptionsofillnessandtheclinicalevaluationofillness.

2.3.7 SOCIALLEARNINGTHEORY

ThesociallearningtheorywasdevelopedbyRotteretal.(1972)toexplainhuman

behaviourincomplexsituations.Therearefourbasicconstructstothetheory,namely:

behaviourpotential(BP);expectancy(E);reinforcementvalue(RV);and,thepsychological

situation(S).Accordingtothetheory,aspecificbehaviour(BP),occurringinagiven

situation(S),isthefunctionoftheexpectancy(E)thatthebehaviourwillleadtoa

particularreinforcementinthatsituationandthevalueofthereinforcement(RV)tothe

individualinthatsituation(WallstonandWallston,1984).Theequationrelatingsocial

behaviourtobehaviourisrepresentedasfollows:

BP=f(E,RV)

Ofalltheconstructs,expectancyreceivesthemostattention.Theexpectancyconstruct

particularlyresearchedis“internalversesexternallocusofcontrolofreinforcement.”This

referstothegeneralizedexpectancy(withregardstoeachelementintheequation,itcan

bemeasuredingeneralorspecificterms,specifictoexpectancy)astowhetherone'sown

behaviourorforcesexternaltooneselfcontrolone’sreinforcement.

WallstonandWallston(1984)usedthistheorytoexplainhealthbehaviour.Theymodified

theequationasfollows:

1.HB=f (HLC× HV)

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2.HB=IHLCT× HVT+PHLC‐CHLC

Where HB = healthbehaviour;

HLC = healthlocusofcontrol;

HV = healthvalue;

IHLC= internalhealthlocusofcontrol;

PHLC = powerfulothershealthlocusofcontrol

CHLC = chancehealthlocusofcontrol

(The subscript  (T) indicate that the raw scores were converted to standardized T‐scores to 

eliminate negative values before multiplying).

UsingtheseequationsWallstonandWallston(1984)generalizedsociallearningtheoryto

predicthealthbehaviour.Accordingtothem,“apersonismostlytoengageinahealth

behaviourgivenabeliefininternalhealthlocusofcontrolandahighvaluingofhealth.”

Lowbeliefinachancehealthlocusofcontrolcouldalsofacilitatehealthbehaviour.Ifa

personbelievesthathealthisstrictlyamatterofchance,thereisnoreasontotakeaction.

Highbeliefinpowerfulothersasahealthlocusofcontrolwillfacilitatehealthbehaviour

recommendedbyhealthprofessionals.WallstonandWallston(1984)alsopointoutthat

thedistinctionbetweenexternalbeliefsPandChasprovenusefulinhealthresearch.

Someauthorsinrecentyearshaveadvancedtheunderstandingofhealthbehavioursby

modifyingthesetraditionalmodels(Hersheyetal.,1975;BerkiandAshcraft,1979)in

ordertomakethemrelevanttotheircontexts.Onesuchmodelisthatpostulatedby

Young(1980)whichisacrossculturaladaptationoftheHBMaimedatexplaining

treatmentdecision‐making.Therearefourmajorelementstothemodel.

1 Gravity—whichreferstothelevelofperceivedseverityoftheillnessheld

bytheindividual'sreferencegroup(thisassumesthatthereexists,priorto

theonsetofillness,somegroupconsensusabouttherelativeand/or

absolutelevelofseriousnessofvariousillnesses);

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2 Knowledge of a home remedy—derivedfromalayreferralsystem(ifsuch

aremedyisunknown,orifitistriedandfoundtobeineffective,the

individualisthenlikelytoturntotheprofessionalreferralsystem).;

3 Faith—thelevelofbeliefintheefficacyofadifferentoftensupernatural

treatmentoption(especiallyfolkremedies);and

4 Accessibility—thecostandavailabilityofhealthservices(similartothe

“perceivedbarriers”intheHBMandto“enablingfactors”inAndersen's

model).

Theproliferationofmodelsleadstoconfusionwithregardtochoosingaviablemodelfor

studyinghealthbehaviour.Thepresentationaboveofafewmodelshighlightsthis

problem.However,Cummingsetal.(1980)afterexamining14modelsofthiskindpointed

outthatalthoughthemodelsdifferintheirtheoreticalperspective,thetypesofhealth

behaviourstheyexplainandthesetoftermstheyusetolabelthedifferentdimensions

andvariables,thegeneralclassesoffactors,atleastsuperficially,appeartobequite

similar.Theyhavesuggested“thatthenumberoftrulydistinctconceptsrelevantto

explaininghealth‐relatedactionsisconsiderablylowerthanthelargenumberofvariables

currentlyemployed”.(p.123).Theseauthors,usingtheactualmodeldeveloperstoactas

judges,examined109variablesextractedfromthefourteenmodelsandcategorisedthem

onthebasisoftheirsimilarities.Sixmajorcategoriesemerged:

“1 accessibility to health care,suchastheindividual'sabilitytopayforhealth

careandawarenessofhealthservices,andtheavailabilityofservices;

2 attitudes towards health,suchas,beliefsinthebenefitoftreatmentand

beliefsaboutthequalityofmedicalcareprovided;

3 threat of illness,suchas,theindividual'sperceptionofsymptomsand

beliefsaboutsusceptibilitytoandtheconsequencesofdisease;

4 knowledge about disease;

5 social interactions, social norms and social structure,and,

6 demographic characteristics(socialstatus,incomeandeducation),”(p.137).

29

Thisstudycontributestowardsamoreunifiedapproachtounderstandinghealth

behavioursanditsintegrativeapproachhasgreatermeritsforinvestigatinghealth

behavioursinvariouspopulationsandsocio‐culturalsettings.

30

2.4CRITICALISSUESINHEALTHBEHAVIOUR

2.4.1 PERSONALANDDEMOGRAPHIC

Severalstudieshavedocumentedcertaindemographicpatternsrelatedtohealth

behaviours.Onesuchstudy(ChristieandLawrence,1978)foundthatattitudestowards

hospitalizationwascorrelatednegativelywithageamongmenandpositivelywithage

amongwomen.

Otherresearchershavenotedgenderdifferencesinhealthbehaviours.Morementhan

womensmokealthoughtherateofdeclineofsmokingismorerapidamongmenthan

women(Fioreetal,1989).Higheralcoholconsumptionhasbeenreportedinmen,

althoughmorewomenhavemoremultipleaddictioninwhichalcoholiscombinedwith

prescriptiondrugs(KossandWoodruff,1991).Withregardtoproblemsofeating,obesity

anddietingtheincidenceofthesedisordersaremorecommonamongwomenthanmen.

Regardingtheutilisationofmedicalcare,itwasfoundthatwomenbetweentheages17

and44maketwiceasmanyvisitstoadoctorthanmen(Verbrugge,1985).Verbrugge

pointsoutthatthemeannumberofvisitsmadebywomentoadoctoris30percent

higherthanformen(ie.aftercontrollingforvisitsrelatedtochildbirth)andthatafterthe

ageof45yearswomen'soutpatientvisitsstillexceedthatofmenby10percentto20

percent.Althoughwomenseemtohavemorechronicillnessesandvisitdoctorsmore

frequently,therateofhospitalisationbetweenthegendergroupsarenotdifferent.

Women'saveragelengthofstayinhospitalsaremuchshorterthanthatofmen.Itis

generallyacceptedthatwomenusemoretypesofmedicationsandtoagreaterextent

thanmendo(Svarstadetal.,1987;Verbrugge,1985).

ZadoroznyjandSvarstad(1990)haveshownthattogetherwithgender,employmentis

alsoassociatedwithlowerincidenceofdruguseamongmenbutnotamongwomen.Ina

studybyLaveetal.(1979)itwasfoundthatlow‐income,unmarriedmaleswhohad

recentlymovedintoacommunitywereleastlikelytohavearegularsourceofhealthcare.

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Womenandmarriedpersonsresidinginacommunityforsometimeandwhohadhigher

incomeshadamorestablesourceofhealth.Anotherstudyshowedthatevenwhen

economicbarrierstohealthcareareremoved,poorpeoplestilldonotusedentalcareto

thesamedegreethatricherpeopledo.Luft,HersheyandMorrel(1976)observedthatin

aruralcommunitythe“healthstatus”andthe“regularsourceofcare”werebetter

predictorsoftheuseofservicesthanincomeormedicalinsurance.Wan(1976)showed

thathealthstatusisafunctionofemploymentstatusinadditiontotheseverityof

disability,theneedforassistanceinmobilityandpsychologicalwell‐being.Working

womentendtohaveadifferentsetofhealthbeliefsandpracticesthannon‐working

womenandthisisconsideredanimportantfactorresponsibleforlowermorbidityintheir

children(Murabaketal.,1990).

Educationhasbeenfoundtoinfluencetheselectionofservicesotherthanthoseofdistrict

clinics(Titkow,1983).IntheU.S.A.educationhasalsobeenfoundtobepositively

correlatedwiththeuseofhospitals(Okafor,1983)andtheseekingofabortionatclinics

(Liet.al.,1990)

AccordingtoMcClain(1977)peoplewhoareacculturated(i.e.especiallythosewhoare

younger,wealthier,andbettereducated)usewesterntreatmentfacilitiestoagreater

extentthanthosewhoarelessacculturated.

2.4.2 HEALTHBELIEFS

Thehealthbeliefsthatpeoplehaveinfluencehowtheyrespondwhentheyperceive

themselvesasill,howtheypreventillness,maintaingoodhealth,diagnosesymptomsand

treatbothersomeand/orpersistentconditions.Theymaytreatthemselvesorconsult

familyorfriends.Clymer,BaumandKrats(1984)foundthatpatientsafterevaluatingtheir

symptomsmostlytreatthemselvesorseekhelpfrommedicalprofessionalsor

alternativelyconsultfolkortraditionalhealers.AccordingtoMechanic(1983)and

ChristmanandKleinman(1983)medicalpractitionersarenormallythelastchoice.

32

AccordingtoMechanic(1976a)healthcarefacilitiesarealsoaffectedbyinter aliathe

dominantbeliefsaboutillness,accessibility,financialmeans,thestigmaassociatedwith

help‐seekingandorganisationalbarriers.Ofthesefactorssharedculturalbeliefsandstyles

(i.e.culturallysanctionedwayofdoingthings)areparticularlyimportant.Inthefollowing

chapterculturalbeliefsspecifictoAfricanpeoplewillbediscussed.

2.5SOCIALSUPPORTANDHEALTH

Thereisanabundanceofresearchthatdemonstratesthepositiveeffectsofsocialsupport

tohealthandhealthbehaviour(CohenandSyme,1985).Theabsenceofsocialsupporthas

beendirectlyrelatedtoincreaseofpsychologicalandpsychiatricsymptomatology

(Henderson,etal.,1978,1980;KesslerandMcLeod,1985)aswellasphysicalillnesses

(Gore,1978;Sarason,etal.,1985;WortmanandConway,1985;Schaefer,Coyneand

Lazarus,1981;Östergren,etal.,1991).Socialsupportisknowntoactasabufferbetween

stressfullifeeventsandhealth(Östergren,1991;Turner,1981;BillingsandMoos,1981)

eveninextremestressfulsituations,suchas,theviolenceinSouthAfrica(Dawes,1990).

CohenandSyme(1985),inattemptingtointegratethefindingsinthisvastarrayof

literaturethatincludesmultipleperspectives,definitionsandoutcomes,definesocial

supportas“theresourcesprovidedbyotherpersons.”(p.4).Socialsupportincorporates

severaldimensions,whichTardy(1985)dividesasfollows:thedirection of support(ie.it

canbegivenorreceived),disposition (theavailabilityvs.utilizationofresources),

description of support versus evaluation of satisfactionwithsupport,content(whatform

thecontacttakes),andnetwork(whatsocialsystem/sprovidethesupport).Social

networkshavebeenfoundtoinfluenceavarietyofhealthbehaviours,namely,theseeking

ofmedicalcare,theinfluenceoflayreferralsandtheutilisationofservicesinfluencedby

family,relativesandfriends.

Twoviewshavebeenputforwardonhowsocialsupportoperatestoimprovehealth.One

viewisthatsupportactsasabuffer thatprotectstheindividualfromtheharmfuleffects

ofstressorstressfulsituations.(CohenandMckay,1984;Dawes,1990).Accordingtothis

33

view,supportmayintervenebetweenthestressfulevent(orexpectationofit)andthe

stressexperience,byreducingorpreventingastressresponse,orbyeliminatingthe

stressexperiencebyinfluencingresponsibleillnessbehavioursorphysiologicalprocesses

(CohenandSyme,1985).

Theotherviewisthedirect effecthypothesisthatsupportenhanceshealthandwell‐

beingregardlessofthelevelofstress.Itisbelievedthattheperceptionthatothersare

willingtohelpcouldresultinincreasedoverallpositivefeelings,enhancedself‐esteem,

stabilityandcontroloverone’senvironmentwhichinturnmayinfluencesusceptibilityto

illnessbyindirectlystrengtheningtheimmunesystem(Zimetetal.,1988).

Itmaybethatbothviewshavevalidity.Whilesocialsupportmaybedirectlyhelpfulinall

circumstances,itmaybeparticularlyeffectiveasabufferduringstressfultimes(Zimetet

al.,1988).

2.6SYMPTOMSANDSYMPTOMPERCEPTION

Leventhal(1986)pointsoutthattheimportanceofsymptomscanbeviewedfromthree

perspectives:thatofpublichealth,medicineandlaypeople.Firstly,fromthepublichealth

perspective,householdsurveysprovideusefulinformationontheincidenceand

prevalenceofavarietyofdiseaseswhicharenecessaryforthecontrolandplanningof

publichealth.Secondly,inmedicine,symptomreportingisoftentheinitialcontactwith

medicalprofessionalsthatguidesthehypothesisformationaboutunderlyingconditions,

theorderingoffurthertestsandthemakingofadiagnosis.Lastly,symptomsareof

particularimportancetothelay‐personsinceitisanessentialstepintheprocessof

seekinghelpforillness.

Peopleexperiencesymptomsofillnessonafairlyregularbasis(Bishop,1984;Mechanic,

1978)althoughmanyofthesesymptomsareignoredandgountreated.InBishop'sstudy

(1984),some“seeminglyserious”symptomswentuntreated.Itwouldappearthenthat

34

theconceptualizationofillnessplaysacriticalroleindeterminingaperson'sillness

behaviour(BishopandConverse,1986).Matthews,etal.,(1983)haveshownthatthe

interpretationgiventosymptomsinfluencesboththeurgencywithwhichhelpissought

aswellassick‐rolebehaviouritself.Illnessrepresentationshavebeenfoundtoplaya

crucialroleinillnessbehaviour.BishopandConverse(1986)inastudyonhowlaypeople

cometoidentifyasetofsymptomsasindicatingaparticulardisease,found“that

informationaboutphysicalsymptomsisorganisedandprocessedaccordingtopre‐existing

beliefsabouttheassociationbetweenparticularsymptomsanddiseases.”(p.95).

Accordingly,these“diseaseprototypes”helpindividualsmakesenseofthechangesthey

experienceandwhattodoaboutthem.Thesediseaseprototypes,however,mayormay

notbeaccurateandmaynotalwaysresultinoptimalhelp‐seeking.

Ontheotherhand,symptomsarenotalwaysreliableindicatorsofdisease.Reasonsfor

suchaviewcomefromsexdifferencesinreportingsymptoms.Womenontheaverage

reportmoresymptomsthanmen(Verbrugge,1985).Thereisalsoalackofclarity

betweenpsychologicalconditionsandsymptoms(somatoformdisorders),symptomsas

productsofenvironmentalconditioningandsymptomsasindicatorsofmental,socialand

diseasestatus(Leventhal,1986).Levenstein(1990),isoftheopinionthatsymptomson

theirownhaveno‘objectivereality’andthat,therefore,aphysicianshouldunderstandhis

patientratherthaninterprethisorhersymptoms.

2.7LIFEEVENTS,STRESSANDILLNESS

Stresshasbeenlinkedtothedevelopment,exacerbationandmaintenanceofanumberof

healthproblems.Severalstudieshaveshownthatthereisadirectrelationbetweenstress

andphysicalillness(RaheandLind,1971;HolmesandRahe,1967;Feuerstein,Labbéand

Kuczierczyk,1987;Selye,1956;TurtonandChalmers,1990;Steptoe,1991).

Severalmodelshavebeenpostulatedtoexplaintheroleofstressintheetiology,

exacerbationandmaintenanceofphysicalillness.Oneofthemostfrequentlycitedisthat

ofSelye(1956),whofocusedonneuro‐endocrineaspects,andconceptualizedstressasa

35

non‐specificresponseadaptedtoprotecttheindividualfromanydemandsmadeonhim

orher.Further,thatstresscanresultfrombothpositiveandnegativeresponses.Levi's

model(1972)suggeststhatanypsycho‐socialchangecanactasastressorandthatthis

stimulusactsneuro‐endocrinolgicallyinapredisposedway.

InRaheandArthur'smodel(1978),emphasisisplacedonthesignificanceofrecentlife

changesorsituationswhichareinfluencedbytheindividual'sperceptiveset.The

perceptivesetisinfluencedbythesocialsupportsandearlylifeexperiences.Includedin

thismodelistheuseofpsychologicaldefenseswhichreducephysicalarousalandasa

resultreducesusceptibilitytoillness.Figure1belowpresentsanoverallviewofthe

conventionalstress‐vulnerabilitymodel(Steptoe,1991).

Steptoe(1991)maintainedthatthepsychobiologicalstressresponse(StageIIinFigure1)

isalooselycoupledsysteminvolvingadjustmentsattheaffective,cognitiveand

behaviourallevels,togetherwithassociatechangesinneuroendocrine,autonomicand

immunefunctionwhichhavebeenchallengedinmodernresearch.Firstly,hechallenges

thenotionofnonspecificity(Selye's‘nonspecificpatternofactivation’)becauserecent

studieshaveshownthatthepatternofneuroendocrineandautonomicresponsesvaries

accordingtotheemotionaldemands.Thatis,itisnotsimplyanintensityeffectbuta

consequenceofcopingbehavioursengagedinthesituation.Secondly,itisdifficultto

applytheviewthatphysiologicalstressresponsesareadaptedtobolstertheorganism's

biologicaldefenceswhichmanifestasanti‐inflammatoryandimmunosuppressiveeffects

ofglucocorticoids.Itissuggestedthatseveralcomponentsoftheactivationprofilemay

havea“regulatoryratherthanadirectresistancefunction.”(p.635).Thirdly,theviewthat

peripheralphysiologicalchangesaresecondarytocentralnervoussystemactivationinthe

stressprocessismisleadingsincerecentevidencesuggestsabi‐directionaltrafficbetween

thetwo.

AccordingtoSteptoe(1991)therearetwomajorissueswiththemodelslinking

psychobiologicalstressresponseswithillness.Firstly,whydosomepeoplebecomeill

whenexposedtoadversecircumstancesandexperienceswhileothersdonot(‘intensity

36

issue’).Secondly,whydosusceptiblepeoplewhohavesimilarlifeexperiencesdevelop

differenttypesofillness(variabilityissue).Theseindividualdifferencesinillness

susceptibilityisascribedtobiologicalpredispositions(refertoFigure1‐StageIII)suchas

geneticmake‐up,healthstatus,nutritionalstate,physicalfitness,andpre‐existing

pathology.Anotherpossibleexplanationforsomeoftheindividualdifferencesinthe

susceptibilityofillnessmaybetheresultofspecificpatternsofpsycho‐biological

responsestoparticularexperiences.Inadditiontothepsycho‐physiologicalview,another

position,whichisoftenoverlooked,throughwhichpsycho‐biologicalresponsesmay

influencehealthisthecognitive‐behaviouralposition.Thisviewimpliesthatcognitive,

affectiveandbehaviouralcomponentsofthepsychobiologicalresponsecaninfluence

healthindependentlyofanydirectactionofstressonthephysiologicalsystem;thatis,

thatpsychosocialstressorsinfluencehealthalterationsinhealth‐relatedbehavioursand

practices,suchas,drinkingalcohol,smoking,regularexercise,sexualbehaviourortheuse

ofseatbelts.Itwouldappearthatthefrequencyofpatternsarealteredbypsychosocial

stressratherthaninfluencingthem.Othercognitivebehaviouralprocessesinclude

attentiontobodilysymptoms,rangingfromextremepreoccupationtoavoidanceordenial

influencehelp‐seekingbehaviour.

37

38

Emotionallyexpressivebehavioursmayalsoaccountforassociationsbetween

psychobiologicalstressandillness.Forexample,in“crying‐inducedasthma”

bronchospasmisprecipitatedbycryingthroughanonspecificpathophysiological

mechanismsuchasbronchialhyperactivityratherthanaspecificpsychophysiological

cause.Studiesofcryinginducedasthmashowthatitistriggeredoffduringstress‐related

episodesofemotionaldisturbanceandismaintainedbyparentalresponses.Also,adverse

lifeexperiencesmayaffectillnessprogressionbydisruptingadherencetomedical

regimensoradvice.Thepointhereisthatcognitive‐behaviouralelementsofthe

psychobiologicalstressresponsescaninfluencethehealthstatusirrespectiveof

psychophysiologicalconnections.Hence,Steptoe(1991)suggestsanelaboratemodel

detailingthecognitive‐behaviouralandpsychophysiologicalprocessesthatmediatestress‐

illnessrelationships(seeFigure2).

Whatisclearintheprecedingdiscussionisthatstressinfluenceshealthinacomplexway.

Morespecifichypothesesrelatedtovariouscognitive‐behaviouralandphysiological

processesareneededinordertofullyunderstandtheactualprocess.

39

40

CHAPTER3

HEALTHINSOUTHAFRICA

ThehealthsystemofSouthAfricaisuniqueinmanyrespectsbecauseitsdevelopmentand

structurehasbeenstronglyinfluencedbyauniquepoliticalideologyofracialseparation.

Althoughthisideology(theapartheidsystem)hasundergoneradicalchangesinthepast

twoyears,theproblemsandeffectsofthepastwillcontinuetobeexperiencedforavery

longtime.Theracialsegregationofthehealthsystemhasledtodiscriminationand

fragmentationinhealthservicesaswellaslargedisparitiesinhealthservicesbetweenthe

differentpopulationgroups.

Therelationshipbetweenapartheidandhealth,bothdirectandindirect,ismulti‐levelled

anditseffectsarefeltinseveralways:

1 thestate‐providedhealthservicesforblackpeoplearegrosslyinadequate

(DeBeer,1984;Reddy,1990;ZwarensteinandBradshaw,1989;Chetty,1990).This

deficiencyhas,obviously,anegativeeffectonhealthcare;

2 theinequalitiesanddiscriminationshaveledtoseveresocialproblems,suchas,

poverty,unemployment,over‐crowding,pooreducationandinadequatehousing

whichnaturallyadverselyaffectthehealthstatusofthesecommunities

(DeBeer,1984);

3 dietarydeficienciesaffecthealthstatus(DeBeer,1984);

4 disruptionsinfamilylifethroughmigrantlabourandinfluxcontrolhaveincreased

thevulnerabilitytoillnessanddiseases(Uyanga,1983;Maforah,1988);

41

5 thestressoflivingunderanoppressivesystem(Dawes,1990)alsodirectlyaffects

thehealthstatusofbothindividualsandwholecommunities;

6 therestrictionanddistortionofnormalpersonalitydevelopment

(Manganyi,1977);and

7 thepromotionandmaintainingofnegativehealthbehaviourandhelp‐seeking

behaviour.

Thissectionwillfocusonthosefactorsthatcontributetonegativehealthbehaviours.One

factorthathasreceivedmuchattentionisthegrosslackofadequatehealthservicesand

healthfacilitiesforblackSouthAfricans.Theterm“healthfacility”refersnotonlytothe

physicalstructurefromwhichhealthcareisdeliveredbutalsotothequantity,rangeand

qualityofcareprovidedbythefacility.ThehealthfacilitiesinSouthAfricaarebiasednot

onlyinfavourofwhitepeoplebutalsotheaffluentandtheurban.Duringtheperiod1983‐

84,theavailabledataforthehospitalsintheTransvaalshowthattherewere6,27beds

per1000populationforwhitesand3,14bedsper1000forblacks(Buch,1987).Thelackof

servicesandfacilitiesundoubtedlyrestrictedappropriatehealthactiononthepartof

thesepeople.Moreover,thesefacilitiesarealwaysovercrowdedandasaresultthereisa

tendencytodelayseekinghelpbecauseoftheinconvenienceofspendingaconsiderable

amountoftimeinordertoseeadoctor.Patientsoftenspendawholedayinordertobe

seenbythedoctorforafewmoments.Itisnotunusualforpatientslivinginruralareasto

leavehomeandspendaweekintransit,sleepingoveratdifferenthospitalsen routein

ordertoobtaintransporttothemainteachinghospitalinthecity,onlytobeseenbya

doctorforfivetotenminutes(Dr.Hunter,personalcommunication,May1992).Within

suchacontextmedicalhelp‐seekingbehaviourwillbedeterminedalmostsolelybythe

severityoftheillness.Thereisverylittlemotivationtovisitadoctorforacheck‐uporto

screenforillnessordiseases.Itistobeexpectedthatlayorfolkmedicinewillbe

substitutedinthesecases.

Inaddition,healthcareconcernsitselfmainlywithcurativeandhospitalservices.In

certaincommunitiessuchassquatterorinformalsettlements,healthfacilitiesarevirtually

non‐existent.Buch(1987)suggeststhatoneofthereasonsforthisabsenceoffacilitiesnot

42

becomingaseriousproblemforthesesettlersisthat“suchcommunitiesarenotyetina

positiontojudgetheirhealthservicesinthesameastutemannerinwhichtheyjudgetheir

educationandhousing.”(p.52).

Healthservicelocationalsoplaysanimportantroleintermsofutilizationofservicesand

help‐seeking.Thebesthealthfacilitiesavailablehavebeendevelopedincloseproximityto

thecitycentre.Theironyofthesituationisthatnotonlyisitdifficultforruralpeopleto

reachthesefacilitiesbutitisalsonotimmediatelyaccessibletothoselivinginurbanareas

aswell.ThereasonforthisisthatduetotheGroupAreasAct,theurbanblackissettled

awayfromthecitycentre.Blacksarethusfacedwithproblems,suchas,accessibilityof

hospitalsandclinics,transportcostsandtheirinability,especiallyiftheyareold,toget

someonetoaccompanythemontheirlongtriptothecity.Thesefactorsobviously

negativelyinfluencehealthbehaviour.

Anotherfactorthatnegativelyinfluenceshealthbehaviouristhepoliticalclimateinthe

country.Intheprocessoflobbyingforademocraticgovernmentandbetterfacilities,the

ideologiesandstrategiesemployedbyvariousorganisationshavetosomedegree

influencedandaffectedthehealthbehaviouroftheAfricanpeople.“Stayaways”inJune

1991andJune1992showedsignificantdecreaseinvisitsbypatientstohospitals

providingservicesprimarilytoblacks(e.g.KingEdwardVIII)andatblackprivatepractices

aswell.Theprotestsandboycottsbynursesin1991andthestrikescalledbytheNational

EducationHealthandAlliedWorkersUnion(NEHAWU)inJune1992resultedinsevere

disruptionofhospitalservices,creatinginmanyinstanceshealthcrises.Hospitalswere

forcedtoreduceadmissionsandprovideonlyemergencyservices.Whiletheseprotests

andboycottsmayhavecertainnationalpoliticalimplications,itsimpactonhealth

behaviouraswellashealthcareontheimmediate,shorttermandlongtermisnotfully

considered,assessedorcomprehended.Notonlyisthehealthofindividualsjeopardized

butthesesexperienceshavethepotentialofbecomingintegratedaspartoftheirhealth

beliefs.

43

Anothercloselyrelatedfactorthathasanegativeinfluenceonhealthbehaviouristhe

responsetohealtheducationprogramsandtheuseorlackofuseofpresentservicesby

someindividualsasaresultoftheirpoliticalbeliefsandaffiliations.Stateeducation

programsandservicesareoftenviewedwithsuspicion;Forexample,therumourdoingits

roundsinsomeblackcommunitiesisthatAIDShadbeenintroducedintoSouthAfricaby

theStatetodestroytheAfricanrace.Suchviewsobviouslycontributetopoormotivation

inindividualstoattendstatehospitalsandaffectstheirattitudeandbehaviour.Another

concernisthatsometimesstatehospitalsbecomeassociatedwithpro‐government

groups.ItisworthnotingthatinNataltherearestrongaffiliationsamongblackstoboth

theAfricanNationalCongress(ANC)andtheInkathaFreedomParty(IFP).Thelatteris

oftenregardedaspro‐government.(MuchoftheviolenceinNatalhasbeenascribedby

mostpoliticalanalystsasemanatingfromclashesbetweenthesestwogroups.Thereisa

beliefinsomeblackcirclesthatthegovernmenthasperpetuatedtheviolence).For

example,itisquitecommonforpsychoticpatients,whoareadmittedtothepsychiatric

wardatstatehospitals,todevelopdelusionsofbeingindangerfromotherpoliticalgroups

becauseofthebeliefthatthehospitalisinsympathywiththatparticulargroup,orthey

maydevelopadelusionthattheyaregoingtobe“brainwashed”bythegovernmentif

theyarehospitalised.Insomecasesmedicalfacilitiesmaybeunderutilisedpartlybecause

ofthepoliticalallegianceofpeopleinitsenvironmenttoanti‐governmentgroups.Acase

inpointisthePrinceMshiyeniMemorialHospitalinUmlazi.Thisdistrustofmedicalcare

systemshasbeennotedamongstminoritygroups,suchas,Jews,PuertoRicansandBlacks

inNorthAmericaaswell(Geertsen,etal.1975;Lendt,1960).

Further,aperson’sbeliefthatbettertreatmentisprovidedatonlycertainhospitalsmay

alsoinfluenceequitableuseofhealthservices.Forexample,patientsofteninsiston

comingtoKingEdwardVIIIHospitalandnotattendafacilityclosertothembecausethey

believethatsuperiortreatmentisprovidedhere.

3.1CULTURALINFLUENCESONHEALTH

44

Itiswellknownthatculturaldeterminantsplayanimportantpartinmaintainingasense

ofgoodhealth.Culturalvalues,normsandexpectationsinfluenceandshapebeliefs,

lifestyles,familyinteractions,roles,socialorganisationandinstitutions(Gochman,1988).

Culturalinfluencesaffectnotonlyperspectivesonhealth,illnessanddisease(e.g.patterns

ofdiseases)butalsoavarietyofhealthrelatedbehaviours,suchas,beliefsthatunderlie

theutilizationofservices(BerkanovicandReeder,1974),seekingofmedicalcare

(BerkanovicandTelesky,1985)responsestopain,responsestosymptoms,(Guttmucher

andElinson,1971;KlienmanandSung,1979),thesick‐role(Davis,1984)andtheuseof

traditionalhealers(Uyanga,1983;FreemanandMotsei,1992).Suchman(1965a)

emphasizedtheplaceofculturalpatterningonsocialorganizationandhealthservices.The

“totalculture'sbeliefsandbehavioursrelatedtohealth,anditssanctioningandorganizing

ofhealingpracticesarereferredtoasa‘healthculture’”(Gochman,1988,p.243).

ForblackSouthAfricans,alongsidethewesternmedicalsystemexistsanoldtraditional

systemofhealingandhealthcare.Theirculturalandsocialbeliefshavebeenshownto

contributetothewaytheyconceptualizeillnessanddiseaseandusehealthcarefacilities.

Traditionally,theyviewillnessintermsofnatural,moralandmagicalaetiologies.See

Figure3below(Wessels,1985a,1985b).

45

46

Ngubane(1977),indiscussingmodelsofillnessamongZulus,notesthedistinction

betweenillnessesthatareuniversalandtreatablebiomedically(umkhuhlane)andthose

whichmayrequireritualisedandindigenouscures(ukufa Kwabantu‐diseaseofthe

Africanpeople).Umkhuhlane,accordingtoNgubane,refersmainlytothoseillnessesthat

“justhappen.”Theyincludeillnessesthatrangefromcommoncoldstoseriousepidemics

suchassmallpox.Theyareseenaspartoftheprocessofageingresultinginthe

dysfunctionofindividualbodyorgansandalsoincludeorganmalfunctionthatmayleadto

otherillnesses,suchas,excessivebileaccumulation(inyongo)whichisbelievedtocause

headaches,nauseaandgeneraldebility.Includedinthiscategoryarediseasesassociated

withdevelopmentininfants;forinstance,measles(masisi),mumps(uzagiga)and

discomfortduringteething.Alsoincludedinthiscategoryareillnessesassociatedwith

seasonalchanges,suchas,diarrhoea(uhudo)andhayfever(isithimulane)whichoccur

mainlyinthesummer.Umkhuhlane mayalsorefertodiseasesthatarebelievedtobe

inherited.Theseincludeepilepsy(isithuthwane),chronicchestpain,asthmaorchronic

bronchitis(ufuba),skininfections(umzimba omubi)aswellasmentalretardationand

certainmentalillnesses(ufuzo).

Medicinesthatareusedtotreattheumkhuhlane categoryofillnessesarebelievedtobe

verypotentandthereforethereisnoneedfortheiradministrationtobeaccompaniedby

rituals.Peoplearereadytoexperimentandtryanynewmedicinetotreattheseillnesses.

Hencewesternmedicinesforthisclassofillnessesarereadilyaccepted.

Theothercategory(ukufa kwabantu)includesillnesseswhoseaetiologyandmeaningis

basedonAfricanculture.AccordingtoNgubane(1977),ukufa kwabantuisusedto

indicatethat“notonlythedisease,ortheirsymptoms,areassociatedwithAfrican

peoplesonly,butthattheirinterpretationisboundupwithAfricanwaysofviewinghealth

anddisease.”(p.24).Itiswiththiscategorythatmentalhealthworkers,suchasclinical

1 Ngubane's Body and Mind in Zulu Medicine represents the most comprehensive primary source on Health and Disease in the Nyuswa- Zulu thought and practice and is very frequently referenced by most researchers in cross-cultural studies. This source is extensively used in this study. This study has also greatly benefited from this source.

47

psychologistandpsychiatrist,aredirectlyinvolved.(Itisthereforegivenfullertreatmentin

3.2).

Itisimportanttonotethatalthoughthisdistinctionbetween“African”and“non‐African”

illnessesisoftenreferredtointheavailableliterature(Cheetam&Cheetam,1976;

Edwardsetal.1983;LeRoux,1973;Wessels,1984a),itisnotwithoutsomelackofclarity.

Forinstance,Mills(1983;1985)hasfoundthatsomeillnessessuchastuberculosisare

viewedbysomeAfricancommunitiespurelybiomedicallywhereasinothercontextsthey

areviewedinthetraditionalway.

3.2AETIOLOGYOFILLNESSINTHEAFRICANWORLDVIEW

3.2.1 EnvironmentalImbalance

AccordingtoNgubane(1977)conceptsofecologyarecentraltotheZuluideaofhealth

andexplanationsofill‐healthmayoftenlieininterpretationsofenvironmental

imbalances.Thebeliefisthatthereisaspecialrelationshipbetweenapersonandhis

environment,andthatplantandanimallifeaffecttheenvironmentaswell.Because

differentplaceshavedifferenttypesofplantsandanimals,environmentsandatmospheric

conditionsvarybetweenregions.Peopleareacclimatizedtowheretheyliveandmoving

toanewregionmayleadtoillnessuntiltheyhaveadaptedtothenewplace.Itisalso

believedthatwhenmoving,bothanimalsandpeopleleavesomethingofthemselves

behindandalsoabsorbsomethingfromtheatmosphereintowhichtheymove.This

“something”thatisleftbehindiswhatisusedbydogswhentrackingandisknownas

umkhondo(track).These“foreignelements”arethusintroducedintoaregionbypeoplein

theirtravelsorwildanimalsandbirdsthattravellongdistances.Theumkhondomaybe

visibleorinvisible;harmlessorharmful.Harmfultracksarereferredtoasemibi(bad).A

personmaycontactadiseasebysteppingoveradangeroustrackorbreathingitin.The

wordumequisusedtorefertoalldiseasescontractedbysteppingoveradangeroustrack,

regardlessofthesymptoms.Theenvironmentmaynotonlybepollutedbytracksbutby

48

thingsdiscardedduringthetraditionalhealingofsomeone,aswellasbynoxious

substancesplacedbysorcerers.Inthiswaytheenvironmenthasthepotentialtobecome

dangerous.Inordertodevelopandmaintainresistancetoevilorillnessesanequilibrium

mustbeestablishedbetweenapersonandhisorherenvironmentaswellasbetween

individualsinasociety.Thisresistanceisneededbecauseitisalsobelievedthataperson

maybeoverpoweredbythepresenceofanotherpersonandbecomeill.Thebalancewith

theenvironmentisachievedbytheuseof“strengtheningmedicines”.Ideally,

strengtheningshouldoccuratleastonceayearinspringbeforethethunderstorms

becausethesestrengtheningtreatmentsprotectagainstlightningaswell.

Ecologicalfactorsareconsideredtheprimarycauseofavarietyofillness.Forexample,

babiesthatcrycontinuously,appearfearfulorshowgeneraldistressaresaidtosuffer

frominyamazana(problemsresultingfromcertainwildanimaltracks).Greenstool

resultingfromdiarrhoeaandawhite‐coatedtonguearebelievedtobetheresultof

contaminationfromlighteningfumes.Miscarriages,still‐birthsandinfantmortalityisalso

associatedwithpollutantsintheenvironmentwhicharecontractedbypregnantor

nursingmotherswhotheninfecttheirbabies.Inadults,symptomsrangingfromgeneral

infirmityofthebodytoevilpossessionareassociatedwithdangersintheenvironment.

3.2.2 SorceryandIllness

Illnessesmayalsoresultfromsorcery(ubuthakathi).Therearethreetypesofsorcerers:

Thefirst,isthe“nightsorcerer”whoisbelievedtobeevil.Theyarealwaysmenandthey

harmothersfornoapparentreason.Anightsorcererusesevilmedicines(potions)andis

believedtohavesupernaturalpowers,suchasresurrectingcorpsesbut,hecannotfly,

changeshape,becomeinvisibleorperformactsassociatedwithwizards.Hisaim,

accordingtoNgubane(1977),istomaketheenvironmentdangerousorputpeopleoutof

balancewiththeenvironment.Heachievesthisbyplacingharmfulmedicinesinthe

environmentsothatpeoplemaystepoveritandcontractumeqo.Thesecondtypeis

referredtoasthe“daysorcerer”whoactsoutrivalryandcompetition.Thesesorcerers

49

maybemenorwomen;thelatterareinthemajority.Theirmethodofharmingpeopleis

referredtoasukudlisa,whichistheaddingofnoxioussubstances,includingwestern

poisons,tothevictim'sfood.Theymayusesupplementarytechniques,suchas,placing

harmfulsubstancesinthevictimspathorstealportionsoftheirvictimssacrificialanimalin

ordertonullifythesacrificeorreverseitspurpose.Thethirdtypeisthe“lineagesorcerer”

(uzalo).Theuzalo aremembers(onlymen)ofacommonlineagewhosharecertainritual

andsocialobligationstowardseachother.Theyarenotsupposedtopractisenightorday

sorceryagainsteachotherbecausethiswillangertheancestors.However,amancan

persuadetheancestortofavourhimandabandononeormoreoftheothermembersof

thelineage.Thisisachievedbytheuseof“blackmedicines”(ukuphehla amanz'amnyama)

inthetreatmentofdisease.

3.2.3 AncestorsandIllness

Ancestors(Ngubane,1977)areprimarilyconcernedwiththewelfareoftheirdescendants.

Whenthingsgowell,peoplebelievethattheyhavethesupportoftheancestors

(Abaphansi banathi)andwhenmisfortunebefallsthem,theancestorsarebelievedtobe

“facingawayfromthem”(Abaphansi basifulathele).Therearetwoclassesofancestors:

thosewhocanpunishorprotectandreward,suchas,aman'smother,father,paternal

grandparentaswellaspaternaluncles;andthosethreegenerationremoved,whodonot

punishorrewardbutareallowedasguestsoftheformerancestralgroup.Theancestors

arebelievedtoliveunderneaththeearth.Theyfrequentthehutofthemostsenior

womenofthegroup(indlu enkulu)andthebyre.Theancestorsareappeasedthrough

sacrifices.Thefollowingisthelistofthesacrificesthatareperformed:

1 Imbeleko‐asacrificetoplaceababyundertheprotectionofancestors;

2 Ukubuyisa‐asacrificetointegratethedeceasedwiththerestofthebody

ofancestralspirits;

3 Ukubonga‐asacrificeforgoodthingsinlife,eg.winningmoneyand

obtainingagoodjob;

50

4 Ukucela izinhlanhla‐asacrificetoseekblessingsfromtheancestorsbefore

undertakinganymajororriskytask,eg.goingtoamajorcitytoseek

employment;

5 Ukushweleza ‐asacrificetoappeasetheancestorsifthereisevidencethatthey

havebeenannoyed;.

6 Ukuthetha‐asacrificeto“scold”theancestorsifmisfortunecontinuesin

spiteoftheirattempttoappeasethem;and

7 Ukukhomba inxiwa‐asacrificewhenmovinghousetoshowtheancestors

thenewhome(Nugubane,1977).

Withouttheprotectionofancestorsthepeoplebecomevulnerabletomisfortuneaswell

asdiseases.Ancestorsaremostoftenannoyedbyquarrellinginahome,lackofpeaceor

thenon‐fulfilmentofmaritalduties.Examplesofillnessesandmisfortunesresultingfrom

thedispleasureoftheancestorsareinfertility,miscarriages,delayedconception,the

suddenillnessofchildren,strokes,paralyses,sleeplessnessandtensionorstrifeinthe

household.

51

3.2.4 Umnyama andIllness

AnotherimportantconceptintheAfricanviewofillnessisumnyama(Ngubane,1977).It

canbetranslated“pollution”whichisconceptualizedas“amysticalforcewhich

diminishesresistancetodisease,andcreatesconditionsofbadluck,misfortune

(amashwa),‘disagreeableness’and‘repulsiveness’(isidina)wherebypeoplearoundthe

patienttakeadisliketohimwithoutprovocation”(p.78).Umnyama initsworstformis

contagious.

Thebehaviouralpatternofthoseinastateofumnyamaisreferredtoasukuzilaandis

characterizedbywithdrawal,asocialbehaviourandabstinencefrompleasurableactivity;

Thoseinflictedbecomepassive,softlyspokenandlethargic;theylosetheirappetitesor

eatsmallquantitiesofpoorqualityfoodanddresssloppily.Post‐partumwomenare

regardedaspolluted(umdlezane)andcanpolluteandcauseill‐healthtotheirchildrenand

family.Thevirilityofmenisaffectediftheyeatfoodcookedbyherorshareeatingutensils

withher.Sheistobeconfinedbecauseevencontactwithcattlewillstoptheirproduction

ofmilk.Shemaynotevengointothefieldslestthecropswither.Otheroccasionsof

pollutionaremenstruation,sexualintercourse(menandwomenareconsideredpolluted

thedayfollowingsexualintercourse),premaritalsex(i.e.thefemalesareconsidered

polluted)andfighting.

Pollutionisalsoassociatedwithdeath.Itisbelievedthatpollutionemanatesfromthe

corpseandthosethathandlecorpsesandthoseassociatedwithdeatharepolluted.This

pollutioniscontagious.Certaindeathsareregardedasmoreintenselypollutingthan

others.Thesearedeathsthroughcaraccidents,drowning,beingstruckbylightning,

fighting,murderand,thosewhodieofincurablediseases,epilepsyandchronicchest

diseases.Theirbodiesareneverbroughttothehomebutareburiedoutsideandweeping

isrestrained.Withregardtomurder,inadditiontothepollutionofthedeath,the

murdererisespeciallypolluted.

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Itisinterestingintheresolutionofthispollutionthroughritualthatpsychologicalaspects

ofimportantlifeeventsareaddressedanddealtwith.Thetraditionalritualsandcultusis

endemictotheprocessofcopingwiththestresses,anxietiesandemotionalinstabilitythat

accompanyimportanteventsinboththelifeofindividualsandcommunities.Clinical

psychologistsprobablyobtaintheirmostimportantcluestounderstandingthepsycheof

theirAfricanpatientstotheextenttheattitudesinformingtheseritualresolutionsare

understood.AsNgubane(1977)pointsout“emotionalstressesenduredduringbothbirth

anddeath—thetwomainspringsofpollution—arepreventedfrominitiatingneurosesby

thediversionoffocusfromunpleasantexperiencestoacomplexityofritualbehaviour.

Thementalstressesandstrainsexperiencedduringthemajorlifecrisesareseenasa

possiblecauseofpermanentdamagetosomepeople'smentalbalance,andthisis

expressedasanoutcomeoffloutingthebehaviourpattern.”(p.82).Wemayaddthateven

wherethereisnodangerofmentalimbalance,thetraditionalperceptionoftheall‐

pervadingpossibilitythatpollutionaffectsgeneralattitudestopsychologicalwell‐being

andsicknessorhealthbehaviour.

3.3ILLNESS,SICK‐ROLEANDHELP‐SEEKINGBEHAVIOUR

AccordingtoNgubane(1977),inZulusociety,whenpeoplefeelsicktheyreportthisto

thosearoundthem.Theyobservethesymptomsandtryandassociateitwithadisease,at

firsttodecidewhetheritisaminorailmentwhichcouldbetreatedathomeoraserious

illnesswhichneedstheattentionofanexpert.Theseverityoftheillnessisassessedbythe

behaviouroftheperson.Ifapersonissickbutcontinuesworkingheorsheissick“but

goesaboutwithit”(uhamba nako).Ifheorsheliesdown(ulele phansi)theillnessis

consideredseriousandthosearoundhimorherbecomeconcerned.

Ifminorailmentspersistorworseninspiteofhomeremedies,anoutsideopinionis

soughtbytakingthepersontoeitheradoctororatraditionalhealer.Itwouldappearthat

noparticularhelp‐seekingbehaviourpatternisfollowedhere.Thedecisiontocontacta

doctororhealerisinfluencedbyfactorssuchastheseriousnessoftheillness,availability

53

ofhealthservices,financialimplicationsandthepersonresponsibleforthedecision.The

headofthehomehastomakethedecisionwhethertoseeatraditionalhealer,doctoror

homeremedies.Iftheheadofthehouseholdisabsentanothermaymakethedecisionbut

nomajordecisionsuchashospitalisationcanbemadewithoutconsultingtheheadofthe

home.Itisimportanttonoteherethatsincetheheadisusuallyawayfromhome(e.g.he

maybeamigrantlabourerinanothercity)thedelayinconsultationcontributestodelays

inhealthaction.

Supportisusuallyprovidedbytheimmediatefamilywhonurseandgivethepatient

attentiondayandnightifrequired.MsengiandDaynes(1981)reportedthatthe

managementofillnessofAfricansintheTranskeiwasprimarilydonebyrelativesandthen

neighbours.Doctors’ordersarestrictlyadheredtoandifnecessaryoutsidevisitorsmay

notbeallowedtovisitthepatient.Familymembersinastateofumnyamamaynotcome

intothehousewerethepatientis.

Ngubane(1977)referstocertaintypicalattitudesandbeliefsthatareimplicitinthis

world‐view.Forinstance,malingeringistreatedwithgreatcontemptandnoself‐

respectingpersonwouldconsiderit.Withregardstosick‐role,apersonisencouragedto

getupassoonasheorshecanbecauseitisbelievedthatlyingdown(unlessabsolutely

necessary)weakensthebody.Gettingupandmovingaroundisbelievedtospeedup

recovery.Africansocietyencouragesstoicism.Painisexpectedtobetoleratedwithout

complaining.Forexample,awomaninlabourwhodoesnotutterasoundiscongratulated

andcomplimentedwhereasthosethatcrydisgracetheirfamily.Inaddition,asickperson

isencouragedtoeattostrengthenthebodyandpromoteaspeedyrecovery.Softfoods

andliquidsarepreparedforthosewithpoorappetites.Inthecaseofinfantswithlossof

appetite,theyare“forcedfed”bytheprocessukaxaka,whichistheholdingofthenoseof

childrensothattheybreathethroughtheirmouthwhichforcesthemouthopensothat

theycanbefed.

3.4TRADITIONALTREATMENTS

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Traditionaltreatment,accordingtoNgubane(1977),isprovidedbytheinyanga

(traditionaldoctor)andisangoma(diviner).Theinyanga,usuallyaman,mustfirstserve

anapprenticeshipforaperiodnotlessthanayear.Sometimestheskillispassedfroma

fathertoasonwhoshowsaninterestintraditionalmedicine.Theisangoma,usuallya

woman,isrequiredtohaveacomprehensiveknowledgeoftraditionalmedicine.Aperson

is“called”orchosentobeaisangomabytheancestorswhobestowspecialpowersonthe

individual.Inadditiontotheinyangaandtheisangomatherearethosewhoprepare

medicinesforaparticulartypeofillnessorpossessknowledgeonhowtodealwith

particularhealthrelatedsituations—theyareknownasthe inyangaofaparticular

diseaseorcondition,forexample,inyanga yomhlabelo—thedoctorwhohandles

fracturedbones.Thesearetheequivalentsofspecialisthealers.

TraditionalhealersplayacentralroleinAfricanruralcommunitiesbuttheirinfluenceis

stillfairlyextensiveamongindustrialisedandurbancommunitiesaswell(Wessels,

1984b).TraditionalhealersaccordingtoCheetamandGriffiths(1980)andWessels(1983;

1985c)arehighlyrespectedindividualsintheircommunitiesandareusuallyconsultedfirst

byallAfricansexceptthosewhohavebecomehighlywesternized.(Wessels,1985c).De

Beer(1980)reportedthat60percentofconsultstotraditionalhealerswerefortreatment

ofadisease.Watts(1980)foundthatthereisatendencytounder‐reporttheuseof

traditionalhealerswhichmeansthatDeBeer'sestimateislowerthanitmayinfactbe.

Withtheriseanddevelopmentoftheindigenouschurches,anewtypeofhealerhas

emerged‐the“prophets”or“faithhealers”(Wessels,1987a,1987b).Theyuseboth

traditionalmethodsaswellas“Christianapproaches”intheirtreatments.Themain

differencesbetween“faithhealers”and“traditionalhealers”arethattheseprophetsare

Christianswhoarechurchleaders;Theyprayanduseholywater,andthesacramentsof

baptism,theeucharistandunction,whereasdivinersusetraditionalherbs,bonesand

medicines(Wessels,1987b;1989).Theprophetsmaybelessknowledgeableofthe

sicknessspecifictoAfricanculturethantraditionalhealers.Inadditiontohealingthose

whohavesufferedmisfortune,faithhealersministertothosewhosufferfrom

55

schizophrenia,epilepsy,mentalretardation,andinheriteddisorders.AccordingtoWessels

(1987b),faithhealersplayaveryusefulroleintheAfricancommunityinhandlingdayto

dayproblemsofliving.Hemaintainsthatbecauseoftheirefficacyinassistingpeoplein

needtheyshouldbegivenrecognitionandtrainedasvillagementalhealthworkers.The

factthattheAfricanIndependentChurchesarethefastestgrowingreligiousmovementin

Africa(thereareover3000differentchurchesinSouthAfricaalone)indicatestheextent

oftheirsuccessinAfricansocieties(Oosthuizen,1986;Sundkler,1976).

Inadditiontoritualssuchasdancing,callingupthespiritsoftheancestorsandbone

throwing(Ngubane,1977;Wessels,1985c)medicinesarealsoadministered.Theseare

usuallymadefromleaves,bark,rootsstems,bulbs,fruitand/orseedthatareeitherfresh

ordriedandsometimespowdered.Thesemedicinesareoftenboiledandtakenorally.

Theyaresometimesusedaspurgatives,usuallytoreduceexcessgallwhichisbelievedto

bethecauseofstomachdisorders.Purgativesarealsotakenintheformofanenema.Itis

believedthatthepurgativescleanoutthecauseoftheillness.Thispractice,however,has

oftencontributedtoirreparablephysicaldamageandevendeath.Inthehospitalsitisa

verycommonexperiencetofindchildrenandadultseriouslyillasaresultoftheuseof

purgatives.Variouslethalsubstanceshavebeenfoundtobeusedasenemas;themost

commonareJeyesFluid,detergents,batteryacidandpotassiumpermanganatethatare

believedtohavecleaningproperties.Someoftheherbsthatareused(e.g.impela)are

extremelypoisonous.Sometimesherbsarebelievedtomakeindividualsomnipotent.For

example,intelezi,whichisgiventoindividualstomurderothersbuttheseindividualswill

notcometodangerorfeelremorseovertheiractions.

Theherbalmedicinesaredividedintothosethathavehealingpropertiesandthosethat

areusedinritualsandhavesymbolicmeaning.Thislattergroupisusuallyusedas

prophylacticsortoremovethecauseofillnessratherthantocureorganicsymptoms.

Faithhealersuseprayerandholywater(iziwasho)forthispurpose.

Based on actual cases seen by the author.

Based on actual cases seen by the author.

56

CHAPTER4

METHOD

4.1SUBJECTS

Thetotalsampleinthisstudy(N=892)consistedof3groupsofurbanAfricanswhowere

20yearsandolder.Group1(N=376)comprisedfirsttimeattenderstothemedical

outpatientsdepartmentattheKingEdwardVIIIHospitalinDurban,SouthAfrica.Theages

rangedfrom20to74yearswithameanof34,88years.Group2(N=362)andGroup3

(N=154)weresamplegroupsdrawnfromtheUmlaziTownshipandtheKwaMashu

Townshiprespectively(seefigures4and5).Thenumberofsubjectsselectedforeachof

theGroups1,2and3weredrawnpro ratatothetotalpopulationofthehospitalout‐

patients,UmlaziandKwaMashutownships,respectively.Throughoutthestudythe

groupswillbereferredtoandidentifiedasfollows:Group1willbereferredtoasthe

HospitalGroup,Group2astheUmlaziGroupandGroup3astheKwaMashuGroup.

TABLEIDISTRIBUTIONOFSAMPLEBYSEXGroup Male(%) Female(%) TotalHospital 164 (43.62) 212 (56.38) 376Umlazi 160 (44.20) 202 (55.80) 362KwaMashu 64 (41.56) 90 (58.44) 154Total 387 (43.50) 498 (56.50) 892

57

58

59

4.1.1 GeneralHospitalGroup

TheKingEdwardVIIIHospital,wherethehospitalsamplewasobtained,wasofficially

openedinDecember1936.Originally,itspurposewastoprovidegeneralmedicalcarefor

AfricansandIndianspatientswhowereatthattimeinadequatelycateredforinthe

existingprovincialhospitals(Dyeretal.,1986).Dyeretal.(1986)pointoutthatthe

hospitalwasbesetwithfinancialproblemsfromitsinception.Thelackoffundswas

partiallyalleviatedbysecond‐handequipmentfromAddingtonHospital,Durbanandthe

initiativeofthenurseswhomademattressesfromthegrassgrowinginthehospital

grounds.Themajorproblemwastheshortageofbeds.Theproblemoftheshortageof

fundsandbedspersiststodayinspiteofthegradualbutsignificantimprovementsmade

overtheyears.Thehospitalwasextendedasmoregroundadjacenttothehospitalwas

acquired.AnotherextensionwastheacquisitionoftheWorldWarIIImperialForces

transitcampatClairwood,Durban,whichwasthendevelopedintothepresent1400‐bed

ClairwoodHospital.Furtherfacilitiesweredevelopedawayfromthehospital,suchasthe

BeatriceClinicinthecitycentrewhichisstillpresentlyoperative.Withtheinceptionofthe

MedicalSchoolin1951,majorexpansionofthehospitalwasundertaken(Dyeretal.,

1986).Today,KingEdwardVIIIHospitalisoneofthemajortraininghospitalsinthe

country.

ThemedicaloutpatientsdepartmentattheKingEdwardVIIIHospitalannuallyattendsto

over1millionpatients.Approximately1500newpatientsareseeneachweek.A

representative,stratifiedsampleoffirsttimeattenderswasselected.Aproportionofthe

samplewasdrawnoneachdayoftheweekattheoutpatientsbecauseofthevariationof

thenumberofnewpatientsattendingeachdayoftheweek.Theformulausedtoobtain

thesamplewas:

2 The choice of sampling techniques, statistical methods and analysis employed in this study were done in consultation with and under the supervision of two statisticians of the Medical Research Council (MRC).

60

where:N1 = No.ofpatientsperNday

(averageover4consecutiveweeks)

N = No.ofpatientsperweek

(averageover4consecutiveweeks)

376 = totalgroupsample

Nday = dayoftheweek

4.1.1 CommunityGroups

ThecommunitysamplesweretakenfromthetwolargestAfricantownshipsclosestto

Durbannamely,UmlaziandKwaMashu.TheUmlaziTownshipwhichislocatedtothe

southofDurbanwithapopulationof306490(populationcensus,1991‐providedbythe

CentralStatisticalServices,Durban)andtheKwaMashuTownshipissituatednorthof

Durbanwithapopulationof156621(populationcensus,1991‐providedbytheCentral

StatisticalServices,Durban).

Arepresentative,randomsamplewasused.Withtheaidofsiteplansalldwellingswere

countedandassignedanumber.Acomputerwasusedtogeneraterandomnumbers

whichwereusedtoselecttheactualhomestobevisitedbytheinterviewers.Alistof

‘spare’homeswasalsogeneratedintheadventofalternativenumbersbeingrequired.

3 This figure represents the last official census of the township. However, this figure does not take into account the large number of squatters in the area.

61

Theurbantownshipsampleswereusedasacontrolgroupbothagainstwhichthehospital

clinicgroupwascompared,andinordertovalidatesomeofthequestionnairesthatwere

usedinthestudy.

4.2METHODOFDATACOLLECTION

TheHIB(AppendixA)inthelanguageoftheparticipants,wasadministeredbytrained

blackinterviewers.Theinterviewersemployedforthisstudyhadatleastamatric

qualificationandwerefluentinEnglishandZulu.Theywerepersonallytrainedbythe

authorandafterdemonstratingsufficientexpertisewereacceptedfortheproject.They

wereaskedtoadherestrictlytotheinstructionsandthetermsdefinedinordertoreduce

thelevelofbias.Theanswerstotheopen‐endedquestionsweretakenverbatiminZulu

andsubsequentlytranslatedverbatimintoEnglish.Ifthequestionwasnotproperly

understooditwasexplainedagaininanopen‐ended,non‐suggestivewayandtheanswer

wasoncemorerecordedverbatim.Therewereseveralreasonsfortheuseofopen‐ended

questions:toascertainpopularandfolkideas,attitudes,valuesandbeliefs;toidentifythe

predominantfactorsofconcernandtoavoidthepossibilityofsuggestionintheanswers.

Thisapproachisconsideredanacceptablewayofobtaininginformationincross‐cultural

settings(Schlebuschetal.,1990).

4.2.1 HospitalGroup

Theinterviewerselectedevery10thnewpatientwaitingtobeseenbythemedicalofficer

atthemedicaloutpatientsdepartment.TableIIbelowshowshowthesamplewas

obtainedsothatitwouldberepresentativeofallthepatientsseenatthehospital.The

finalnumberperday,includedinthehospitalsample,wasbasedonanaveragetakenover

threeweeks.

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TABLEII SAMPLESELECTIONFORHOSPITALGROUPWk Mon Tues WedThurs Fri Sat T1 310 300 269 242 240 64 14252 297 279 261 208 207 45 12973 280 271 206 214 173 22 1166T l887 850 736 664 620 131 3888Av 295.67 283.33 245.33 221.33206.6743.67 1296Sm 79.84 76.51 66.26 59.78 55.83 11.80 T=total;Av=averageandSm=sample

Interviewersintroducedthemselves,explainedtothepatientwhatthestudywasallabout

andrequestedtheirparticipation.Theyweretoldthattheirparticipationwasvoluntary

andthattheirrefusaltoparticipatewouldnotprejudicetheminanyway.Ifthepatient

decidedtoparticipate,theinterviewerassistedthepatientcompletetheHIB.

Aftercompletion,theinterviewerthankedthesubjectfortheircooperationandthetime

theyhadvolunteered.

4.2.2 CommunityGroup

Theinterviewersequippedwithasiteplanoftheareawiththeselecteddwellingsmarked,

visitedthepre‐determinedaddressesduringtheeveningsandonweekendsinorderto

ensurethatallthemembersofthefamilywereathome.Theyintroducedthemselves,

63

explainedthepurposeofthestudyandrequestedtheirparticipation.Whenpermissionto

conductthestudywasobtained,theinterviewerallocatedanumber(printedonadisc)to

eachmemberofthehousehold,eventhoseunavailableatthetime.Thediscswere

thrownintoapacketandonewasrandomlyselected.Theindividualrepresentedbythe

selecteddiscwasaskedtocompletetheHIBwiththehelpoftheinterviewer.(Ifthe

personselectedwasabsent,theinterviewerreturnedbyappointmenttocomplete

theHIB).

OncompletionoftheHIB,theinterviewerthankedthesubjectandothermembersofthe

familyfortheircooperationandthetimetheyhadvolunteered.

Theinterviewerswentthroughthelistofpre‐selectedhomesinexactlythesamemanner.

Ifpermissiontoconducttheinterviewwasrefusedoraparticularhomecouldnotbe

visited,theinterviewerselectedoneofthehomesfromthesparelistinstead.The

completedHIBwasreturnedtothewriterforanalysis.

4.3MATERIALS

TheHIBcomprisedofthefollowingquestionnairesandinventorieswhichwereusedto

elicitinformation:

1. HealthandIllnessQuestionnaire(HIQ)

2. HealthBeliefQuestionnaire(HBQ)

3. SocialSupportQuestionnaire(SSQ)

4. Hopkin'sSymptomChecklist(HSCL)‐(modified)

5. LifeExperienceSurvey(LES)‐(modified)

4.3.1 HealthandIllnessQuestionnaire(HIQ)

64

Thisquestionnairewasdesignedbythewritertoelicitinter aliainformationonhealthand

illness(seeAppendixA,pp1‐6).Thequestionnaireisdividedintoseveralsub‐sections.

Section1.1‐7(p.1)wasusedtocollectbiographicalinformationsuchasage,sex,ethnic

group,educationallevel,district,thenumberofyearsofresidenceinanurbanareaand

natureofemploymentorworkingskills.

Section2.1‐5(p.1)wascompletedbythehospitalgrouponly.Thissectionassessedfactors

suchascostoftransport,timetakentotraveltothehospital,availabilityofsickleaveby

patientswaspertinent,therefore,onlytothehospitalgroup.

Section3.1‐8(p.2)wascompletedbythehospitalgrouponlybecauseitelicited

informationthatdealtwithfactorsassociatedwithhospitalattendance.Thesewere

factorsthatprecipitatedthepatientsattendanceatthehospital,theperson's

understandingoftheseprecipitatingfactors,thechoiceofhospitalandthenatureofthe

disclosuretoothersabouthisorherillness.

Section4.1‐3(p.3)wascompletedbythecommunitygrouponlybecausethesequestions

assessedthechoiceofservicesinthecommunity.

Section5.1‐5(pp.3‐4)lookedattheuseofmedicalandsupplementaryservicesand

medication,andwascompletedbyallthegroups.

Section6.1‐5(pp.4‐5)elicitedinformationonreligiousandculturalbeliefs.Theseincluded

religiousaffiliations;consultationwithtraditionalhealers,faithhealersandherbalists;

costofservicesprovidedbytraditionalhealersandtheuseofprayer.Allgroups

completedthissub‐sectionofthequestionnaire.

Section7.1‐5(pp.5‐6)assessedhealthandillnessbeliefs.Subjectswererequiredtoexplain

whattheyfeltconceptssuchas'ill','sick','well'meant.Theywererequiredtolistwhat

65

theythoughtmadepeoplesick,whathealthactionsweretakenand/orwhathelp

seekingoccurred.

4.3.2 HealthBeliefQuestionnaire(HBQ)

Thisisa31itemquestionnaire(seeAppendixA,p.7)designedforthepurposesofthis

studytoascertainhealthandillnessbeliefs.Asdiscussedalreadyinthepreviouschapters,

thehealthandillnessbeliefsarenotonlystronglycolouredbythetraditionalworld‐view

butthattheAfricanviewofillnessisuniqueinmanyrespects.Further,thegroupsbeing

assessedareacculturatingandareadoptingwesternbeliefsaswell.Noneoftheexisting

scalesonhealthandillnessbeliefswerefoundtobesuitablebecausetheyeitherdidnot

takeintoaccounttheAfricanconceptofhealthandillnessorwerestandardisedfor

westernpopulations.Inaddition,theydidnotassessthesevariablesatalevelsuitablefor

thepurposeofthisstudy.Further,somescaleswereeithertoogeneralforourpurposeor

werespecificallyconstructedtomeasurementalhealth.Theseincludescalessuchas,the

HealthLocusofControlScale(Wallston,Wallstonetal.,1976)ortheMultidimensional

HealthLocusofControlScale(WallstonandWallston,1981)andRotter'sInternal‐

ExternalLocusofControlScale(Rotter,1966).

Thecomplexsystemofhealthandillnessbeliefsofthiscommunity,therefore,

necessitatedthedevelopmentofanappropriatequestionnaire.Thequestionnairehadto

haveitemsthatwererelevantforthiscultureandhadtobebroadenoughtomeasurea

varietyofhealthbeliefstotakeintoaccounttheacculturationprocessatworkinthis

community.

TheHBQrequirestherespondentstorateonafourpointLikertscalewhethertheyagree,

sometimesagree,disagreeorwere‘notsure’aboutthestatementpresented.

66

4.3.2.1ConstructionofQuestionnaire

BasedonareviewofliteratureonAfricanbeliefs,thesuggestionsofsixmentalhealth

professionalsworkinginacross‐culturalsettingandwhodealprimarilywithAfrican

patientsandthepersonalexperienceofthewriter,38itemswereselected.Thefaceand

contentvalidityofthequestionnairewasestablishedbyaskingapanelofexpertsinthe

areaofcross‐culturalissuestochecktheitems.Thepanelofexpertsweremadeupof

threeclinicalpsychologistsandtwopsychiatristswhomaderecommendationstoimprove

theselectionofquestionsandthesesuggestionswereincorporatedinthescale.

4.3.3 SocialSupportQuestionnaire(SSQ)

AsocialsupportmeasurewasincludedintheHIBbecauseoftheviewthatsocialsupport

actsasabufferagainstdiseaseandare,therefore,necessaryfortheindividualtocope

withlifechangesandadverseevents.TheSSQisa15itemquestionnaire(seeAppendixA,

p.8)designedbythewritertomeasureprimarilythequalitativeandquantitativeaspects

ofaperson’snetworkofrelationshipsthathelphimorherinadversecircumstances.A

reviewofseveralsocialsupportquestionnairesshowedthattheywereinappropriateasa

measurementinthecontextofAfricanculture,apointmadealsobyMcFarlaneauthorof

‘TheSocialRelationshipScale’(personalcommunication,10September,1990).The

variationinthestandardsofsocialadjustmentfromoneculturetoanotherisregardedas

amajorprobleminthemeasurementofsocialsupport(Weissman,1975).

ThesocialnetworkamongblackSouthAfricansisuniqueinmanywaysastheusualsocial

supportsarenotavailable.Africanfamilyunitshavesteadilybeenbrokenup.Maforah

(1988)pointsoutthatthedisintegrationoftheAfricanfamilyhasbeeninfluencedinter 

aliabyEuropeancontactwithAfricawhichdisruptedfamilylife;neweconomicsystems;

politicalexploitationbroughtaboutbyforcedlabour,racialsegregationandalienation

fromtheland.Inourpresentcontext,fathersandmothersaswellareforcedtoliveaway

67

fromtheirfamiliesinordertofindworkorfurthertheirstudies.Lawsgoverningblackre‐

settlement(e.g.theNativeLandActsof1913and1936,thehomelandspolicyandthe

GroupAreasAct)haveallcontributedtotheerosionofblackfamilies.Theireffectslast

longaftertheyhavebeenremovedfromthestatutebooks.

IndevelopingthisquestionnaireIwasguidedmainlybytheSarason'setal.(1985)Social

SupportQuestionnaire,McFarlaneetal.(1981)SocialRelationshipScaleandThe

MultidimensionalScaleofPerceivedSocialSupport(Zimetetal.,1988).

Eachquestionhasatwopartresponse.Firstly,therespondentsarerequiredtolistthe

peopleintheirenvironmentwhoprovidethesupportsuggestedbythequestion.

Secondly,theyarerequestedtoratetheirlevelofsatisfactionwiththesupporteitheras

verysatisfied,satisfied,dissatisfiedorverydissatisfied,ona4pointLikertscale.The

questionnairealsoallowstherespondenttoratetheaccessibilityofsupport,theproximity

ofthesupportandthemodeofsupport.

4.3.3.1ConstructionofQuestionnaire

Afterselectingtheitemsforthequestionnaire,theyweregiventothreepsychiatristsand

twoclinicalpsychologistswhohadworkedwithAfricanpatientsforover10years,fortheir

opinions.Therewasgeneralagreementamongthemthatthequestionnaireshouldalso

assesswhetherthereissomeoneavailableatalltimeswhowouldprovidehelp,whether

thesepersonswereavailableimmediatelyorlivedadistanceaway,themodethrough

whichsocialsupportisobtained(whetherinperson,bytelephoneorthroughthepost)

andtheassessmentofnon‐familysupport(forexample,neighbours,priestsand

communityleaders).Othersuggestionsincludedincreasingthenumberofitemssothat

itemswouldbemorespecificandthere‐phrasingofsomeitems.Theserecommendations

wereassessedandseveralincludedinthequestionnaire.

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4.3.4 SymptomInventory(SI)

Anessentialstepintheprocessofseekinghelpforone'sillnessistheinterpretationthat

thesufferergivesofthesymptomsheorsheexperiences(Bishop,1984;Mechanic,1978;

Pennebaker,1982).Mostoftensymptomsareignoredorgountreatedandsometimes

evenserioussymptomsareignored(Bishop,1984).AccordingtoBishopandConverse

(1986),itisessentialtotakeintoconsiderationthewaysinwhichlaypersons

conceptualizephysicalsymptomsanddiseasesincethisprocessplaysacriticalrolein

determiningaperson'shealthbehaviour.Forexample,Matthewsetal.(1983)showed

thattheinterpretationgiventosymptomsofmyocardialinfarctioninfluencestheurgency

ofmedicalhelp‐seekingaswellasillnessbehaviourandsickrolebehaviour.

Itwas,therefore,alsonecessarytoassesstheperceptionsandinterpretationofthe

commonsymptomsinthisstudyaswell.TheSIusedinthisstudyisamodifiedversionof

theHopkin'sSymptomChecklist(1974).Thewriterusedtheoriginal58itemsandadded

25additionalitemstomakethescaleappropriateforthepurposeofthisstudy.The

additionalitemswereobtainedthroughaprocessofinterviewswithseveralmedical

doctorsfromboththemedicaldepartmentsandpsychiatricdepartmentsattheKing

EdwardVIIIHospital.Thoseconsideredascommonsymptomswereincludedasthe

additionalitems.

Thesubjectshadtoindicatedwhethertheyhadexperiencedthesymptomandthereafter

rateitsseverityonafourpointLikertscalerangingfromveryserioustonotserious.A

categoryofnotsurewasalsoincluded.

Itwasenvisagedthatthepresentstudycouldalsobeusedtodevelopastandardised

symptominventoryscaleforSouthAfricanconditions.SeeAppendixA.

4.3.5 LifeExperienceSurvey(LES)

69

Twowidelyusedinstrumentsusedforassessinglifechangesandexperiencesarethe

ScheduleofRecentExperiences(HolmesandRahe,1967,andtheLifeExperienceSurvey

(Sarasonetal.,1978).AmodifiedversionoftheLifeExperienceSurveywasusedinthis

study.Thewriterusedtheoriginalscaleinordertodevelopaninstrumentspecifically

usefulfortheSouthAfricancontext.AsinthecaseoftheSItheoriginalitemsoftheLife

ExperienceSurveywasexpanded,inthisinstancebythreeadditionalitems.Theitems

thatwereincludedreferredtotherecentexperiencesofviolenceandtheresultanteffects

inthepopulationunderstudy.Theothermodificationstothisquestionnaireincluded

changingmonetaryvaluesfromU.S.dollarstoSouthAfricanequivalents.

4.4TRANSLATIONOFQUESTIONNAIRES

AllquestionnairesweretranslatedintoZulu,thespokenlanguageofthepeople

participatinginthestudy.TheEnglishversionofthequestionnairewasgivenfor

translationtotwoqualifiedandexperiencedhealthworkers(aclinicalpsychologistanda

psychiatrist),whohavebeenworkingwithAfricanpatientsandwhowerefluentinboth

ZuluandEnglish.

Thetranslatedquestionnairewasthengiventoanindependenthealthworker(a

psychiatrist,whowasfluentinbothEnglishandZulu)totranslatebackintoEnglish.

Whereverdiscrepancieswerefound,theywerecorrected.Thismethodofbacktranslation

isanacceptedmethodandisknowntoproducetranslationsofagoodquality.(Brislin,

1980).Inaddition,thetranslationandconstructionofallquestionnairesweredonein

accordancewiththeguidelinesandrulessuggestedbyRetief(1988)onthewritingand

modifyingofitemsforcross‐culturaluse.

ItshouldbeborneinmindthatthereismuchvariationintheZuluthatisspokeninthe

ruralareascomparedtothatspokeninthetownshipsandcities.Theaimwastoachievea

levelsuitablefortheurbangroupbeingstudiedandtoalsomakeitunderstandableata

muchbroaderlevel.

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4.5PILOTSTUDY

TenvolunteerssimiliartothoserequiredinthesamplewereaskedtocompletetheHIB.At

thisstagethetrainedinterviewerswerequalifiedpsychiatricnursingsisters.Theywere

chosenbecauseoftheirexperienceinsocialscienceresearch.Thepurposeofthisphase

wastoascertainproblemsintervieweesmayexperienceincompletingthequestionnaires,

toidentifyanyitemsthatwereperhapsambiguousandtolocateotherdifficultiesthat

mayaffectthestudy.

Thisexerciseprovedtobeveryuseful.Firstly,severalambiguousitemsemergedandwere

corrected.Secondly,sometranslationerrorswereidentified.Anexampleofsuchanerror

isthesymptom“runnynose”whichwastranslated“anosethatliterallyran”.These

translationerrorswerecorrected.Thirdly,itwasfoundthatemotional,psychological

and/orpsychiatricitemswerebeingendorsedbyrespondents.Thereasonforthiswasthe

influenceofthetrainedpsychiatricnursingsisters.Itwasdecidedhereaftertousenursing

sistersnottrainedinpsychiatryandnon‐medicalpersonnel.

Thispre‐testprocedurealsohelpedtoassessthequalityofthetranslation,amethod

suggestedbyBrislin(1980),whostatedthattheefficacyofthismethoddependsonthe

controlexercisedduringthetestingandtheextenttowhichthefeedbackisincorporated

inthefinalrevisionsofthetest.Bothoftheserequirements,thatisthestrictcontroland

theintegrationoffeedback,werestrictlyadheredto.

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CHAPTER5

RESULTS

Theresultsoftheinterviewsandthefindingsofthequestionnairesarepresentedinfive

mainsections.Theanalysisofthedatafromquestionnaireoneispresentedfirst,followed

bytheanalysisoftheHealthBehaviourQuestionnaire,theSocialSupportQuestionnaire,

theSymptominventoryandtheLifeExperienceSurvey,inthatorder.

5.1DEMOGRAPHICDATA

TheageofthesubjectsintheHospitalGrouprangedfrom20to99years(Mn=33.23

years).TheageofthesubjectsintheUmlaziGrouprangedfrom20to74years

(Mn=34,88years)andtheKwaMashuGrouphadarangeof20to58years(Mn=33,41

years).Themeanageforthethreegroupscombinedwas33.84.

TableIIIbelowgivesabreakdownoftheagesforeachgroup.Mostofthecombined

sample(90,71%)wereinthe20to49yeargroup.Fortythreepercentofthesamplewere

intheagegroup20to29,26%inthe30‐39yearagegroupand21%inthe40to49year

agegroup.Therewasnosignificantdifferencebetweenthemeanageforeachgroup.

Figure6representstheagedistributiongraphically.

72

73

TABLEIII

AGEDISTRIBUTIONOFGROUPS

AgeinyearsGroup 20‐29 30‐39 40‐49 50+ N(%) N(%)N(%) N(%)Hospital 173 (46.5) 93 (25.00) 66 (17.74) 40(10.75)Umlazi 151 (41.9) 91 (25.28) 86 (23.89) 32 (8.89)KwaMashu 54 (37.0) 47 (32.19 35 (23.97) 10 (6.85)Total 378 (43.1) 231(26.31) 187 (21.30) 82 (9.34)

TableIVshowstheethnicdistributionforeachofthegroups.Themajorityofthe

respondentswereZulu(85.09%).ThenexthighestgroupwastheXhosa(9,94%).These

twogroupsaccountedfor95.03%ofthesample.TheothergroupscomprisedSotho

(N=9),Swazi(N=3),Tswana(N=1)andZanzibar(N=1).Unknown(N=29).However,all

couldspeakZulu.

74

TABLEIV ETHNICDISTRIBUTION Group Zulu Xhosa Other

N (%) N (%) N (%) Hospital 321 (85.83)38 (10.16)15 (4.01) Umlazi 295 (86.01)35 (10.20)13 (3.79) KwaMashu 120 (81.08)13 (8.78) 15 (10.14) Total 736 (85.09)86 (9.94) 43 (4.97)

75

TABLEV EDUCATIONALLEVELOFGROUP LevelofEducation Hospital Umlazi KwaMashu Total

N (%) N (%) N(%) N (%) NoEducation 53 (14.10) 22 (6.15) 18 (11.69) 93 (10.47) Classi‐Std1 25 (6.65)6 (1.68)0 (0.00)31 (3.49) Std2‐Std4 46 (12.23) 25 (6.98) 4 (2.60) 75 (8.45) Std5‐Std7 114 (30.32) 72 (20.11) 21 (13.64) 207 (23.31) Std8‐Std10 123 (32.71)184 (51.40)98 (63.64)405 (45.61) Technikon/college 5 (1.33) 38 (10.61) 9 (5.84) 52 (5.86) University 10 (2.65) 11 (3.07) 4 (2.60) 25 (2.82) Total 376 358 154 888 TableVprovidesabreakdownin3groupingsoftheeducationallevelofthoseinterviewed.

Achi‐squareanalysisrevealedasignificantdifferencebetweenthelevelofeducationin

theHospital,UmlaziandKwaMashuGroups(χ2=114,49,p<0.001).Themajorityofthe

combinedsample(68.92%)haveasecondaryschooleducation.Approximatelyeleven

percenthadaprimaryschooleducationandeightpercent,apostmatricqualification.The

subjectsintheHospitalGroupappearedtohavealowerlevelofeducationcomparedto

thecommunitysamples.Forexample,ahigherpercentageoftheHospitalGrouphadno

formaleducation(14.10%)orprimaryleveleduction(18.88%)thanthecommunitygroups.

(SeeFigure7).Residenceinanurbanarearangedfrom1to82years.(TableVIprovides

theinformationregardingthetermsofresidence).Asignificantdifferencewasfoundin

thenumberofyearseachofthesubjectsinthegroupshaveresidedinanurbanarea

(χ2=30.46,p<0.01).Althoughmostofthesubjectshadbeenlivinginanurbanareafor

morethantenyears,theHospitalsamplehadahigherpercentageofsubjectswhohad

residedinurbanareasforlessthan10years.(SeeFigure8).

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TABLEVI

YEARDISTRIBUTIONOFURBANLIVING

No.ofYearsGroups <5 5‐10 >10 TotalHospital 93(24.73) 34(9.04) 249(66.22) 376Umlazi 39(10.77) 23(6.35) 300(82.87) 154KwaMashu 23(14.95) 10(6.49) 121(78.57) 362Total 155(17.38) 67(7.51) 870(75.11) 892

77

78

79

ThesubjectsintheHospitalGroup(N=376)werereferredtothehospitalfromdistricts

throughoutNatalandevenbeyonditsborders.TableVIIliststhesubjects'residential

areas.Thehospital,however,ismostfrequentedbypatientsinandaroundtheDurban

area.Thesouthandnorthareaswhichhasthehighestrepresentation(71.27%),naturally

includedtheUmlaziandKwaMashutownships.Ofthe38.56%ofpatientsintheDurban

(south)group,29.5%werefromUmlazi.Theremainingsubjectsfromthisgroup(9.06%)

residedintheIsipingo,Amanzimtoti,Malvern,ChatsworthandMerebankareas.Ofthe

northgroup32.71%ofthepatientsfromtheDurban(north)area,20.2%residedinKwa

Mashu.Theremaining12.51%ofthesouthgroupcamefromtheInanda,Verulam,

TongaatandareasuptotheTugelaRiver.Theresultssuggestthatthemaincatchment

areasforthishospitalextendsfromAmanzimtotiinthesouthtoPinetownand

surroundingareasinthewest,andtheTugelaRiverinthenorth.Thiscatchmentarea

accountsfor82.97%ofitspatients.

TABLEVII DESTINATIONSOFHOSPITALSUBJECTS

District N % Durban(south) 145 38.56 Durban(north) 123 32.71 Pinetownandsurroundingarea 36 9.04 NatalMidlandsPietermaritzburg

andsurrounding 14 3.72 CentralSouthUmzintoandsurrounding 12 3.19 SouthPortShepstoneandsurrounding 10 2.66 Durbancentralandsurrounding 10 2.66 NorthTugelaZululand 7 1.86 Transkei 5 1.33 NorthernNatal(Drakensbergarea) 3 0.80 Lesotho 1 0.27 Unknown 10 3.20

80

Achi‐squaredanalysisontheoccupationsofthesubjectsbetweenthethreegroups

showedsignificantdifferences(χ2=171.52,p<0.01).TableVIIIgroupstheoccupationsof

thesubjectsaccordingtothecodingofoccupationguide(SchlemmerandStopforth,

1979).Thisguidewasdevelopedtoencouragestandardisationofthecodingof

occupationsinSouthAfrica.Inaddition,thisguidewaschosenbecauseitwasdeveloped

withcarefulconsiderationofcodesforAfricans.Thesubjectsattendingthehospitalwere

foundtobelessskilledcomparedtothoseinthecommunitygroups(seeFigure9).

However,acomparisonofthecommunitygroupsshowthattheKwaMashuGrouphavea

higherpercentageofsemi‐skilledartisansandprofessionalsthantheUmlaziGroup.

TABLEVIII SUBJECTSOCCUPATIONS

Semi‐ MiddleProfess‐ Group Unskilled skilled Artisans White‐collar ional Hospital 272 (72.34) 27 (7.18) 25 (6.65) 2 (0.53) 35 (9.31) Umlazi155 (42.82)30 (8.29)44 (4.93)11 (3.04) 79 (21.82) KwaMashu 28 (18.18) 29(18.83) 34 (22.08) 5 (3.25) 49 (31.82) Total 455 (51.01) 86 (9.64) 103(11.55) 18 (2.02) 163(18.27)

81

82

5.2TIMEANDTRANSPORTCOSTSOFHOSPITALPATIENTS ThecostoftravelincurredbypatientsattendingthehospitalrangedfromR1.00toR52.00.dependingfromwheretheycame.TheaveragecostwasR6.27.Thisrefersonlytothecostoftraveltothehospitalandnotothercostssuchashospitalfeesandlunch. Somepatientslefthomeasearlyas2h00toattendthehospital.Allleftby8h00.Ontheaveragetheyarrivedatthehospital1hourandfortythreeminuteslater.Ofthosewhoattendedthehospital,160(42.60%)reportedthattheywereunemployed.Ofthoseemployed,179patients(47.60%)reportedthattheyhadtotakethedayofffromworkinordertoattendthehospital.Forty‐two(23.46%),whotookthedayoff,reportedthattheywouldnotgetpaidorcompensatedforlossofearnings. Theresultsshowthat298patients(79.26%)wereunaccompaniedtothehospital.Ofthe20.74%whowereaccompanied,21(26.92%)wereaccompaniedbytheirspouse;12(15.38%)bytheirchildren;5(6.41%)byfriends;5(6.40%)bytheirbrothers;3(3.85%)byauntsand3(3.85%)byneighbours.Inmostofthecasespatientswereaccompaniedbyfemalesratherthanmales.Apossiblereasonforthismaybethatthemenmorelikelywouldbeatwork. 5.3HELPSEEKINGBEHAVIOUROFHOSPITALPATIENTS Inordertounderstandthefactorsand/orattitudesthatinfluencedthepatientsmedicalhelpseekingbehaviour,severalopen‐endedquestionswereasked.Thequalitativedataobtainedfromthesequestions,arepresentedbelow.ThedatarepresentstheviewsoftheHospitalGroupsinceonlytheyhadtocompletethissection. Twohundredandtwenty‐onepatients(59%)chosetoattendKingEdwardVIIIHospitalbecausetheybelievedthatitprovidedthebestserviceforAfricanpatients.Thesepatientsfeltthattheservices,facilitiesandtreatmentatthehospitalwereverygood,thatthehospitalhadplentyofdoctorstoattendtotheirneedsandthatthehospitalwaswellknownandrecognizedforitsgoodtreatment. Forty‐six(12%)ofthepatientschosetocometothehospitalbecausetheywerereferredbytheirgeneralpractitioner;38(10.3%)wereeitherreferredortransferredfromanotherhospitalorclinic.Twenty‐six(7%)wereencouragedtoattendthehospitalbytheiremployersorfamilymembersbecausetheythoughtthatthehospitalprovidedthebesttreatment.

The term spouse is used inclusively of boyfriend or girlfriend, since couples live together and only regard their partner as a spouse when the lobola has been paid. Lobola refers to the payment of bride price or dowry, that the husband is required to pay the brides father.

83

Eightpatients(2.2%)attendedthehospitalbecausetheyfeltthatthecostoftreatmentwasmuchcheaperthanotherhospitals.Sevensubjects(1.9%)didnotrespondorgaveinappropriateanswers. 5.3.1 ChoiceofDaytoAttend Twohundredandninety‐sixofthe376patientsrespondedtothequestionthataddressedthechoiceofdaytoattendthehospital. Themajorityofpatients(N=149,50.34%)attendedonthedaytheyfeltthattheywereeithergettingworse,theirconditionwasdeterioratingorthattheirpainwasbecomingunbearable.Ineighty‐sixcases(29.05%)thedayofattendancewasdeterminedeitherbyanappointmentorbecausetheyfeltthatthehospitalwillnotbebusy.Twenty‐three(7.77%)hadtowaittogetpaidbecausetheydidnothavesufficientmoneytoattend. About21(7.1%)attendedonthedaytheirreferringdoctorhadarrangedanappointmentwiththehospital.Asmallnumber,8,(2.70)reportedthattheyweretoobusyatworkorschoolandhadnotimetoattendearlier.Sevenhadtowaitfortransport(2.4%);1patienthadtoarrangeforsomeonetolookafterherchildrenandanotherattendedontheadviseandinsistenceofafriend. 5.3.2 Patient'sFirstSuspicionsofIllnessandAttendance Themajorityofpatientsattendedthehospitalwithinamonthofsuspectingtheywereill.Onehundredandthirty‐five(35,9%)attendedwithinaweek,42(11,2%)within2weeks,20(5,3%)bythethirdweekand45(12,0%)bythefourthweek—acumulativepercentageof65,4%(N=246).Themeanattendanceoverayearperiodwas5,85weeks(SD.9,82).TableIXprovidesabreakdownoftheattendance.Figure10depictstheattendancegraphically.

84

TABLEIX ILLNESSPRECIPITATIONANDATTENDANCETOHOSPITAL

Week/s N %

≤1 135 35.9 ≤2 42 11.2 ≤3 20 5.3 ≤4 45 12.0 5‐8 34 9.0 9‐12 11 3.0 13‐16 6 1.7 17‐20 4 1.1 21‐24 5 1.4 25‐28 5 1.4 29‐32 7 1.9 49‐52 8 2.2 >1year 50 13.9

85

86

5.3.3 PatientsReasonsfornotAttendingEarlier

Onehundredandsixty‐twopatients(43,50%)didnotattendthehospitalearlierbecause

theyfeltthattheirillnesswasnotseriousenough,thatthesymptomsdidnotbotherthem

ortheydeniedanyillnessexisted.Thesepatientsfeltthattheywouldgetbetterwithout

anymedicalintervention.Seventy‐four(19,90%)wereseeingaprivatedoctororattending

anotherclinicorhospital.“Nomoney”wasgivenby55(14,80%)asareasonfornot

attendingearlier.Eight(2,20%)wenttoapharmacyforhelp.Seven(1,90%)ofthepatients

indicatedthiswastheearliestappointmenttheycouldget.Seven(1,90%)hadeitherno

transportornoonetobringthemtothehospital.Six(1,60%)describedthemselvesas

beingtooseriouslyilltoattend.Onereportedthattheillnessremittedforashortwhile,

whereasanotherpatientwentto“churchpeople”forhelp.Oneofthepatientsreported

thatshewastooafraidtocomeearlier.Eleven(3,00%)feltthattheyhadnotdelayed.(See

Figure11).

5.3.4 FeelingsorexperiencesthatsuggestedtothepatientsthattheywereIll

Twohundredandthirty‐eightpatients(63,3%)feltthattheyweresickbecausethey

experiencedonlyphysicalsymptoms.Sixty‐four(20,8%)felttheyweresickbecausethey

hadexperiencedonlypsychologicalsymptoms,suchas,forgetfulness,worry,or

depression,aswellaschangesinaffect,sleeppatterns,energylevelsanddecreased

appetite.Twohundredandforty‐three(79,2%)hadacombinationofphysicaland

psychologicalsymptoms.

Threehundredandtwenty‐sevenpatients(87,0%)wereworriedaboutthesymptomsthey

wereexperiencingasopposedto42(11,2%)whowerenotreallyconcernedalthoughthey

felttheyweresick.

87

88

Asmanyas148(46,2%)patientsdidnotknowwhatwaswrong.Theresponsesofthose

whofeltthattheydidknowwhatwaswrongwiththemwerevaried.Forty‐three(13,4%)

thoughttheyhadflu;40(12,5)feltthattheirillnesswasduetosomeformofinfection

becausetherewerevisiblesigns,suchas,soresorlacerations.Twenty‐six(8,1)thought

thattheyhadaterminalillnesssuchascancerorAIDSandthattheyweregoingtodie.

Otherexplanationsincluded,17(5,3%)whofeltthattherewassomethingwrongwith

theirblood,thattheirbladderwasdirtyorthattheyhadwaterintheirheads.Twelve

(3,7%)feltthattheirillnesswasduetowitchcraft,thecrossingofapathwheresomeritual

wasperformed,theinhalingofabadspiritorthattheywerepoisonedbysomeone.

Twelve(3,7%)feltthatitwassomeknownclinicalsyndrome,suchas,diabetes,asthmaor

highbloodpressure.11(3,4%)feltthattheirillnesswastheresultofnormal

developmentalprocesses,suchas,puberty,pregnancyandoldage.Nine(2,8%)attributed

theirillnesstoseasonalortemperaturechangesand2(0.6%)feltthatitwasduetoapast

surgicalprocedure.

5.3.5 IllnessDisclosure

Threehundredandtwenty‐two(86%)ofthehospitalpatientstalkedabouttheirillness

andconcernstootherspriortoattendingthehospitalwhileonly49(13,2%)didnot.Of

thosewhodidspeaktoothers,92(28,3%)hadspokentotheirmothers;76(23,4%)to

theirspousesorboy/girlfriends;30(9,2%)tofriends;21(6,5%)totheirchildren;20(6,2%)

totheiremployer;17(5,2)toasister;12(3,7%)toabrother;12(3,7%)toarelative;10

(3,1)totheirfather;7(2,2%)tobothparentsand5(1,5%)totheirgrandmother.Only8

(2,5%)hadspokentoadoctor.

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5.4SERVICES

5.4.1 Choiceofdoctor,hospitalandpharmacybythecommunitygroups.

Thechoiceofadoctorbyindividualsinthecommunitysamplegroupsarereflectedin

TableX.Thesubjectswereaskedtoindicatethelocationofadoctortheywouldvisitif

theyhadtoandwhytheywouldchoosethatparticulardoctor.Itappearsfromthe

responsesthatthereisatendency,naturally,forpeopletouseservicesthatarethe

closesttothem(58.6%).

TABLEX LOCATIONOFDOCTOR Choice Umlazi KwaMashu Total

N(%) N(%) N(%) Withintownship 211 (63.7) 66 (42.9) 277 (58.6) Outsidetownship 106 (32.1) 54 (35.1) 160 (33.8) City 3 (0.9) 21 (14.8) 24 (5.1) StaffDoctor 5 (1.5) 1 (0.7) 6 (1.3) Anywhere 6 (1.8) 0 6 (1.3) Total 331 142 473

ThereasonsforchoosingaparticulardoctorarelistedinTableXI.Themainfactorsthat

seemtomotivatethechoiceofadoctoraretheproximityandqualityofservice.The

majoritychoseadoctorclosesttothem(34.9%)orbecausetheyperceivedthatthey

wouldgetgoodservice(28.6%).Only11.6%consideredcostinthechoiceofadoctor.

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TABLEXI REASONSFORCHOOSINGADOCTOR Reason/s Umlazi KwaMashu Total

N(%)N(%) N(%) Nearest 140 (38.5) 43 (30.5) 183 (34.9) Goodservice 98 (25.6) 52 (36.9) 150 (28.6) Familydoctor 67 (17.5)9 (6.4)76 (14.5) Cheapest 42 (11.0) 19 (13.5) 61 (11.6) Nearesttowork 18 (4.7) 14 (9.9) 32 (6.1) Staffservices 13 (3.4) 4 (2.8) 17 (3.2) Medicalaid 5 (1.3) _ 5 (0.9) Total 383 141 524

ThechoiceofhospitalandthereasonsfortheirchoicearefoundinTableXIIandTableXIII

respectively.Hereagain,theproximityandqualityofserviceplayanimportantroleinthe

choiceofservices.KingEdwardVIIIHospitalisstillpreferredbybothcommunities

althoughPrinceMshiyeniMemorialHospital(whichisinUmlazi)isequallypopularinthe

Umlazicommunity.However,KwaMashudoesnothaveahospitalclosetothemwhich

accountsforthehighernumberofpatientsattendingKingEdwardVIIIHospitalfrom

there.Theseresultsalsoshowthatasmuchas12.8%useprivateservices.Thefactthat

44.9%feltthattheirchoiceofhospitalwasdeterminedaccordingtothequalityofservice

and33.8%becauseitwasnearesttothem,supportstheviewthatconvenienceand

qualityofservicearethemostimportantfactorsforuseoftheseservices.

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TABLEXII CHOICEOFHOSPITAL Hospital Umlazi KwaMashu Total

N(%) N(%) N (%) KingEdwardVII 122 (35.3) 84 (58.4) 206 (40.7) PrinceMshiyeni 147 (42.5) 9 (6.3) 156 (30.8) Private(Indian,city) 18 (5.2) 17 (11.9) 35 (6.9) Clairwood 31 (8.9) 1 (0.6) 32 (6.3) McCords ‐ 16 (11.2) 16 (3.2) MedicalTowers 14 (4.0) 1 (0.6) 15 (3.1) Private(White,city) 9 (2.6) 5 (3.5) 14 (2.8) St.Mary's 1 (0.3) 4 (2.7) 5 (1.0) KingGeorgeV 3 (0.9) ‐ 3 (0.6) KwaDabekaDay . ‐ 3 (2.1) 3 (0.6) Addington ‐ 3 (2.1) 3 (0.6) Madedeni 1 (0.3) 1 (0.6) 2 (0.4) Total 350 156 506

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TABLEXIII REASONSFORCHOOSINGAHOSPITAL Reason/s Umlazi KwaMashu Total

N(%) N(%)N(%) Goodservice 119 (34.0) 108(69.2) 227(44.9) Nearest 146 (41.8) 25 (16.1) 171(33.8) Nearesttowork 50 (14.3) 10 (6.4) 60 (11.9) Cheapest 19 (5.4) 8 (5.1) 27 (5.3) Referred 12 (3.4) 5 (3.2) 17 (3.4) MedicalAid 3 (0.8) ‐ 3 (0.6) Noreferralrequired 1 (0.3) ‐ 1 (0.2) Total 350 156 506

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Thechoiceofapharmacy(TablesXIVandXV)isinkeepingwithchoicesofotherservices.

Thesetablesshowthatproximityandqualityofservicearethemostimportantfactors

relatedtochoiceofmedicalandhealthservices.

TABLEXIV CHOICEOFPHARMACY Location Umlazi KwaMashu Total

N(%) N(%)N(%) Localtownship 143 (49.7) 46 (35.1) 189 (44.7) City 93 (31.8) 45 (34.4) 138 (32.6) Outsidetownship 47 (16.1) 37 (28.2) 84 (19.9) Anywhere 7 (2.4) 3 (2.3) 10 (2.4) Total 292 131 423

TABLEXV REASONSFORCHOOSINGAPHARMACY Reason/s Umlazi KwaMashu Total

N(%) N(%)N(%) Nearest 100 (33.0) 54 (37.8) 154 (34.5) Goodservice 67 (22.1) 31 (21.6) 98 (22.0) Nearesttowork 67 (22.1) 23 (16.1) 90 (20.2) Cheapest 44 (14.5) 7 (4.9) 51 (11.4) Wellstocked 19 (6.3) 20 (14.0) 39 (8.7) Trustthem 3 (0.9) 7 (4.9) 10 (2.2) Referred 3 (0.9) 1 (0.6) 4 (0.9) Total 303 143 446

5.5SUBJECTSPERCEPTIONSOFTREATMENT

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Themajorityinthesample(n=739,83,8%)whohadreceivedmedicalservicesfroma

privatedoctororahospitalreportedthattheywerepleasedwiththetreatment.χ2=93.18

(p<0,01)wasobtained.SeeTableXVIforeachofthegroupsresponses.Itappears,

however,thatthecommunitysamples,Umlazi(83.9%)andKwaMashu(84.7%)were

generallymorepleasedwithtreatmentatthehospitalthantheHospitalgroup(53.2%).

TABLEXVI SUBJECTSPERCEPTIONSOFTREATMENT Perception Hospital UmlaziKwaMashu Total

N(%)N(%) N(%) N(%) PleasedwithRx 152(53.2) 281(83.9) 111(84.7) 544(72.3) NotpleasedwithRx89 (31.1) 24 (7.2) 10 (7.6) 123(16.4) Notsure 45 (15.7) 30 (9.0) 10 (7.6) 85 (11.3) Total 286 335 131 752

Thetwofactorsthatpleasedpatientsmostabouttheirtreatmentwerethattheirillnesses

werecured(N=224,37.71%)andtheserviceandcarewereverygood(N=330,55.55%).

TableXVIIliststheaspectsthesubjectsweremostpleasedwithandTableXVIIIliststhose

aspectsoftreatmentthatrespondentswerenotpleasedabout.

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TABLEXVII TREATMENTFACTORSSUBJECTSWEREPLEASEDABOUT Factors Hospital Umlazi KwaMashu Total

N(%) N(%) N(%) N(%) Goodservice

andcare 83 (48.0) 167 (54.4) 80 (70.2) 330 (55.5) Illnesscured 78 (45.1) 117 (38.1) 29 (25.4) 224 (37.7) Gaveinjection5 (2.9) 19 (6.2) 2 (1.8) 26 (4.4) Gavemedication 4 (2.3) 4 (1.3) 3 (2.6) 11 (1.9) Cost 2 (1.1) ‐ ‐ 2 (0.3) GaveRxnever

seenbefore 1 (0.6) ‐ ‐ 1 (0.2) Total 173 307 114 594

TABLEXVIII TREATMENTFACTORSSUBJECTSWERENOTPLEASEDABOUT Factors Hospital Umlazi KwaMashu Total

(N=146) (N=133) (N=54) (N=333) PoorDr‐Pt relationship 38 (26.0) 72 (54.1) 31 (57.4) 141 (30.3) Poorfacilities 21 (14.4) 67(50.4)34 (63.0)122 (26.2) Timedelays 17 (11.6) 52 (39.1) 17 (31.5) 86 (18.5) Illnessnotcured 67 (45.9) 15 (11.3) 2 (3.7) 84 (18.1) Cost 10 (6.8) 18 (13.5) 4 (7.4) 32 (6.9)

Asignificantnumberofthesubjects(N=702,92,2%)werewillingtoseekmedicalservices

inthefuture(χ2=2,359,p<0,01).Whereas24(3,1%)didnotwanttoand37(4,7%)felt

thattheywerenotsureiftheywouldseekmedicaltreatmentagain.

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TableXIXshowsthatpatientsobtaintheirmedicationthroughconsultationswithmedical

doctors.Averysmallpercentageobtainedmedicationfrompharmaciesorfriends.Asto

whytheyweregivenmedicationpatientrespondedthus:352(46,8%)knewthattheyhad

totakemedicationbecauseoftheirillnessalthoughtheydidnotunderstandthenatureof

theillness;304(40,4%)tookmedicationhavingunderstoodquitewellthenatureoftheir

illness.Onlyasignificantfew(p<0,01)prescribedmedicationforthemselvesbecausethey

felttheyhadtheflu(5,1%)orbecausetheyhadpain(7,7%).

TABLEXIX SOURCESOFMEDICATION Source Hospital UmlaziKwaMashu Total

(N=296) (N=334) (N=130) Privatedoctor177 (59.8)207 (62.0)48 (36.9)432 (57.1) Clinic/hospital 77 (26.0) 104(31.1) 66 (50.8) 247(32.6) Pharmacy 24 (8.1) 16 (4.8) ‐ 40 (5.3) Staffdoctor 12 (4.1) 6 (1.8) 13 (10.0) 31 (4.1) Friends/ relatives 6 (2.0) 1 (0.3) ‐ 7 (0.9)

Thereweresignificantdifferencesinthewaythesubjectsrespondedtowhetherwestern

medicineswerebeneficialtothem.TableXXliststheresponses.Differencesoccurred

betweentheHospitalandthecommunitygroup.Westernmedicationswereperceivedby

thehospitalattendersasbeinglessbeneficial.TheHospitalGroup(20.00%)demonstrated

greaterdoubtabouttheefficacyofwesternmedicationthanbothcommunitygroups;

Umlazi(5.1%)andKwaMashu(5.4%)

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TABLEXX SUBJECTSPERCEPTIONSOFWESTERNMEDICINES Perception Hospital Umlazi KwaMashu Total

N(%)N(%) N(%) N(%) Helpful 160 (51.6) 299 (89.5) 116 (89.9) 575 (74.4) Nothelpful 88 (28.4) 18 (5.4) 6 (4.7) 112 (14.5) Notsure 62 (20.0) 17 (5.1) 7 (5.4) 86 (11.1) Total 310 334 129 773

Withregardtotheuseofvitaminsupplements,466(53.1%)didnottakesupplements

whereas412(46.9%)respondentsreportedhavingusedthem.MoreoftheKwaMashu

Group(55.7%)usedvitaminsupplementsthantheUmlaziGroup(40.4%).(χ2=141.76,

p<0.05).Thereasonfortakingvitaminsupplementsalsosignificantlydifferedbetweenthe

groups(p<0.01).SeeTableXXI.

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TABLEXXI REASONSFORTAKINGVITAMINS Reason/s Hospital Umlazi KwaMashu Total

(N=184) (N=145) (N=88) Increasestrength 66 (35.9) 77 (53.1) 32 (36.4) 175(42.0) Health/active protective 40 (21.7) 33 (22.8) 22 (25.0) 95 (22.8) Cure/treatillness 29 (15.8) 7 (4.8) 17 (19.3) 53 (12.7) Bloodsupplement 12 (6.5) 8 (5.5) 8 (9.1) 28 (6.7) Advised(non‐ medical) 11 (6.0) 9 (6.2) 8 (9.1) 28 (6.7) None 26 (14.1) 11 (7.6) 1 (1.1) 38 (9.1)

5.6RELIGIOUSANDCULTURALBELIEFS

TableXXIIprovidesabreakdownofthereligiousandculturalaffiliationsofthethree

groups.Eighty‐ninepercentofthetotalsamplewereChristian,6.6%belongedto

traditionalAfricanreligiousgroups,2.8%‘other’and1.4%claimedtobelongtoboth

ChristianandTraditionalreligion.

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TABLEXXII RELIGIOUSANDCULTURALBELIEFS Beliefs Hospital Umlazi KwaMashu Total

(N=357) (N=343) (N=151) Christian 317(88.8) 321(93.6) 121(80.1) 759(89.2) Traditional 21 (5.9) 17 (5.0) 18(11.9) 56 (6.6) Other 10 (2.0) 2 (0.6) 12 (7.9) 24 (2.8) Christianand traditional 9 (2.5) 3 (0.9) ‐ 12 (1.4)

SubjectsresponsestoseekingtraditionalhealingfortheirillnessesarefoundinTableXXIII.

Helpfromtraditionalhealersweresoughtby14.5%;24,4%visitedfaithhealersand5.67%

soughthelpfrombothtraditionalandfaithhealers.Themajorityofthesubjectsreported

non‐useoftraditionalreligiousservices(55.4%).Thereappearstobeagreaterrejectionof

thesetraditionalservicesbyboththeHospitalGroup(57.4%)andtheUmlaziGroup

(58.7%).Ofthosethatusetraditionalservices,faithhealersarefrequentedmoreoften

thantraditionalhealers.

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TABLEXXIII USEOFTRADITIONALHEALERS. Type Hospital UmlaziKwaMashu Total

(N=357) (N=339) (N=151) None 205(57.4) 199(58.7) 65 (43.1) 469(55.4) FaithHealer 93 (26.1) 76 (22.4) 38 (25.2) 207(24.4) Traditionalhealer 42 (11.8) 51 (15.1) 30 (19.9) 123(14.5) Traditionaland faithhealer 17 (4.8) 13 (3.8) 18 (12.0) 48 (5.67)

ThetreatmentsadministeredbythesehealersarelistedinTableXXIV.Thesubjects

reportedthatthetreatmentveryoftenwasacombinationofmethods.Holywater

(64.44%)andherbs(24.60%)aremostoftenused.Althoughtheyarefaithhealersprayer

isusedinonly13.63%ofthecaseswhoapproachedthesehealersforhelp.

TABLEXXIV TREATMENTGIVEN Treatment Hospital UmlaziKwaMashu Total

(N=148) (N=87)(N=139) Holywater 100(67.6) 63 (72.4) 51 (36.7) 241 (64.44) Herbs 26 (17.6) 47 (54.0) 19 (13.7) 92 (24.60) Trad.medicines 36 (24.3) 13 (14.9) 19 (13.7) 68 (18.18) Prayer 13 (8.8) 17 (19.5) 21 (15.1) 51 (13.63) Candles 3 (2.0) 11 (12.6) 5 (3.6) 19 (5.08

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ThefrequencyofvisitstotraditionalhealersislistedinTableXXV.Subjectsgenerally

consultedtraditionalhealersforabout3timesandthereafterthereappearstobea

declineinattendance.Ofthosewhosoughttraditionalhealers,33.8%attendmorethan6

times.

TABLEXXV FREQUENCYOFVISITSTOTRADITIONALHEALERS Noofvisits Hospital Umlazi KwaMashu Total

(N=150) (N=139) (N=87) 1 38 (25.3) 18 (12.95) 7 (8.1) 63 (17.0) 2 39 (26.0) 37 (26.6) 22 (25.3) 98 (26.1) 3 24 (16.0) 19 (13.7) 14 (16.1) 57 (15.2) 4 1 (0.7) 3 (3.5) 1 (0.7) 10 (2.7) 5 5 (3.3) 13 (9.4) 3 (3.5) 21 (5.6) 6+ 43 (28.7) 33 (38.0) 51 (36.7) 127 (33.8)

Theaveragepaymentpertreatmenttothetraditionalhealersvariedforeachgroup:the

HospitalGroup(R84.62),theUmlaziGroup(R68.23)andTheKwaMashuGroup(R95.29).

Thereweresignificantdifferences(p<0.01)betweenthegroupsabouthowtheyfeltabout

theusefulnessorbenefitofthetraditionalorculturaltreatment.TableXXVIshowsthat

80.5%oftheKwaMashuGroupfeltthatthetraditionaltreatmentswerebeneficial

whereasonly40.4%oftheHospitalGroupand64.3%oftheUmlaziGroupfeltitwas

beneficial.However,theHospitalGroupindicatedgreaterdispleasurewithtraditional

treatments.

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TABLEXXVI SUBJECTSPERCEPTIONSOFTHEEFFECTIVENESSOFTRADITIONALTREATMENT Perception Hospital UmlaziKwaMashu Total

(N=151) (N=140) (N=87) Rxhelped 70 (40.4) 90 (64.3) 70(80.5) 230 (60.9) Rxdidnothelp 40 (26.5) 13 (9.3) 7 (8.1) 60 (15.9) Notsure 41 (27.2) 37 (26.4) 10(11.5) 88 (23.3) Rx=treatment

ThedatainTableXXVIIsupportstheviewthatofthosewhousedtraditionaltreatment

methods,anoverall47.40%,willcontinuetraditionaltreatment.Ap<0,05significancewas

obtainedbetweenthegroups(χ2=35.65).AgreaternumberintheHospitalGroup

(58.55%)indicatedthattheywillcontinuetraditionaltreatmentthantheUmlaziGroup

(38.88%)andKwaMashuGroup(42.22%)

TABLEXXVII CONTINUATIONOFTRADITIONALTREATMENT

Hospital UmlaziKwaMashu Total (N=152) (N=144) (N=90)

Cont.trad.Rx89 (58.55) 56(38.88)38 (42.22)183 (47.40) Discont.tradRx 63 (41.5) 88 (61.1) 52 (57.8) 203(52.6) Rx=treatment

TableXXVIIIindicatestheuseofprayerbyindividualsasamethodof‘treatment’fortheir

illness.Prayerismostoftensoughtfromchurchpeople,suchas,ministers,

deaconsandwoman'sprayergroups,(50,0%).Othersourcesfromwhichprayerissought

arethefamily(25,4%)andfriendsorneighbours(16,4%).

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TABLEXXVIII PRAYERASATREATMENTFORILLNESS

Hospital UmlaziKwaMashu Total N(%)N (%) N(%) N(%)

Pray 59 (16.1) 65 (18.8) 50 (35.5) 174(20.4) Donotpray 308(83.9) 281(81.2) 91 (64.5) 680(79.6) Total 367(43.0) 346(40.5) 141(16.5) 854

Twenty‐onepercentreportedconsultingaherbalistfortheirillness.SeeTableXXIX.There

issignificantlygreateruseofherbalistbythecommunitygroupsthantheHospitalGroup

(χ2=6.23,p<0.05).

TABLEXXIX CONSULTATIONOFHERBALISTS

Hospital UmlaziKwaMashu Total N(%)N(%) N(%) N(%)

Herbalistseen61 (16.5)77 (21.8)45 (30.4) 183 (21.0) Herbalistnotseen 309(83.5) 276(78.0) 103(70.0) 688(79.0) Total 370(42.4) 353(41.0) 148(17.0) 872 Severalfolkmedicineswerereportedtohavebeenused.Laxativesappeartobethemost

popularsubstanceconsumed.TableXXXprovidesabreakdownofthesubstanceseach

groupused.

104

TABLEXXX USEOFTRADITIONALOR“LAY”SUBSTANCES Substance Hospital Umlazi KwaMashu Total

N(%) N(%) N(%)N(%) Laxatives 316 (84.0) 328 (90.6) 138 (90.0) 782 (88.0) Ointments 135 (35.9) 145 (40.1) 63 (41.0) 343 (38.5) Vomitingmeds. 130 (35.0) 106 (29.3) 74 (48.1) 310 (35.0) Strengthening meds. 135 (36.0)118 (33.0)38 (25.0)291 (33.0) Holywater 124 (33.0) 105 (29.0) 47 (31.0) 276 (31.0) Herbs 78 (20.7) 69 (19.1) 53 (34.4) 200 (22.4) Hot/cold preparations 40 (10.6) 41 (11.3) 38 (25.0) 119 (13.3) OTHER....................................................................................................................................... Glucose 42 (11.1) 55 (15.2) 2 (1.3) 99 (11.1) Castoroil 42 (11.1) 35 (9.7) 6 (4.0) 83 (9.3) Warmwater 42 (11.1) 32 (8.8) 1 (0.6) 75 (8.4) Epsomsalts 16 (4.3) 19 (5.2) 1 (0.6) 36 (4.0)

5.7HEALTHANDILLNESSBELIEFS(QUALITATIVERESPONSES)

Thesubjectswereaskedtorespondtoseveralopen‐endedquestionabouthealthand

illnessbeliefs.Belowisasummaryoftheirresponses.

5.7.1 Whatiswrongwithyouandwhydoyouthinkso?

OnlytheHospitalGrouphadtorespondtothisquestionbecauseitwasmostappropriate

forthesesubjectssincetheywereseekingmedicalhelpatthehospital.Ofthosethat

answered43.40%(n=152)didnotknowwhatwaswrongwiththem.Themostcommon

explanationsfortheirsymptomswere:14.00%(n=51)understoodthesesymptomsasa

105

recognizedmedicaldisorder;11.80%(n=43)feltitwasduetoinfection;6.00%(n=22)felt

iswasaresultof‘somethingwrongwiththeblood(thatis,theirbloodwaseitherdirtyor

weak),thattheyhadtoomuchofgallinthebody,theirbodywasweakortheyhaddirty

organs';4.40%(n=16)feltthatitwasduetoinjury;4.10%(n=15)duetobewitchment,evil

orevilspiritpossession,crossingapathwherearitualwasperformedorasaresultofthe

ancestorsbeingangry;2.50%(n=9)oldage;2.20%(n=8)poornutrition,theusedirty

drinkingwaterorpoorlivingconditionsand1.70%(n=6)feltthatitwasduetotheirbrain

notfunctioningproperly.Otherlesscommonreasonswereseasonalchanges0.80%(n=3),

alcoholanddrugabuse1.10%(n=4),bodymalfunctioning1.10%(n=4),sideeffectsof

medication0.80%(n=3),anger0.80%(n=3)andtemperaturechange0.50%(n=2)

Thereasonstheygaveformakingtheabove'diagnoses'were:38.80%(n=132)gavea

reasonableexplanation;13.80%(n=47)becausetheyhadphysicalsymptomsand/or,they

werenotfunctioningastheyhadpreviously;2.10%(n=7)hadbeentoldsobyothers;

1.80%(n=6)becauseofcognitivechangesand/orvegetativeshifts;0.6%(n=2)cessationof

traditionbeliefsorbeliefinGodand0.30(n=1)environmentalchange.

5.7.2 Whatdoesitmeantobesick?

Therespondentsexperienceddifficultyrespondingtothisquestion.Mostrespondedto

thisquestionasfeeling"nauseous","tovomit"or"feelweak".Thereappearedtobeno

differenceintheconceptbetweensickandill.Theterm'ukugula'isusedmostoftenfor

beingorfeelingill.

5.7.3 Whatdoesitmeantobeill?

PatientsresponsestothisquestionarefoundinTableXXXIbelow.Generallyillnessmeant

notfeelingwellor'free'inthebody,soulandlife;notfeelinggoodornormal;being

worried,havingproblems,beinguncomfortableandunrelaxed;perceivingpain;and

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experiencingphysicalandpsychologicalsymptoms.Theresponsesmadeshowthatthe

subjectsholdanholisticviewofillness.Biopsychosocialsymptomatologyisconsideredas

causeorreasonsforillness.

5.7.4 Whatdoesitmeantobewell?

Thesubjectsviewofhealthisinkeepingwiththeirviewofillness.Yetagainthesubjects

holdaholisticviewofhealth.Wellnessisassociatedwithfeeling'free'andgoodinbody,

soulandlifeingeneral;havingnoworries,problems,feelingcomfortableandrelaxed;no

perceptionofpainandnophysicalorpsychologicalsymptoms.Theirresponsesarefound

inTableXXXII.

107

TABLEXXXI MEANINGOFBEINGILL Meaning Hospital UmlaziKwaMashuCombined

(376) (362) (154) (892) % % % %

Donotfeelwell/freeinyourbody/ soul/life,donotfeelgood,normal worried,haveproblems, uncomfortable,notrelaxed 76.90 65.50 63.60 70.00 Pain 15.70 32.00 39.00 26.30 Ineffective,unproductive 9.31 8.84 14.90 10.10 Unhappy,sad(facialandmood change) 6.64 7.46 6.49 7.00 Donotlookphysicallywell/healthy, notstrong,fitphysically 8.20 12.99 16.88 11.70 Notlively,active,orenergetic‐slowed 3.46 6.63 11.04 6.10 Bodyorgansnotfunctioning2.13 7.73 7.79 5.40 Havesymptoms 3.19 6.63 4.55 4.80 Haveinfection/disease 3.39 0.55 12.99 3.50 Somethingforeigninthebody 0.80 5.25 0.65 2.60 Poorappetite 2.39 2.76 5.19 3.00 Sleeppoor 3.19 2.76 1.95 2.80 Dependent(selfcare) 1.06 2.49 1.95 1.80 Needfordoctor/hospital 2.13 0.28 0.65 1.10 Somethingwrongwithblood 1.86 ‐ 0.65 0.90 Goingtodie 1.06 ‐ ‐ 0.40 Asocial,withdrawn ‐ 0.55 0.65 0.30 Imbalancementally,physicallyand emotionally. ‐ ‐ 1.30 0.20 Bewitched/badspirit 0.53 ‐ ‐ 0.20

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TABLEXXXII MEANINGOFBEINGWELL Meaning Hospital UmlaziKwaMashu Combined

(376)(362) (154) (892) % % %%

Feelwellinyourbodyandsoul, feelinggood,normal,noworries, problems,freeinyoursoul,life, enjoyinglife/content 64.63 53.04 45.45 56.61 Healthy,goodweight,strong,fit, physical 32.45 48.07 57.14 43.05 Nopain 21.28 29.56 25.97 25.45 Happy,excited,joy 28.46 21.27 13.64 22.99 Lively,active,energetic 14.10 13.26 14.29 13.75 Effective,productive 9.04 8.01 18.18 10.20 Psychologicallyandmentallyfit 3.29 5.80 14.29 5.83 Bodyorgansfunctioning 1.60 4.97 6.49 3.81 Noinfection/disease 1.60 1.93 13.64 3.81 Goodappetite 2.39 3.31 1.30 2.58 Independent 4.26 0.28 2.60 2.35 Nosymptoms 0.79 2.21 3.90 1.91 Noneedfordoctor/hospital 2.13 0.28 1.95 1.35 Visitingothers 1.33 0.83 2.60 1.35 Bewitched/badspirit 0.27 ‐ ‐ 0.11

Thesubjects'responsestowhattheybelievedthattheindicatorsof'beingwell'and'being

ill'were,arefoundrespectivelyinTableXXXIIIandTableXXXIV.Physicalability,moodand

psychologicalwell‐beingareconsideredindicatorsofbeingwell.Poorvegetativefunction,

physicalability,moodaswellasphycologicalwell‐beingisconsideredindicatorsof'being

ill'.

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TABLEXXXIII INDICATORSOFBEINGWELL Meaning Hospital UmlaziKwaMashuCombined

(376) (362) (154) (892) % % %%

Strong,fit,physical 28.19 38.95 38.31 34.30 Happy,excited,joy,singing,dancing, laughs,jokes,humour 27.39 24.59 43.51 29.04 Lively,active,energetic 30.59 10.54 24.03 27.58 Toworkproperly,workshard, effective,productive 16.76 25.41 31.17 22.76 Health,goodweight,notneglected 6.84 23.20 12.37 18.39 Good,normal,feelwellinyourbody, freeinyoursoul,life,enjoying life/content,comfortable 18.09 16.02 20.78 17.71 Goodappetite 15.96 16.22 13.64 15.92 Nopain 7.45 11.88 18.18 11.09 Facialexpression 9.84 12.99 1.95 9.75 Mobility 9.57 5.80 5.19 7.29 Playingwithothers,notvisitingothers 8.78 4.97 6.49 6.84 Quick,sharp,concentrate 4.52 7.46 7.79 6.39 Symptoms 3.46 7.18 13.64 6.73 Talksproperly,loud 5.05 5.52 8.44 5.83 Sleepwell 3.99 5.25 4.55 4.59 Psychologicallyandmentallyfit, talkappropriately 0.80 2.49 9.09 2.91 Changeofattitude,motivated 1.86 3.31 ‐ 2.13 Noneedfordoctor/hospital 2.39 0.55 0.65 1.34 Agitatednotrelaxed 0.53 0.28 ‐ 0.34

110

TABLEXXXIV INDICATORSOFBEINGILL Meaning Hospital UmlaziKwaMashu Combined

(n=376) (n=362) (n=154) (n=892) % % % %

Goodappetite 39.36 47.79 26.62 40.58 Notlively,active,energetic 37.23 35.36 44.14 37.67 Sleepwell 22.61 25.69 14.29 22.42 jokes,humour,happy, excited,joy 23.67 11.33 35.71 20.74 Health,goodweight, neglected 16.49 24.03 14.29 19.17 Workshard,effective, productive 15.69 12.15 22.73 15.47 Pain 9.31 17.40 27.92 15.81 Nosymptoms 8.51 15.47 8.44 11.32 Vomit,nausea 6.12 14.36 3.90 9.08 Dizzy,faint,weak 9.31 10.22 5.19 8.97 Notgood,normal,donotfeel wellinbody,notfreeinsoul, life,notenjoyinglife,not content,worried,problems, uncomfortable 11.44 3.59 11.69 8.29 Talksproperly,loud 5.05 8.84 7.79 7.06 Strong,fit,physical 4.52 8.84 4.55 6.28 Quick,concentrate,psycho‐ logicallyandmentallyfit 2.13 9.39 5.84 5.72 Normalbodytemp 3.46 5.25 10.39 5.38 Noneedfordoctor/hospital 6.64 2.49 0.65 3.92 Notvisitingothers 1.33 7.18 4.55 4.26 Changeofattitude,motivated 4.26 2.49 7.79 4.15 Mobility 3.72 3.04 3.25 3.36 Agitatednotrelaxed/ aggressive 2.39 2.49 6.49 3.14 Independent 0.80 1.66 6.49 2.13 Facialexpression,laughs,cries 1.06 2.76 1.30 1.79 Bodyorgansfunctioning 0.27 0.28 4.55 1.01

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TABLEXXXV REASONSPEOPLEGETSICK/ILL

Reasons Hospital UmlaziKwaMashu Combined (n=376) (n=362) (n=154) (n=892) % % % %

Diet,poornutrition,junkfood 63.03 76.52 53.25 66.82 Coldwhilesleeping,noor poorshelter,dirty,squatter conditions,drinkingdirty water,pollution,poor environments 62.24 73.48 63.64 66.45 Disease/infection,germs 11.70 10.77 23.38 13.34 Noexercise 6.64 21.82 11.69 13.68 Psychologicalproblems, worry,badthoughts/moods, stress 9.57 10.77 25.97 12.89 Non‐complianttoDrsRx, notgoingforregularcheck ups,delaying/procrastinating attendancetodoctors 7.98 9.94 14.29 9.86 Largeconsumptionof alcohol 6.91 7.18 11.69 7.85 Beliefandfollowing traditionalRx. 10.90 2.47 10.39 7.50 Notkeepingyourselfhealthy5.057.18 3.90 5.72 Poverty 1.33 3.59 20.13 5.49 Overcrowding 2.663.87 15.58 5.38 Socialproblems 6.12 3.59 7.14 5.27 Smokeexcessively 1.33 6.63 5.19 4.15 Injuries,accidents, violence,war,unrest 3.46 3.59 1.95 3.25 Poorhealthfacilities/apartheid 1.60 3.04 5.19 2.80 Increasedresponsibility 2.66 3.31 0.65 2.58 Laziness 1.33 1.66 6.49 2.35 ForgetGod ‐ 1.38 3.25 2.32 Substanceabuse 1.06 3.87 1.30 2.24 Seasonorweatherchanges 1.06 3.31 2.60 2.24 Weak,notstrong 1.33 1.38 5.84 2.13 Overworking 1.06 0.83 3.25 1.34 Allergic,takingsomething notgoodforyourbody 0.53 2.76 0.65 1.64 Somethingforeignenters

112

theirbody ‐ 2.49 0.65 1.57 Pooreducation ‐ ‐ 1.30 1.30 Todie ‐ 1.10 ‐1.10 Lossofculture 1.060.28 1.95 1.10 Bewitchment ‐ 0.55 1.30 0.93 Bodymalfunctioning 0.53 0.55 2.60 0.90 Notrestingorrelaxing 0.27 1.38 1.30 0.90 Oldage 1.33 0.55 ‐ 0.78 Attackwithoutacause,natural 0.27 0.28 1.30 0.62 Promiscuity 1.06 0.28 ‐ 0.56 Inherited ‐ 0.28 0.65 0.47 Badtermswithneighbours/ family 0.79 0.28 0.65 0.45 Insufficientsleep 0.27 0.55 ‐ 0.34 Malingering ‐ 0.28 ‐ 0.28 Nosupport ‐ 0.28 ‐ 0.28 Don'tcleantheirstomachs 0.27 0.28 ‐ 0.22

TableXXXVliststheresponsesthesubjectsmadetothequestion,'whypeoplegetill?'

Poornutritionanddiet,poorlivingconditionsandpovertywerethemainreasonsgiven

forgettingill.Theotherpopularreasonswerediseasesandinfections,lackofexerciseand

psychologicalstressesandconflicts.Thereisalsoavarietyofotherreasonslisted.

5.8ILLNESSBEHAVIOUR

Thesubjectswereaskedwhattheywouldnormallydowhentheyfelttheywereill.Their

responsesappearinTableXXXVI.Significantdifferences(chi‐squared)werefoundinthe

waythegroupsrespondedtohelp‐seekingbehaviourfromahospital,pharmacy,

traditionalhealer,useofprayer,selfmedicationordenial.Themajorityofpatients

indicatedthattheywouldseeadoctor(81.5%).TheKwaMashuGroupdiffered

significantlyintheiruseofthehospitalandpharmacy,selfmedicatinganddenialoftheir

illness.TheHospitalGroupusedprayermoreoftenthanthecommunityGroups.

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TABLEXXXVI ILLNESSBEHAVIOUROFSUBJECTS

Behaviour Hospital UmlaziKwaMashu Total n% n% n% n%

Gotoadoctor 295 (78.5) 301 (83.1) 131 (85.1) 727 (81.5) Gotoahospital 275 (73.1) 282 (77.9) 103 (66.9) 660 (74.0)** Gotoapharmacy 145 (38.6) 153 (42.3) 86 (55.8) 384 (43.1)* Pray 171 (45.5) 132 (36.5) 62 (40.3) 365 (41.0)** Askothersforhelp 137 (36.4) 137 (37.8) 70 (45.5) 344 (38.6) Ignoreit 129 (34.3) 104 (28.7) 83 (53.9) 316 (35.4)* Medicateyourself 101 (26.9) 92 (25.4) 99 (64.3) 292 (32.7)* Gotosomeonefor

prayer 63 (16.8) 76 (21.0) 30 (19.5) 169 (19.0) Readaboutit 31 (8.2)68 (18.8)17 (11.0)116 (13.0)* Gotoatraditional

healer 48 (12.8) 40 (11.0) 9 (5.8) 97 (10.9)

* p<0.01

** p<0.05

5.9HEALTHANDILLNESSBELIEFS

Cronbach'scoefficientalphatestwasdonetoestablishthereliabilityoftheHBQ.A

reliabilityof0.76wasobtained.Acomparisonofthegroupsoneachitemispresented

belowinTableXXXVII.

TABLEXXXVII COMPARISONSOFGROUPSRESPONSESONHBQITEMS(IN%)

HospitalUmlaziKwaMashuTotal (N=376)(N=362)(N=154)(N=892)

114

1. Peoplegetsickbecausethey

arenotstrong.

Agree 48.4 37.9 21.4 39.46* Sometimesagree 22.1 29.8 26.6 26.01 Disagree 22.6 28.4 37.7 27.58 Notsure 7.0 3.8 14.3 6.95

2. Peoplegetsickbecausethey

donoteattheproperfoods.

Agree 57.2 47.5 48.7 51.85 Sometimesagree 33.8 43.4 37.0 38.27 Disagree 6.4 6.6 11.0 7.30 Notsure 2.7 2.5 2.6 2.58

3. Illnessisduetodesertion

byGod.

Agree 11.2 11.9 3.2 10.10* Sometimesagree 21.0 26.2 12.3 21.66 Disagree 52.7 49.2 71.4 54.55 Notsure 15.2 12.4 13.0 13.69

4. Illnessiscausedbyinfection.

Agree 60.9 52.8 66.9 58.83** Sometimesagree 27.4 32.6 24.7 29.13 Disagree 8.5 6.9 2.6 6.86 Notsure 3.2 6.9 5.8 5.17

5. Illnessiscausedbywitchcraft

orsorcery.

Agree 22.9 20.4 11.0 20.02** Sometimesagree 30.3 22.9 33.1 28.05 Disagree 26.9 35.4 33.8 31.79 Notsure 20.0 19.9 20.8 20.14

6. Peoplegetsickbecausesomeone

115

hascursedordonesomething eviltowardsthem.

Agree 16.8 11.0 11.0 13.48 Sometimesagree 19.9 26.0 24.7 23.26 Disagree 38.3 39.8 40.9 39.44 Notsure 25.0 22.9 22.7 23.82

7. Peoplegetsickbecausethey

donotexerciseregularly.

Agree 36.2 36.5 32.5 35.69 Sometimesagree 34.3 35.9 46.1 37.04 Disagree 15.4 10.8 11.0 12.79 Notsure 14.1 16.6 10.4 14.48

8. Sickness'comes'fromthedevil.

Agree 13.6 11.3 13.6 12.70 Sometimesagree 15.7 13.0 9.1 13.48 Disagree 45.2 50.3 50.0 48.20 Notsure 25.5 25.1 26.6 25.62

9. Peoplegotodoctorsonlywhen

theyareseriouslyill.

Agree 42.3 35.1 38.3 38.76* Sometimesagree 27.9 27.9 42.9 30.56 Disagree 14.9 14.1 13.6 14.38 Notsure 14.6 22.7 5.2 16.29

116

10. Doctorsaretheonlyonesthat cantreatpeoplewhoareill.

Agree 20.2 9.1 13.0 14.53* Sometimesagree 22.3 19.9 9.7 19.26 Disagree 40.2 45.6 68.8 47.52 Notsure 17.3 24.6 7.8 18.69

11. Thereisnothingapersoncan

dotopreventthemselvesfrom gettingill.

Agree 19.9 12.7 18.2 16.74* Sometimesagree 25.0 23.5 10.4 21.91 Disagree 40.4 41.2 59.7 44.16 Notsure 14.6 22.1 11.7 17.19

12. Peoplegetsickbecausethey

donotkeepthemselvesclean.

Agree 34.0 30.1 39.6 33.56*** Sometimesagree 37.5 40.3 44.2 39.98 Disagree 16.5 13.5 11.0 14.41 Notsure 12.0 14.9 5.2 12.05

13. Therearesomeillnesses

thatdoctorscannottreat.

Agree 38.3 48.9 75.3 49.10* Sometimesagree 36.4 25.1 11.0 27.53 Disagree 12.8 11.0 5.2 10.79 Notsure 12.5 14.9 7.1 12.58

14. Peopleinheritillnessfrom

theirparents.

Agree 25.3 29.8 16.9 25.79* Sometimesagree 42.6 42.5 64.9 46.62 Disagree 18.4 14.4 9.1 15.20 Notsure 13.9 13.0 7.8 12.39

117

15. Ifapersontakesgoodcare ofthemselvestheywill notgetsick.

Agree 31.4 27.3 31.2 29.94** Sometimesagree 34.3 35.1 39.6 35.82 Disagree 19.9 17.1 21.4 19.21 Notsure 14.4 19.3 5.8 15.03

16. Peopleareabletocure

themselveswhentheyaresick.

Agree 19.1 23.8 16.2 20.61*** Sometimesagree 37.2 29.3 43.5 35.25 Disagree 28.5 26.0 27.3 27.36 Notsure 15.2 20.4 12.3 16.78

17. Ifapersongetssickit

istheirownfault.

Agree 11.7 9.1 3.2 9.29* Sometimesagree 23.7 22.4 33.8 25.14 Disagree 51.1 47.2 53.2 50.40 Notsure 13.6 19.6 7.8 15.18

18. Visitingadoctorforregular

checkupscanpreventaperson gettingsick.

Agree 42.8 29.8 38.3 36.98* Sometimesagree 29.8 31.5 40.3 32.47 Disagree 14.4 15.2 10.4 14.09 Notsure 13.0 22.4 10.4 16.46

19. Doctorscanmaketheillness

betterbuttheycannottreat thecause.

Agree 38.0 32.3 33.1 34.98*** Sometimesagree 32.7 28.7 40.3 32.51 Disagree 14.4 18.5 14.9 16.20 Notsure 14.9 20.2 10.4 16.31

118

20. Mostillnessescanbetreated athome.

Agree 26.9 22.9 21.4 24.49* Sometimesagree 31.6 34.0 19.5 30.70 Disagree 23.1 22.9 41.6 26.41 Notsure 18.4 19.3 15.6 18.40

21. Olderpeopleknowalotabout

illnessandcanadviceothers whattodo.

Agree 32.7 26.8 29.2 29.91** Sometimesagree 35.4 35.4 39.6 36.34 Disagree 15.2 13.3 20.1 15.35 Notsure 16.8 23.5 9.7 18.40

22. PeopleshouldpraytoGodto

curethemoftheirillness.

Agree 27.4 23.5 37.7 27.64* Sometimesagree 29.5 25.1 39.0 29.44 Disagree 23.4 25.4 14.3 22.70 Notsure 19.7 25.7 8.4 20.22

23. Peoplegetsickbecausethey

arelazyanddonotworkhard enough.

Agree 18.9 17.7 13.0 17.47** Sometimesagree 36.4 37.0 30.5 35.85 Disagree 28.5 22.7 37.7 27.85 Notsure 16.2 22.4 16.2 18.83

24. Whensickthetreatmentgiven

byeldersorolderpeoplecan reallybehelpful.

Agree 17.8 20.4 13.0 18.17* Sometimesagree 37.2 36.2 37.0 37.02 Disagree 23.1 14.4 31.8 21.22 Notsure 21.8 28.2 16.9 23.59

119

25. Illnessisaformof punishmentforthewrongor badthingsapersonhasdone.

Agree 13.0 10.5 7.8 11.17 Sometimesagree 21.3 18.8 15.6 19.41 Disagree 44.7 48.3 60.4 49.21 Notsure 21.0 21.3 15.6 20.20

26. Peoplegetsickwhensomething

foreigninvadestheirbody.

Agree 40.2 33.4 49.4 39.37** Sometimesagree 33.2 32.3 25.3 31.79 Disagree 16.0 16.6 10.4 15.38 Notsure 10.6 16.9 11.7 13.46

27. Sicknessoccursbecauseyoudo

notdotheritualsorprayer requiredbythepriestorancestors.

Agree 15.4 11.3 5.2 12.04* Sometimesagree 26.1 15.5 16.9 20.25 Disagree 37.8 42.3 59.7 43.53 Notsure 20.8 30.7 17.5 24.18

28. Apersoncanbecomeillif

theywalkorcrossoverapath orspotwheresomeritual wasperformed.

Agree 24.2 25.4 11.0 22.57** Sometimesagree 33.2 27.1 33.1 30.93 Disagree 22.6 24.3 32.5 25.17 Notsure 20.0 22.4 22.1 21.33

29. Sicknessoccursbecauseyour

bodyisnotfunctioningproperly.

Agree 33.0 29.6 50.0 34.76* Sometimesagree 35.6 37.6 33.1 36.23 Disagree 18.9 19.6 5.8 17.04 Notsure 12.5 12.4 9.1 11.96

120

30. Illnessisduetodemon.evil orbadspiritpossession.

Agree 14.9 9.9 9.7 12.06** Sometimesagree 14.9 17.4 24.0 17.59 Disagree 51.9 48.3 39.0 48.48 Notsure 18.4 23.8 25.3 21.87

31. Illnessisduetopunishment

ordesertionbytheancestors

Agree 15.8 16.3 7.1 14.53** Sometimesagree 15.0 13.0 22.1 15.43 Disagree 49.5 44.2 48.1 47.18 Notsure 19.8 26.5 21.4 22.86

*p<0.001

**p<0.01

***p<0.05

Thegroupsdifferedsignificantlyoncertainitems.Theseitemsandthestatistical

significantvaluesarepresentedbelow:item1,betweenall3groups(χ2=50.86,p<0.001);

item3,betweentheHospitalGroupandKwaMashuGroup(χ2=19.16,p<0.001)andthe

KwaMashuGroupandUmlaziGroup(χ2=27.69.p<0.001);item4,all3groups(χ2=17.85,

p<0.01);item5,betweenall3groups(χ2=17.93,p<0.01);item9,betweenall3groups

(χ2=33.24,p<0.001);item10,betweenall3groups(χ2=61.59,p<0.001);item11,between

all3groups(χ2=37.05,p<0.001);item12,betweentheHospitalGroupandKwaMashu

Group(χ2=9.37,p<0.05)andbetweentheKwaMashuandUmlaziGroup(χ2=12.30,

p<0.01);item13,betweenall3groups(χ2=68.92,p<0.001);item14,betweenthe

HospitalGroupandKwaMashuGroup(χ2=23.66,p<0.001)andtheKwaMashuGroupand

UmlaziGroup(χ2=22.96,p<0.001);item15,betweentheKwaMashuGroupandUmlazi

Group(χ2=15.14,p<0.01);item16,betweentheHospitalGroupandUmlaziGroup

(χ2=8.97,p<0.05)andbetweentheKwaMashuGroupandUmlaziGroup(χ2=13.37,

121

p<0.01);onitem17,betweentheHospitalGroupandKwaMashuGroup(χ2=15.89,

p<0.01)andtheKwaMashuGroupandUmlaziGroup(χ2=20.70,p<0.001);onitem18,

betweentheHospitalGroupandUmlaziGroup(χ2=17.92,p<0.001)andbetweentheKwa

MashuGroupandUmlaziGroup(χ2=14.87,p<0.01);item19,betweenKwaMashuGroup

andUmlaziGroup(χ2=11.30,p<0.01);item20,betweentheHospitalGroupandKwa

MashuGroup(χ2=20.65,p<0.001)andtheKwaMashuGroupandUmlaziGroups

(χ2=21.85,p<0.001);item21,betweentheKwaMashuGroupandUmlaziGroup

(χ2=14.63,p<0.01);item22,betweentheHospitalGroupandKwaMashuGroup

(χ2=19.64,p<0.001)andtheKwaMashuGroupandUmlaziGroup(χ2=36.65,p<0.001);

item23,betweentheKwaMashuGroupandUmlaziGroup(χ2=13.79,p<0.01);item24,

betweentheHospitalGroupandUmlaziGroup(χ2=11.53,p<0.01)andtheKwaMashu

GroupandUmlaziGroup(χ2=25.73,p<0.001);item26,betweentheKwaMashuGroup

andUmlaziGroup(χ2=13.69,p<0.01);item27,betweenall3groups(χ2=44.67,p<0.001);

item28,betweentheHospitalGroupandKwaMashuGroup(χ2=13.82,p<0.01)andthe

KwaMashuGroupandUmlaziGroup(χ2=14.65,p<0.01);item29,betweentheHospital

GroupandKwaMashuGroup(χ2=22.09,p<0.001)andtheKwaMashuGroupandUmlazi

Group(χ2=27.63,p<0.001);item30,betweentheHospitalGroupandKwaMashuGroup

(χ2=13.82,p<0.01)and,item31,betweenHospitalGroupandKwaMashuGroup(χ2=

14.09,p<0.01).Themeansandstandarddeviationsofeachitemforthegroupsappearin

TableXXXVIII

Item1assessedthebeliefthatapersongetssickbecausetheyarenotstrong.Onthisitem

theHospitalGroupagreedmorethanthecommunitygroups.Overalltherespondentsdid

'agree'or'sometimesagree'thatifapersonisnotstrongenoughhewillgetsick.Itseems

thatthosewhoattendthehospitalshaveastrongerbeliefthatthosewhoareillarenot

strong.Therewassomewhodisagreedwiththisviewrangingfrom22.6%intheHospital

Groupto37.7%inthecommunityGroup.Therewasgeneralagreementbyallgroupsthat

aperson'sdietmayleadtoillness(item2).Thisisinkeepingwithreasonsthesubjects

122

offeredwhypeoplegetsick(TableXXXV).Thesubjectstendedtodisagreewiththeview

thatillnessisduetodesertionbyGod(item3),especiallythoseintheKwaMashuGroup

(71.4%).Althoughthereisagreementthatitsometimescouldbetrue.Thebeliefthat

illnessiscausedbyinfectionwasoverwhelminglyendorsedbyallsubjects(item4).

Item5,whichrequiredthesubjectstorespondtothebeliefthatillnesswascausedby

witchcraftorsorceryyieldedmixedresponses.Halfofthesubjectseitheragreedor

sometimesagreedordisagreed.Althoughthebeliefisnotadominantoneitobviouslyis

animportantbeliefininterpretingandunderstandingtheirillnesses.Initem6thatdeals

withthebeliefthat'sicknessisduetoacurseorbewitchmentbyothers,therewerealso

mixedresponse.Thereis,however,aslightlyhighertendencytodisagreewithsuch

beliefs.Thereisageneralbeliefamongthesubjectsthatlackoforinadequateregular

exerciseleadstoillhealth(item7).Althoughsmall,therearesomewhodisagreeorare

notsureofthebenefitsofregularexercise.Mostsubjectsdisagreedwiththebeliefthat

sicknesscomesfromthedevil(item8).Ontheaverage25.62%wherenotsure.Asimilar

percentageagreedorsometimesagreed.

Theconsultingofdoctorsastheonlyhelp‐seekingbehaviourwhenseriouslyill(item9)

wasadominanthealthseekingbehaviour.Yetmostofthesubjectsdisagreedwiththe

beliefthatonlydoctorscantreatpeoplewhoareill(item10),thisbeingmoresointhe

communityGroupsthantheHospitalGroup.Ofthosewhoagreedwiththisbelief,the

HospitalGroupshowedgreateragreement.Onitem11,whichassessedthebeliefthat

thereisnothingapersoncandotopreventillness,alargenumberdisagreed;16.74%

agreed,21.91%sometimesagreedand17.19%werenotsure.Thismayindicatethat

thereisabeliefinaninternallocusofcontrolinthepreventionofillness.Sicknessasa

resultofpoorselfcareand/orhygienewasendorsedbymostofthesubjects(item12).

Theintervieweesagreedorsometimesagreedthatsomeillnesscannotbetreatedby

medicaldoctors(item13).Thiswouldsuggestthenthatifindividualsdonotbelievethat

doctorscantreatallillnessestheywouldseekhelpfromothersourcesandpersonsthey

123

feltwouldprovideappropriatetreatment.Subjectsalsoendorsedthebeliefthat

sometimesillnessesareinherited(item14).

Onitem15,subjectsendorsedthebeliefthattakingcareofoneselfcanprevent

illnesses.19,21%disagreedand15.03%werenotsure.Again,theissueofinternallocusof

controlinhealthbehaviourmustbeconsidered.Thesubjectsfeltthattheywereableto

effectacurethemselveswhenill(item16);27.36%disagreedand16.78%werenotsure.

However,theydidnotseeanyreasontoblamethemselvesfortheillness(item17).Only

inafewinstancesdidtheyagreethattheirillnesscouldbetheirfault.

'Visitingadoctorforregularcheckupscanpreventapersongettingsick'wasagreedor

sometimesagreedbymostrespondents(item18).However,14.09%disagreedand

16.46%werenotsure.Inaddition,subjectsexpressedthebeliefthatdoctorscantreat

symptomsbutnotthecause(item19).

Therewasageneralisedresponsetothebeliefthatmostillnessescanbetreatedathome

(item20);24.49%agreed,30.70%agreedsometimes,26.41%disagreedand18.40%were

notsure.Respondentsalsobelievedthatolderpeopleknowalotaboutillnessesandthat

theycanprovideappropriateadvice(item21);29.91%agreedand30.70%sometimes

agreed.

Item22dealtwiththebeliefthatpeopleshouldpraytoGodtocurethemoftheirillness.

Theresponsevariedfrom27.64%agreeing,29.44%agreeingsometimes,22.70%

disagreeingand20.22%notbeingsure.Item23lookedatthebeliefthatpeoplegetsick

becausetheyarelazyanddonotworkhardenough.Mostofthesubjectssometimes

agreed(35.85%).

Beliefsaboutthetreatmentgivenbyeldersorolderpeoplewasassessedbyitem24.The

mostcommonresponsewas'sometimesagree'(37.02%).Thesecondhighestresponse

wasnotsure(23.59%);18.17%agreedand21.22%disagreed.

124

Asmuchas49.21%ofthesubjectsdisagreedwiththebeliefthatillnessisaformof

punishmentforthewrongorbadthingsthatapersonasdone(item25).However,19.41%

agreedsometimes,11.17%agreedand20.20%werenotsure.

Thebeliefthatapersongetssickasaresultofsomethinginvadingtheirbody(item26)

wasawidelyacceptedbeliefbysubjectseitheragreeing(39.37%)orsometimesagreeing

(31.79%).Only13,46%werenotsureand15.38%disagreedwiththestatement.TheKwa

Mashusubjectsshowedthehighestagreementwiththestatement(49.4%)andlowest

disagreement(10.4%).Item27assessedthebeliefthatsicknessoccurredasaresultofnot

performingtherequiredritualsorprayerstotheancestors.Although43.53%disagreed

withthisbelief,12.04%agreed,20.25%agreedsometimesand24.18werenotsure.The

KwaMashusubjectsdemonstratedtheleastagreementwiththestatement(5.2%)and

highestdisagreement(59.7%).Avariedresponsewasobtainedforthebeliefthatpeople

canbecomeilliftheywalkorcrossoverapathorplacewheresomeritualwasperformed

(item28).Theresponse'sometimesagree'wasthemostcommon(22.57%),while22.57%

agreedand21.33%werenotsure.25.17%disagreedwiththebelief.TheKwaMashu

Groupdemonstratedthelowestagreementwiththisbelief.

Thebeliefthatsicknessistheresultofmalfunctioningorimproperfunctionofthebody

(item29)appearstobeacommonbeliefoftherespondents;34.76%agreedand36.23%

sometimesagreed.TheKwaMashusubjectsshowedahighagreementwiththestatement

(50.0%)andthelowestdisagreement(5.8%)

Therewasahighdisagreementwithstatement30thatillnessisduetodemon,evilorbad

spiritpossession(48.48%).BoththecommunityGroupsshowedlowagreement;Umlazi

9.9%andKwaMashu9.7%.TheHospitalGroupdemonstratedmoreagreementwiththe

belief(14.9%).However,theHospitalGroupalsorespondedwiththehighest

disagreement(51.9%).

Thelastitemassessedthebeliefthatillnessisduetopunishmentordesertionbythe

ancestors.Therespondentsshowedhighdisagreementwiththisbelief(47.18%).

125

Although,22.86%werenotsure,14.53%agreedand15.43%sometimesagreedwiththe

belief.TheKwaMashuGroupindicatedalowagreementwiththisbelief.

TABLEXXXVIII MEANSANDSTANDARDDEVIATIONSOFEACHHBQITEMFORGROUP

Item Hospital Umlazi KwaMashu No. MeanSD MeanSD MeanSD

1 1.88 0.99 1.98 0.912.45 0.98* 2 1.55 0.73 1.64 0.721.67 0.78 3 2.72 0.85 2.62 0.852.94 0.62* 4 1.54 0.78 1.68 0.881.47 0.81** 5 2.43 1.05 2.55 1.032.65 0.94** 6 2.72 1.02 2.75 0.932.76 0.93

7 2.07 1.04 2.07 1.071.99 0.93 8 2.83 0.96 2.89 0.912.90 0.95 9 2.02 1.08 2.24 1.161.86 0.84* 10 2.55 1.00 2.86 0.892.72 0.79* 11 2.50 0.97 2.73 0.952.65 0.91* 12 2.06 0.99 2.13 1.011.82 0.82*** 13 1.99 1.01 1.92 1.091.43 0.89* 14 2.20 0.97 2.11 0.982.08 0.76* 15 2.17 1.03 2.29 1.072.02 0.88** 16 2.39 0.96 2.43 1.072.36 0.90*** 17 2.66 0.85 2.79 0.872.67 0.67* 18 1.98 1.05 2.30 1.131.93 0.95* 19 2.06 1.06 2.27 1.122.03 0.96*** 20 2.33 1.06 2.39 1.052.52 1.01* 21 2.16 1.06 2.34 1.122.11 0.94** 22 2.35 1.08 2.53 1.111.93 0.93* 23 2.42 0.97 2.50 1.032.59 0.92** 24 2.49 1.02 2.51 1.112.53 0.93* 25 2.73 0.94 2.81 0.892.84 0.78 26 1.97 0.99 2.17 1.081.84 1.04** 27 2.63 0.98 2.93 0.962.98 0.74* 28 2.38 1.06 2.44 1.102.66 0.95** 29 2.11 1.00 2.15 0.991.74 0.94* 30 2.74 0.93 2.86 0.892.81 0.93** 31 2.73 0.95 2.81 1.012.85 0.84**

126

*p<0.001

**p<0.01

***p<0.05

Afactoranalysiswithvarimaxrotation(SASpackage)oftheitemswasdone.Ninefactors

whereretainedaccordingtotheMineigencriterion.Itemswithloadingof0.35ormore

wereincludedineachfactor.Thefactoranalysisrevealedninefactorswitheigenvalues

>1.TheresultsofthefactoranalysisappearinTableXXXIX.

TABLEXXXIX FACTORANALYSISOFTHEHBQ(COMBINED)

Items Loading* Eigen‐ Vari‐ value ance% Factor1 4.33 3.06 31. Illnessisduetopunishmentordesertion

bytheancestors 0.81 30. Illnessisduetodemon,evilorbad

spiritpossession 0.75 6. Peoplegetsickbecausesomeoneascursed

ordonesomethingeviltowardsthem 0.63 25. Illnessisaformofpunishmentforthe

wrongorbadthingsapersonhasdone 0.54 5. Illnessiscausedbywitchcraftorsorcery 0.53 27. Sicknessoccursbecauseyoudonotdo

theritualsorprayersrequiredbythe priestorancestors 0.53

28. Apersoncanbecomeilliftheywalk orcrossoverapathorspotwheresome ritualwasperformed 0.46

8. Sickness'comes'fromthedevil 0.43 Factor2 3.27 2.41 3. IllnessisduetodesertionbyGod 0.74

127

1. Peoplegetsickbecausetheyare notstrong 0.60

17. Ifapersongetssickitistheirownfault 0.56 Factor3 1.94 2.08 2. Peoplegetsickbecausetheydonot

eattheproperfoods 0.68 4. Illnessiscausedbyinfection 0.50 12. Peoplegetsickbecausetheydonot

keepthemselvesclean 0.46 14. Peopleinheritillnessesfromtheirparents 0.43 Factor4 1.51 2.01 20. Mostillnessescanbetreatedathome 0.71 24. Whensick,thetreatmentgivenbyelders

orolderpeoplecanreallybehelpful 0.64 21. Olderpeopleknowalotaboutillness

andcanadviseotherswhattodo 0.63 16. Peopleareabletocurethemselves

whentheyaresick 0.49 Factor5 1.25 1.84 29. Sicknessoccursbecauseyourbodyis

notfunctioningproperly 0.66 23. Peoplegetsickbecausetheyarelazy

anddonotworkhardenough 0.58 7. Peoplegetsickbecausetheydonot

exerciseregularly 0.58 26. Peoplegetsickwhensomething

foreigninvadestheirbody 0.50 Factor6 1.18 1.46 10. Doctorsaretheonlyoneswhocan

treatpeoplewhoareill 0.70 11. Thereisnothingapersoncandoto

preventthemselvesfromgettingill 0.61 9. Peoplegotodoctorsonlywhenthey

areseriouslyill 0.41

128

Factor7 1.15 1.45 18. Visitingadoctorforregularcheckups

canpreventapersongettingsick 0.79 15. Ifapersontakesgoodcareof

themselvestheywillnotgetsick 0.60 Factor8 1.07 1.24 22. PeopleshouldpraytoGodtocure

themoftheirillness 0.68 Factor9 1.01 1.19 19. Doctorscanmaketheillnessbetter

buttheycannottreatthecause 0.80 *Itemswithloadingsof0.35ormoreonafactorwereretained.

Theninefactorswhichemergedcouldbedescribedasfollows:

Factor1:Externalevilorancestralinfluence‐cultural(aetiology)

Theitemsthatloadedonthisfactorsuggestthattheaetiologyofillnessistheresultof

'punishmentordesertionbytheancestors';'demon,evilorbadspiritpossession';

'becausesomeonehascursedordonesomethingeviltowardsanother';'formof

punishmentforthewrongorbadthingsapersonhasdone''witchcraftorsorcery';'donot

dotheritualsorprayerrequiredbythepriestorancestors';'theywalkorcrossoverapath

orspotwheresomeritualwasperformed';'comesfromthedevil'.

129

Factor2:Selfblame(aetiology)

Theitemsthatloadedonthisfactorsupportstheaetiologyofillnessasaresultofthe

individualnotbeingstrongenough.IllnessisduetodesertionbyGod;becausepeopleare

notstrong;oritistheindividual'sfault.

Factor3:Medicalreason(aetiology)

Theitemsthatloadedonthisfactorsuggestthatpeoplegetsickbecausetheydonoteat

theproperfoods;illnessiscausedbyinfection;peoplegetsickbecausetheydonotkeep

themselvesclean;peopleinheritillnessesfromtheirparents.

Factor4:Selfmedication(treatment)

Thisfactordealswithtreatment.Theitemsthatloadedheresuggestthatmostillnesses

canbetreatedathome;treatmentgivenbyeldersorolderpeoplecanreallybehelpful;

olderpeopleknowalotaboutillnessandcanadviseotherswhattodoandpeopleare

abletocurethemselveswhentheyaresick.

Factor5:Physicalweaknessorbodymalfunctioning(aetiology)

Thisfactorsuggeststhatsicknessoccursbecausethebodyisnotfunctioningproperly;

peoplegetsickbecausetheyarelazyanddonotworkhardenough;ortheydonot

exerciseregularlyorpeoplegetsickwhensomethingforeigninvadestheirbody.

130

Factor6:Medical(treatment)

Theitemsthatloadedonthisfactorsupportstheviewthatdoctorsaretheonlyoneswho

cantreatpeoplewhoareill,thatthereisnothingapersoncandotopreventthemselves

fromgettingillandthatpeoplegotodoctorsonlywhentheyareseriouslyill.

Factor7:Selfcare(prevention)

Thisfactorrepresentsitemsthatinvolveselfcareasapreventativemeasureagainst

illness.Theitemsthatloadedonthisfactorincludedvisitingadoctorforregularcheckups

topreventapersongettingsick;ifapersontakesgoodcareofthemselvestheywillnot

getsick;

Factor8:Useofprayer(treatment)

Theitemthatloadedonthisfactor'peopleshouldpraytoGodtocurethemoftheir

illness'suggestprayerandtheevokingofGod'sassistanceasamethodoftreatment.

Factor9:Holisticbelief(treatment)

Thisfactorsuggestthatthemedicalmodelisonlypartlyeffectiveasatreatment.Theitem

loadingonthisfactor'doctorscanmaketheillnessbetterbuttheycannottreatthecause'

suggestadditionalmethodstothemedicalmodel.

Factorscoreswerecalculatedforeachoftheninefactorsbyaddingthevaluesoneach

item.Amultivariateanalysis(MANOVA)wasperformedontheninefactorswithmain

131

effects:group,sexandurbanisation(0‐5yearsand>5years).Agewasusedasacovariate.

ThefactorscoresforeachfactorisfoundinTableXL.

TABLEXL MEANFACTORSCORESONTHENINEFACTORSRELATINGTOHEALTHBELIEF Factor Hospital Umlazi KwaMashu

Mean SD Mean SD Mean SD

1 17.83 4.31 18.99 3.86 19.37 4.23 2 8.55 1.80 8.45 1.67 8.77 1.25 3 6.65 1.69 6.69 1.85 6.46 1.53 4 7.90 1.95 7.82 1.92 8.36 2.29 5 7.31 2.03 7.12 1.86 7.00 1.81 6 6.17 1.62 6.61 1.32 6.82 1.44 7 3.52 1.22 3.79 1.08 3.57 1.22 8 1.95 0.80 2.03 0.82 1.74 0.72 9 1.72 0.73 1.83 0.78 1.79 0.71

Onfactor1nomaineffectsorinteractionswerefound.

OnFactor2therewassignificantdifferencesbetweenlivinginanurbanareafor0‐5years

and>5years.(F(1,885)=13.59,p=0.0003).OnFactor3theanalysisrevealedsignificant

differencesinthegroupbyurbaninteraction(p=0.0179),andsignificancewitheffecton

age(p=0.0015).SignificantdifferencesbetweentheHospital,UmlaziandKwaMashu

Groups(p=0.0220),urban(p=0.0355),groupbyurbaninteraction(p=0.0031)werefound

onfactor4.

Onfactor5significantdifferenceswerefoundbetweengroups(p=0.0012),groupsby

urbaninteraction(p=0.0003)andage(p=0.0483)

Forfactor6significantdifferenceswerefoundbetweengroups(p=0.0370)andbetween

groupsbyinteraction(p=0.0370).

132

Significantdifferenceswasfoundonfactor7dependingonthenumberofyearspatients

werelivinginanurbanarea(p=0.0165),ingroupbysex(p=0.0407)andingroupbylivingin

urbanareas(p=0.0250).

Onfactor8thesignificantdifferenceswerebetweengroups(p=0.0146)andbetween

groupbyurbandwelling(p=0.0137).

Onfactor9significantdifferenceswerefoundingroupbyurbandwelling(p=0.0423)and

age(p=0.0106).

5.10SOCIALSUPPORT

ThereliabilityoftheSSQwasdeterminedbysubjectingittotheCronbach'salphatest.A

Cronbach'scoefficientalphaof0.91wasobtained.TableXLIliststhepercentageof

responsesoneachitem.Itwouldappearfromtheresponsesthatthesubjectsinallgroups

weregenerallysatisfiedwiththesocialsupporttheyreceivedandperceivedthemselvesas

asourceofsupportaswell.

133

TABLEXLI COMPARISONSOFSSQITEMSBETWEENGROUPS(in%)

Hospital Umlazi KwaMashu Combined (N=368) (N=360) (N=152) (N=880)

1. Whocanyoureallycount

ontolistentoyouwhen youneedtotalk?

Verysatisfied 60.05 53.31 64.24 58.00 Satisfied 39.13 46.69 35.10 41.54 Dissatisfied 0.82 0.00 0.00 0.34 Verydissatisfied 0.00 0.00 0.66 0.11

2. Whocouldyoureallycount

ontohelpyouinanemerg‐ encyorcrisissituation.

Verysatisfied 52.72 52.50 57.89 53.52 Satisfied 46.26 46.94 40.79 45.57 Dissatisfied0.82 0.28 1.32 0.68 Verydissatisfied 0.27 0.28 0.00 0.23

3. Whohelpsyoufeelthatyou

areagoodandworthwhile person?

Verysatisfied 55.59 52.22 51.66 53.53 Satisfied 42.78 46.39 45.70 44.76 Dissatisfied1.09 0.83 0.66 0.91 Verydissatisfied 0.54 0.56 1.99 0.80

134

4. Whomcanyoureallygoto whenyouareworriedand/ orunderpressure?

Verysatisfied 53.53 52.91 42.38 51.36 Satisfied 44.57 46.26 56.95 47.36 Dissatisfied1.63 0.55 0.66 1.02 Verydissatisfied 0.27 0.28 0.00 0.23

5. Whocanyoucountonwhen

yougenerallyneedhelpfor reasonsotherthanan emergencyorcrisis?

Verysatisfied 48.50 49.58 41.72 47.78 Satisfied 50.14 49.58 54.97 50.74 Dissatisfied1.36 0.83 2.65 1.37 Verydissatisfied 0.00 0.00 0.66 0.11

6. Whocanyoureallycount

ontohelpyouifthingsgo wrong,youhaveamishapor runoutofluck?(eg.fired fromyourjob,meetan accident,etc.)

Verysatisfied 50.95 49.58 47.37 49.77 Satisfied 47.97 50.15 48.68 48.97 Dissatisfied0.81 0.28 3.95 1.13 Verydissatisfied 0.27 0.00 0.00 0.11

7. Whocanyoureallycounton

togiveyouusefuladvice, guidanceorsuggestions thathelpyoutoavoid makingmistakes?

Verysatisfied 48.91 48.20 49.34 48.69 Satisfied 49.46 50.42 49.34 49.83 Dissatisfied1.36 1.39 1.32 1.36 Verydissatisfied 0.27 0.00 0.00 0.11

8. Whodoyoufeelwould

helpifafamilymember

135

orsomeoneveryclose toyoudied?

Verysatisfied 45.11 49.72 42.00 46.47 Satisfied 53.26 47.78 54.67 51.25 Dissatisfied1.36 2.22 2.67 1.94 Verydissatisfied 0.27 0.28 0.67 0.34

9. Whodoyoufeeltruly

lovesyoudeeply?

Verysatisfied 55.83 57.50 70.20 58.98 Satisfied 43.09 41.94 29.80 40.34 Dissatisfied0.54 0.28 0.00 0.34 Verydissatisfied 0.54 0.28 0.00 0.34

10. Whocanyoucountonto

comfort/consoleyouwhen youareveryupset?

Verysatisfied 46.17 48.88 53.33 48.51 Satisfied 51.91 50.84 46.00 50.46 Dissatisfied1.64 0.28 0.67 0.92 Verydissatisfied 0.27 0.00 0.00 0.11

11. Whocanyoureallycount

ontosupportyouinmajor decisionsorplansyoumake?

Verysatisfied 50.68 44.60 52.00 48.41 Satisfied 48.23 54.29 47.33 50.57 Dissatisfied1.09 1.11 0.00 0.91 Verydissatisfied 0.00 0.00 0.67 0.11

136

12. Whodoyouknowwhomyou cantrustwithasecretor informationthatcould getyouintrouble?

Verysatisfied 49.86 45.98 50.34 48.34 Satisfied 48.77 52.91 46.26 50.06

Dissatisfied 0.82 0.83 2.72 1.14 Verydissatisfied 0.54 0.28 0.68 0.46

13. Whodoyoucountonwhen

youareill?

Verysatisfied 49.05 40.28 57.33 46.87 Satisfied 49.05 58.89 41.33 51.76 Dissatisfied1.63 0.56 0.67 1.02 Verydissatisfied 0.27 0.28 0.67 0.34

14. Whocanyoureallycounton

whenyougetintotrouble?

Verysatisfied 48.91 42.46 54.05 47.13 Satisfied 50.55 55.87 45.95 51.95 Dissatisfied0.55 1.40 0.00 0.80 Verydissatisfied 0.00 0.28 0.00 0.11

15. Whodoyouthinkwillcome

toyouiftheyhadaneed orproblem?

Verysatisfied 57.14 48.19 45.27 51.44 Satisfied 41.76 50.97 52.70 47.42 Dissatisfied1.10 0.56 1.35 0.92 Verydissatisfied 0.00 0.28 0.68 0.23

Themeansandstandarddeviationsofthesubjects'responsesforeachitemontheSSQ

arepresentedinTableXLIV.

137

TABLEXLII MEANSANDSTANDARDDEVIATIONSOFSSQITEMSBYGROUPS Item Hospital Umlazi KwaMashu No. Mean SD Mean SD Mean SD

1. 3.59 0.51 3.53 0.50 3.63 0.52 2. 3.51 0.53 3.52 0.52 3.57 0.52 3. 3.53 0.55 3.50 0.55 3.47 0.62 4. 3.51 0.55 3.52 0.53 3.42 0.51 5. 3.47 0.53 3.49 0.52 3.38 0.57 6. 3.50 0.53 3.49 0.51 3.43 0.57 7. 3.47 0.54 3.47 0.53 3.48 0.53 8. 3.43 0.54 3.47 0.56 3.38 0.58 9. 3.54 0.54 3.57 0.52 3.70 0.46 10. 3.44 0.54 3.49 0.51 3.53 0.51 11. 3.50 0.52 3.43 0.52 3.52 0.54 12. 3.48 0.55 3.45 0.53 3.46 0.59 13. 3.47 0.55 3.39 0.52 3.55 0.55 14. 3.48 0.51 3.41 0.54 3.54 0.50 15. 3.56 0.51 3.47 0.53 3.43 0.56

5.10.1 Comparisonsofgroupsonaccessibilityandproximity

Analysisofvariancewasperformedonthevariablesaccessibility(immediateanddelayed)

andproximity(nearbyandfar).Significantdifferenceswerefoundbetweenthethree

groupsonallthesevariables(TableXLII).

TABLEXLIII ANOVAOFACCESSIBILITYANDPROXIMITY

df F p

138

Accessibility:

Immediate 2 98.72 p<0.0001* Delayed 2 71.07 p<0.0001**

Proximity:

Nearby 2 110.30 p<0.0001* Far 2 67.08 p<0.0001**

Duncan'sMultipleRangeTestwasperformedasaposthoctestforpairwisecomparisons.

TheresultsarefoundinTableXLIII.

Themodeinwhichthesubjectsobtainedtheirsupportwasasfollows:HospitalGroup

(N=376),304(80.85%)usedthetelephoneand123(32.71%)wrote;UmlaziGroup

(N=362),20(5.52%)usedthetelephoneand100(27.62%)wrote;withtheKwaMashu

Group(N=154),147(95.45%)telephonedand92(59.74%)wrote.BoththeHospitaland

theKwaMashuGroupsusedthetelephoneasthemainmeansofcommunicationandfor

obtainingsocialsupport.Theotherwaywasbypostalservice.

Afactoranalysisofthesubjects'responsesonthefifteenitemsontheSSQwasdone.The

rotationalvarimaxmethodwasusedandtwofactorsemerged(TableXLV).

TABLEXLIV DUNCAN'SMULTIPLERANGETEST

Duncan's GroupingMean N Group

139

Accessibility(immediate)

A 3.43 154 KwaMashu B 2.03 362 Umlazi C 1.75 376 Hospital

Accessibility(delayed)

A 1.66 154 KwaMashu B 0.69 362 Umlazi B 0.62 376 Hospital

Proximity(Nearby)

A 3.40 154 KwaMashu B 2.00 362 Umlazi C 1.64 376 Hospital

Proximity(Far)

A 1.71 154 KwaMashu B 0.70 362 Umlazi B 0.70 376 Hospital

Thesubjectsreportedobtainingsocialsupportfrommainlyfamilyandfriends.Thefamily

supportwasasfollows:mother(27,78%),spouse(22.53%),friend(7.80%),brother

(7.17%),father(6.59%),sister(5.38%),children(4.16%)andpriest/minister(1.34).No

subjectreportedfathersupportonitem10‐‘Whocanyoucountontocomfortorconsole

youwhenyouareveryupset?’

140

TABLEXLV FACTORANALYSISOFTHESSQ(COMBINED)

Items Loading* Eigen‐ Vari value ance%

Factor1 6.74 4.21 2. Whocouldyoureallycountontohelp

youinanemergencyorcrisissituation? 0.72 4. Whocanyoureallygotowhenyouare

worriedand/orunderpressure? 0.72 5. Whocanyoucountonwhenyougenerally

needhelpforreasonsotherthanan emergencyorcrisis? 0.72

6. Whocanyoureallycountontohelpyou ifthingsgowrong,youhaveamishap orrunoutofluck?(eg.firedfromyour job,meetanaccident,etc.) 0.71

3. Whohelpsyoufeelthatyouareagood andworthwhileperson? 0.70

1. Whocanyoureallycountontolisten toyouwhenyouneedtotalk? 0.65

7. Whocanyoureallycountontogiveyou usefuladvice,guidanceorsuggestions thathelpyoutoavoidmakingmistakes? 0.63

8. Whodoyoufeelwouldhelpifafamily memberorsomeoneveryclosetoyoudied? 0.54

Factor2 1.37 3.90 13. Whodoyoucountonwhenyouareill? 0.78 14. Whocanyoureallycountonwhenyou

getintotrouble? 0.75 15. Whodoyouthinkwillcometoyouif

theyhadaneedorproblem? 0.72 12. Whodoyouknowwhomyoucantrustwith

asecretorinformationthatcouldget youintrouble? 0.71

11. Whocanyoureallycountontosupport youinmajordecisionsorplansyoumake? 0.69

10. Whocanyoucountontocomfort/ consoleyouwhenyouareveryupset? 0.59

9. Whodoyoufeeltrulylovesyoudeeply? 0.56 *Itemswithloadingsof0.35ormoreonafactorwereretained

Factor1

141

Theitemsthatloadedhighonthisfactordealswithsupportinanemergencyorcrisis

situation;whenyouareworriedand/orunderpressure;needhelpforreasonsotherthan

anemergencyorcrisis;helpyouifthingsgowrong,youhaveamishaporrunoutofluck?

(eg.firedfromyourjob,meetanaccident,etc.);helpsyoufeelthatyouareagoodand

worthwhileperson;tolistentoyouwhenyouneedtotalk;togiveyouusefuladvice,

guidanceorsuggestionsthathelpyoutoavoidmakingmistakes;helpifafamilymember

orsomeoneveryclosetoyoudied.

Factor2

Theitemsthatloadedhighonthisfactordealswithsupportwhenill;whenyougetinto

trouble;iftheyhadaneedorproblem;cantrustwithasecretorinformationthatcould

getyouintrouble;inmajordecisionsorplansyoumake;tocomfort/consoleyouwhen

youareveryupset';whoyoufeeltrulylovesyoudeeply.

Factorscoresforeachofthefactorsonthesocialsupportquestionnairewerecalculated

byaddingthevaluesforeachitemonthefactor.A3‐wayMultivariateAnalysisofVariance

(MANOVA)wasperformedonthetwofactorstodeterminewhethertherewere

differencesbetweenthe3groups(Hospital,UmlaziandKwaMashu),betweenmalesand

femalesandbetweenlivinginanurbanareafor0‐5yearsand>5years.(TheMANOVA

testsforwithinsubjecteffectsandrelatedinteractions).Theactualagewasusedasa

covariateintheanalysis.

TheoverallFtestsyieldedsignificanteffectsforbothFactor1(F=2.08,p<0.0162)and

Factor2(F=1.83,p<0.0404).

OnFactor1themaineffects(group,sexandurbandwelling)showednosignificantresults.

Howeverthereweresignificantinteractionsbetweengroupbysex(p=0.0072),groupby

urbandwelling(p=0.0178)andsexbyurbandwelling(p=0.0289).SeeTableXLVI.

142

TABLEXLVI MANOVAONFACTOR1OFSSQ

df SD F p Group 2 31.06 1.64 0.1940 Sex 1 27.49 2.91 0.0885 Urban 1 3.76 0.40 0.5284 Groupbysex 2 93.86 4.97 0.0072* Groupbyurban 2 76.54 4.05 0.0178** Sexbyurban 1 5.27 4.79 0.0289** Groupbysexbyurban 2 34.30 1.81 0.1636 Age 1 57.92 6.13 0.0135**

*p<0.01

*p<0.05

Asignificantgroupbysexinteractionmeantthatthemalesandthefemalesinthe3

groupsrespondeddifferentlytofactor1.Agealsohadasignificanteffectonthefactor

(p=0.0135).

TableXLVIIshowsthesignificantinteractionsonfactor2betweengroupandsex

(p=0.0465)andgroupbyurbandwelling(p=0.0160).

143

TABLEXLVII MANOVAONFACTOR2OFSSQ

df SD F p Group 2 16.59 1.11 0.3291 Sex 1 17.68 2.37 0.1238 Urban 1 20.43 2.74 0.0981 Groupbysex 2 45.89 3.08 0.0465* Groupbyurban 2 61.98 4.16 0.0160* Sexbyurban 1 5.50 0.74 0.3905 Groupbysexbyurban 2 10.66 0.72 0.0894 Age 1 1.23 0.17 0.6846 *p<0.05

ItisalsoapparentfromtheMANOVAthatthereisagoodcorrelationbetweenFactor1

andFactor2(r=0.670).

5.11SYMPTOMPERCEPTIONS ReliabilitywasdeterminedusingtheCronbach'scoefficientalphatest.Ahighreliabilityof

0.96wasachieved.Thepercentageofsubjectsineachgroupwhohadexperiencedthe

symptomsinthemodifiedsymptominventoryisfoundinTableXLVIII.

144

TABLEXLVIII EXPERIENCEOFSYMPTOMSBYEACHSUBJECTBYGROUP

Symptom HospitalUmlazi KwaMashu Total 1 Headaches 93.86 92.07 93.42 93.12 2 Nervousnessorshakiness

inside 53.98 47.59 66.45 56.01 3 Beingunabletogetrid

ofbadthoughtsorideas 31.52 29.12 36.49 32.38 4 Faintnessordizziness 59.93 43.05 65.3356.10 5 Lossofsexualinterest

orpleasure 25.45 20.28 42.28 29.34 6 Feelingcriticalofothers 29.09 40.00 27.63 32.24 7 Baddreams 65.34 58.13 68.21 63.89 8 Difficultyinspeakingwhen

youareexcited 50.54 55.52 48.00 51.35 9 Troublerememberingthings 48.55 45.33 52.32 48.73 10 Worriedaboutsloppinessor

carelessness 48.73 50.35 51.66 50.25 11 Feelingeasilyannoyedor

irritated 56.52 51.22 63.58 57.12 12 Painsintheheartorchest 40.43 32.17 44.08 38.89 13 Itching 48.55 44.95 81.2158.24 14 Feelinglowinenergyor

sloweddown 56.36 57.04 78.15 63.85 15 Thoughtsofendingyourlife 18.84 30.66 11.8420.44 16 Sweating 71.38 65.97 68.87 68.74 17 Trembling 42.55 37.98 27.81 36.11 18 Feelingconfused 50.36 42.86 51.32 48.18 19 Poorappetite 61.96 63.88 63.58 63.14 20 Cryingeasily 35.87 37.63 26.67 33.39 21 Feelingshyoruneasywith

theoppositesex 37.09 35.44 31.58 34.70 22 Afeelingofbeingtrapped

orcaught 25.82 32.40 18.42 25.55 23 Suddenlyafraidfornoreason 34.55 35.89 33.55 34.66 24 Temperoutburstyoucould

notcontrol 49.82 50.17 46.71 48.90 25 Constipation 52.73 59.16 79.47 63.79 26 Blamingyourselfforthings 50.18 54.86 64.00 56.35 27 Painsinthelowerpartof

yourback 52.19 49.13 54.00 51.77

145

28 Feelingblockedorstymied ingettingthingsdone 35.79 35.44 42.3837.87

29 Feelinglonely 46.91 50.69 72.3756.66 30 Feelingblue 40.22 47.06 59.87 49.05 31 Worryingorstewingabout

things 48.00 54.33 74.17 58.83 32 Feelingnointerestinthings 42.34 38.19 58.94 46.49 33 Feelingfearful 38.77 41.96 47.3342.69 34 Yourfeelingsbeing

easilyhurt 41.82 44.10 51.32 45.75 35 Havingtoaskothers

whatyoushoulddo 51.83 51.21 54.61 52.55 36 Feelingothersdonot

understand 38.69 47.74 49.01 45.15 37 Feelingthatpeopleare

unfriendlyordislikeyou 34.07 48.59 43.71 42.12 38 Havingtodothingsveryslowly

inordertobesureyouare doingthemright 57.86 59.52 61.18 59.52

39 Heartpoundingorracing 44.77 33.80 43.71 40.76 40 Nauseaorupsetstomach 53.99 54.17 72.85 60.34 41 Feelinginferiortoothers 41.30 56.40 36.18 44.63 42 Sorenessofyourmuscles 45.29 43.94 63.16 50.80 43 Loosebowelmovements 63.64 76.82 72.37 70.94 44 Difficultyinfallingasleep

orstayingasleep 50.91 43.94 74.83 56.56 45 Havingtocheckanddouble

checkwhatyoudo 58.39 55.71 75.66 63.25 46 Difficultymakingdecisions 40.88 36.81 60.26 45.98 47 Wantingtobealone 48.18 38.06 52.63 46.29 48 Troublegettingyourbreath 33.45 31.25 26.00 28.23 49 Hotorcoldspells 45.99 40.21 59.73 48.64 50 Havingtoavoidcertain

placesoractivitiesbecause theyfrightenyou 36.86 42.01 46.26 41.71

51 Yourmindgoingblank 24.54 28.13 19.21 23.96 52 Numbnessortinglingin

partsofyourbody 26.37 24.13 23.65 24.72 53 Alumpinyourthroat 29.20 29.72 38.6732.53 54 Feelinghopelessabout

thefuture 35.40 33.33 41.33 36.69 55 Troubleconcentrating 32.12 32.64 37.75 34.17 56 Weaknessinpartsofyourbody 35.77 25.00 20.95 27.24 57 Feelingtenseorkeyedup 30.40 29.51 28.67 29.53 58 Heavyfeelingsinyour

146

armsorlegs 33.94 29.51 27.52 30.32 Additionalitems 59 Fever 79.93 79.44 88.74 82.70 60 Chills 64.47 70.48 75.66 70.20 61 Sorethroat 63.50 69.90 82.00 71.80 62 Achesandpainsallover 62.41 59.16 70.39 63.99 63 Sneezing 66.42 59.93 86.75 71.03 64 Runnynose 51.27 43.55 67.32 54.05 65 Stomachpain 56.93 47.06 73.33 59.12 66 Swelling 34.18 24.31 26.67 28.39 67 Hairloss 21.82 36.24 27.15 28,40 68 Painduringurination 30.55 29.51 40.6733.58 69 Skinrash 42.70 41.96 58.94 47.87 70 Coughing 66.18 61.94 80.00 69.37 71 Blurredvision 32.36 42.51 30.2635.04 72 Slurredspeech 20.36 25.69 18.54 21.53 73 Vomiting 31.64 32.29 48.67 37.53 74 Bloodinstool 17.45 20.07 17.4518.32 75 Coughingblood 21.09 19.10 9.21 16.47 76 Burningsensationsalloveror

incertainpartsofthebody 36.36 35.79 23.49 31.88 77 Lossofweight 41.82 52.26 44.0846.05 78 Swollenglands 21.45 23.26 15.13 19.95 79 Nightsweats 46.91 39.58 36.18 40.89 80 Bleeding 20.07 26.65 24.83 23.85 81 Dischargefromear,noseoreyes 14.18 18.53 15.44 16.05 82 Vaginalorpeniledischarge 17.88 20.83 34.23 24.31 83 Bloodinurine 11.31 16.96 15.5414.60

147

5.12SUBJECTSRATINGOFSEVERITYOFSYMPTOMS

TableXLIXpresentsthemeanandstandarddeviationsofthesubjectsratingofseverityofsymptoms.Theseverityofthesymptomswereratedasfollows:notserious=1;serious=2andveryserious=3.Themeanscoreforeachitemindicatesthattheitemswereratedasbeingeitherseriousorveryseriousbythesubjects.TABLEXLIXMEANANDSTANDARDDEVIATIONOFSEVERITYOFSYMPTOMSItem Hospital Umlazi KwaMashuNo. Mean SD Mean SD Mean SD1. 2.87 0.83 2.63 0.72 2.63 0.772. 2.34 0.87 2.05 0.82 2.45 0.933. 2.07 0.05 1.96 0.88 2.36 0.914. 2.36 0.89 2.04 0.89 2.54 0.845. 2.04 0.87 1.87 0.89 2.74 1.036. 2.09 0.81 2.21 0.97 2.17 0.847. 2.50 0.87 2.41 0.92 2.55 0.788. 2.29 0.84 2.34 0.99 2.49 0.859. 2.25 0.87 2.05 0.85 2.65 0.8810. 2.35 0.93 2.35 1.01 2.46 0.8211. 2.39 0.86 2.47 1.01 2.57 0.8212. 2.19 0.88 1.99 0.89 2.52 0.8213. 2.22 0.88 2.02 0.83 2.37 0.7414. 2.36 0.92 2.21 0.83 2.21 0.6215. 1.99 0.84 1.98 0.93 2.99 1.1516. 2.50 0.92 2.14 0.76 2.26 0.6717. 2.26 0.93 1.97 0.84 2.38 0.8518. 2.28 0.94 2.06 0.90 2.59 0.9019. 2.39 0.95 2.35 0.92 2.36 0.7420. 2.15 0.94 2.12 0.99 2.24 0.8221. 2.04 0.92 1.93 0.93 2.40 0.8122. 1.96 0.86 1.87 0.94 2.41 0.9423. 1.97 0.93 2.03 1.02 2.59 0.9424. 2.18 1.04 2.43 1.09 2.69 0.9025. 2.08 0.93 2.23 0.93 2.49 0.7926. 2.15 0.99 2.23 1.03 2.53 0.8627. 2.18 1.04 2.21 1.03 2.56 0.8428. 2.03 0.99 1.80 0.82 2.59 0.94

148

29. 2.12 0.98 2.15 1.03 2.43 0.8330. 2.08 1.02 2.01 1.01 2.33 0.8531. 2.15 1.01 2.13 1.05 2.66 0.8032. 2.05 0.96 1.90 0.97 2.49 0.8633. 2.06 0.99 2.02 1.02 2.62 0.8334. 2.09 1.01 2.12 1.06 2.61 0.8335. 2.16 0.99 2.08 1.04 2.56 0.8636. 2.09 0.99 2.24 1.09 2.54 0.8437. 2.10 1.01 2.41 1.16 2.68 0.9538. 2.35 1.09 2.50 1.15 2.70 0.9339. 2.17 1.03 1.96 1.05 2.68 0.9140. 2.15 0.98 2.15 0.99 2.49 0.7741. 2.11 1.02 2.24 1.09 2.67 0.8442. 2.09 1.05 2.09 1.12 2.34 0.8243. 2.41 0.87 2.44 0.78 2.55 0.7444. 2.24 0.88 2.02 0.82 2.73 0.7345. 2.44 0.96 2.50 1.06 2.58 0.8246. 2.27 0.89 2.02 0.92 2.70 0.7847. 2.29 0.90 2.16 0.96 2.64 0.8948. 2.07 0.83 1.95 0.89 2.71 0.9749. 2.21 0.92 2.02 0.87 2.59 0.7950. 2.17 0.92 2.22 1.02 2.62 0.8651. 1.97 0.89 1.90 0.89 2.97 1.0552. 2.02 0.90 1.85 0.82 2.39 0.9453. 2.05 0.87 1.86 0.84 2.48 0.8354. 2.23 0.91 2.02 0.94 2.83 0.8755. 2.09 0.89 2.03 0.94 2.66 0.8956 2.11 0.88 1.90 0.87 2.37 0.9657. 2.08 0.90 1.87 0.85 2.35 0.9158. 2.14 0.89 1.98 0.93 2.21 0.8959. 2.55 0.89 2.44 0.78 2.49 0.7560. 2.45 0.93 2.44 0.78 2.53 0.8061. 2.41 0.93 2.35 0.74 2.52 0.7962. 2.41 0.94 2.34 0.86 2.32 0.7463. 2.40 0.90 2.17 0.74 2.21 0.5964. 2.25 0.92 2.18 0.92 2.28 0.7165. 2.30 0.95 2.13 0.86 2.57 0.8266. 2.07 0.90 1.90 0.90 2.55 0.8967. 1.88 0.88 1.91 0.93 2.34 0.9468. 1.99 0.94 1.94 0.92 2.57 0.8469. 2.08 0.91 2.03 0.92 2.36 0.7570. 2.30 0.98 2.17 0.88 2.42 0.7171. 1.98 0.90 1.99 0.99 2.86 0.8772. 1.88 0.89 1.72 0.89 2.39 0.8873. 1.98 0.85 1.87 0.99 2.54 0.8474. 1.84 0.88 1.65 0.92 2.59 0.97

149

75. 1.89 0.93 1.72 0.96 3.11 1.0276. 2.05 0.94 1.91 0.95 2.35 0.8077. 2.08 0.92 2.09 1.02 2.42 0.7978. 1.89 0.91 1.75 0.95 2.48 0.9579. 2.08 0.96 1.82 0.95 2.57 0.8280. 1.80 0.85 1.79 1.00 3.07 1.0481. 1.81 0.90 1.65 0.91 2.62 0.8982. 1.87 0.93 1.67 0.96 3.20 0.9983. 1.79 0.92 1.64 0.95 2.86 0.915.13EXPERIENCESTRESSORSANDLIFECHANGES TheresponseonthemodifiedLESwassubjectedtotheCronbach'scoefficientAlphatest

andareliabilityof0.71wasobtained.Thissuggeststhatthequestionnairehadgood

constructvalidity.

TheLEScontainedanumberofeventswhichsometimesbringsaboutchangeinthelives

ofindividualsexperiencingthemandwhichnecessitatessocialreadjustment.Thesubjects

wereaskedtoindicatethoseeventstheyhadexperiencedwithinthepastyear.TableL

liststhepercentageofsubjectsineachgroupwhohadexperiencedtheseevents.

150

TABLEL EXPERIENCEOFSTRESSORPERGROUP Event Hospital Umlazi KwaMashu Total

% % % % 1. Marriage 34.9 42.3 11.0 29.40 2. Detentioninjailor

comparableinstitution 5.9 6.3 7.1 6.43 3. Deathofspouse 6.9 9.9 5.2 7.33 4. Majorchangeinsleeping

habits(muchmore/lesssleep) 11.2 6.1 18.8 12.03 5. Deathofclosefamily

a.mother 12.0 17.4 5.8 11.73 b.father 22.9 15.7 9.7 16.10 c.brother 10.1 7.7 7.7 8.50 d.sister 15.7 12.5 3.2 10.47 e.grandmother 17.3 14.1 7.7 13.03 f.grandfather 12.5 7.4 9.1 9.67 g.other(specify) 10.3 6.6 16.9 11.27

6. Majorchangeineating habits 13.0 10.7 16.2 13.30

7. Foreclosureonmortgage orloan 1.8 2.3 2.6 6.70

8. Deathofclosefriend 22.9 15.5 15.618.00 9. Outstandingpersonal

achievement 8.8 6.9 19.5 11.73 10. Minorlawviolations

(traffictickets, disturbingthepeace) 6.4 3.6 3.2 4.40

11. Male:wife/girlfriend pregnant 12.5 6.4 7.8 8.90

12. Female:pregnant 13.9 7.2 6.5 9.20 13. Changedworksituation

(differentworkrespon‐ sibilty,majorchange inworkingconditions& workinghours) 5.6 5.8 14.3 8.57

14. Newjob 7.0 10.2 11.0 9.40 15. Seriousillnessof

closefamilymember: a.mother 13.3 6.9 9.7 9.97 b.father 7.7 4.5 6.5 6.23 c.brother 8.3 4.1 5.2 5.87

151

d.sister 7.0 5.0 6.5 6.17 e.grandmother 12.7 10.2 7.1 10.00 f.grandfather 5.6 5.3 5.1 5.33 g.other(specify) 3.7 3.0 8.4 5.03 h.spouse 4.0 3.3 7.7 5.00

16. Sexualdifficulties 12.0 5.5 7.7 8.40 17. Troublewithemployer

(indangeroflosing job,beingsuspended, demoted,etc.) 4.0 2.8 4.5 3.77

18. Troublewithin‐laws 8.5 9.4 8.4 8.77 19. Majorchangein

financialstatus(alot offoralotworseoff) 8.0 5.0 24.712.57

20. Majorchangein closenessoffamily members(increasedor decreasedcloseness). 14.9 11.6 26.0 17.5

21. Gaininganewfamily member(throughbirth, adoptionorfamily membermovingin) 21.0 23.7 21.4 20.03

22. Changeofresidence 24.2 22.1 23.3 23.20 23. Maritalseparation

frommate(dueto conflict) 2.1 2.7 1.9 2.23

24. Majorchangeinchurch activities(increased ordecreased attendance) 4.5 2.8 6.5 4.60

25. Maritalreconciliation withmate 8.3 3.9 4.5 5.57

26. Majorchangewithnumber

ofargumentswithspouse (alotmoreoralot lessarguments) 4.0 1.7 3.8 3.17

27. Marriedmale:Changein wife'sworkoutsidethe home(beginning/in‐ ceasingwork,changing tonewjobetc.) 1.3 0.6 5.2 2.30

28. Marriedfemale:Changein husband'swork(lossof job,beginningnewjob,

152

retirement,etc.) 4.0 2.0 5.2 3.73 29. Majorchangeinusual

typeand/oramountof recreation 5.6 3.1 6.4 5.03

30. Borrowingmorethan R10000(buyinghome, business,etc.) 3.2 4.1 14.97.40

31. Borrowinglessthan R10000(buyingcar, TV,gettingschool loan,etc.) 3.5 3.0 12.7 6.40

32. Beingfiredfromjob 6.4 3.3 4.5 4.73 33. Male:Wife/girlfriend

havingabortion 3.2 1.1 1.9 2.07 34. Female:Havingabortion 7.5 1.4 5.8 4.90 35. Majorpersonalillness

orinjury 9.8 4.4 11.0 8.40 36. Majorchangeinsocial

activities,e.g,parties, movies,visiting (increasedordecreased participation) 6.1 1.6 13.0 6.90

37. Majorchangeinliving conditionsoffamily (buildingnewhome, remodelling,deterioration ofhomeorneighbourhood)28.2 17.9 17.521.20

38. Divorce 1.6 1.4 4.5 2.50 39. Seriousinjuryorillness

ofclosefriend 10.9 8.0 13.610.83 40. Retirementfromwork 2.4 1.1 2.6 2.03 41. Sonordaughterleaving

home(duetomarriageor college) 6.7 6.4 5.1 6.07

42. Endingofformalschool 8.0 3.0 11.6 7.53 43. Separationfromspouse

(duetoworkortravel) 6.1 4.7 3.6 14.40 44. Engagement 8.5 2.2 8.4 6.37 45. Breakingupwith

boyfriend/girlfriend 20.2 13.2 9.0 14.13 46. Leavinghomeforthe

firsttime 9.1 5.0 9.7 7.93 47. Reconciliationwith

boyfriend/girlfriend 21.3 13.2 11.6 15.37

153

48. Unrestinyourarea* 26.3 18.3 36.3 26.97 49. Boycotts/strikes/

protest* 16.3 13.0 25.3 18.20 50. Housedamaged/burnt

throughunrest* 9.8 6.7 11.0 8.93 *newitemsaddedtotheoriginalscale

TheimpactoftheselifeexperiencesonthesubjectsarefoundinTableLI.Theminussign

indicatesnegativeimpact.

Thereweresignificantdifferences(chi‐squared)inthewaythegroupsperceivedthe

extentortheimpactofthefollowinglifeexperiences:Marriage(item1)wasregarded

positivelywiththeUmlaziGrouphavingmoreofthisexperiencethantheothergroups

(p<0.0001).TheKwaMashuGroupshadtheleastnumberofmarriages.However,the

subjectsgenerallyfoundthemarriageexperienceapositiveexperience.Engagement(item

44)significantlyoccurredmoreinKwaMashuthantheothergroups(p<0.0317).

Engagementsarealsoseenpositively.Reconciliationwithboyfriendorgirlfriend(item47)

hadagreaterimpactintheHospitalandUmlaziGroupthantheKwaZuluGroup.The

impactofmaritalreconciliation(item25)wasmorepositiveintheHospitalGroup.The

impactofoutstandingpersonalachievement(item9)wassignificantlyhigherintheKwa

MashuGroup.Item9seemedtoofhadapositiveimpactforthesubjectsinthisgroup.

Thesignificantnegativeimpactsweredeathofaspouse(item1);changeinsleepinghabits

(item4);deathofmother,father,sister,grandmotherandotherclosefamily(item5);

seriousillnessofotherclosefamilymemberandspouse(item15);troublewithemployer

(item17);changeinthenumberofargumentswithspouse(item26);changeinhusband's

work(item28);changeintheamountofrecreation(item29);borrowingmorethanR10

000(item31);majorpersonalinjury(item35);majorchangesinlivingconditions(item37)

andunrestinyourarea(item48).

154

TABLELI EXTENTOFIMPACTPERGROUP Event Hospital Umlazi KwaMashu p‐value 1. Marriage 0.73 1.08 0.20 0.0001 2. Detentioninjailor

comparableinstitution ‐0.09 ‐0.11 ‐0.15 NS 3. Deathofspouse ‐0.12 ‐0.26 ‐0.19 0.0542 4. Majorchangeinsleeping

habits(muchmore/lesssleep) ‐0.22 ‐0.09 ‐0.21 0.0390 5. Deathofclosefamily

a.mother ‐0.30 ‐0.51 ‐0.21 0.0033 b.father ‐0.57 ‐0.46 ‐0.27 0.0316 c.brother ‐0.20 ‐0.20 ‐0.26 NS d.sister ‐0.40 ‐0.37 ‐0.10 0.0040 e.grandmother ‐0.48 ‐0.41 ‐0.18 0.0130 f.grandfather ‐0.37 ‐0.22 ‐0.27 NS g.other(specify) ‐0.23 ‐0.19 ‐0.51 0.0004

6. Majorchangeineating

habits ‐0.11 ‐0.05 ‐0.01 NS 7. Foreclosureonmortgage

orloan 0.00 ‐0.06 00.06 NS 8. Deathofclosefriend ‐0.45 ‐0.28 ‐0.31 NS 9. Outstandingpersonal

achievement 0.14 0.20 0.40 0.0085 10. Minorlawviolations

(traffictickets, disturbingthepeace) ‐0.01 ‐0.01 ‐0.03 NS

11. Male:wife/girlfriend pregnant 0.20 0.09 0.10 NS

12. Female:pregnant 0.11 ‐0.01 0.07 NS 13. Changedworksituation

(differentworkrespon‐ sibilty,majorchange inworkingconditions, workinghours) 0.04 0.11 0.04 NS

14. Newjob 0.14 0.18 0.16 NS 15. Seriousillnessof

closefamilymember: a.mother ‐0.30 ‐0.19 ‐0.21 NS b.father ‐0.21 ‐0.13 ‐0.16 NS

155

c.brother ‐0.13 ‐0.12 ‐0.07 NS d.sister ‐0.15 ‐0.13 ‐0.20 NS e.grandmother ‐0.24 ‐0.28 ‐0.14 NS f.grandfather ‐0.12 ‐0.15 ‐0.05 NS g.other(specify) ‐0.06 ‐0.09 ‐0.24 0.0059 h.spouse 0.02 ‐0.09 ‐0.25 0.000

16. Sexualdifficulties ‐0.17 ‐0.14 ‐0.14 NS 17. Troublewithemployer

(indangeroflosing job,beingsuspendedor demoted) ‐0.04 ‐0.07 ‐0.16 0.0668

18. Troublewithin‐laws ‐0.12 ‐0.22 ‐0.21 NS 19. Majorchangein

financialstatus(alot offoralotworseoff) ‐0.07 ‐0.03 ‐0.13 NS

20. Majorchangein closenessoffamily members(increasedor decreasedcloseness). ‐0.01 0.09 0.17 NS

21. Gaininganewfamily member(throughbirth, adoptionorfamily membermovingin) 0.34 0.57 0.49 NS

22. Changeofresidence 0.09 0.13 0.24 NS

156

23. Maritalseparation frommate(dueto conflict) 0.00 0.01 ‐0.06 NS

24. Majorchangeinchurch activities(increased ordecreased attendance) 0.04 0.03 ‐0.01 NS

25. Maritalreconciliation withmate 0.18 0.10 0.06 0.0604

26. Majorchangewithnumber ofargumentswithspouse (alotmoreoralot lessarguments) 0.08 ‐0.00 ‐0.07 0.0052

27. Marriedmale:Changein wife'sworkoutsidethe home(beginning/in‐ ceasingwork,changing tonewjobetc.) 0.00 ‐0.01 ‐0.05 NS

28. Marriedfemale:Changein husband'swork(lossof job,beginningnewjobor retirement) 0.02 ‐0.03 ‐0.12 0.0061

29. Majorchangeinusual typeand/oramountof recreation 0.08 ‐0.02 0.04 0.0403

30. Borrowingmorethan R10000(buyinghome, business,etc.) 0.00 ‐0.04 0.12 0.0136

31. Borrowinglessthan R10000(buyingcar, TV,gettingschool loan) 0.04 0.01 0.00 NS

32. Beingfiredfromjob ‐0.12 ‐0.08 ‐0.10 NS 33. Male:Wife/girlfriend

havingabortion ‐0.04 ‐0.03 ‐0.10 NS 34. Female:Havingabortion ‐0.06 ‐0.04 ‐0.06 NS 35. Majorpersonalillness

orinjury ‐0.13 ‐0.08 ‐0.28 0.0336 36. Majorchangeinsocial

activities,e.g,parties, movies,visiting (increasedordecreased participation) 0.01 0.02 0.12 NS

37. Majorchangeinliving conditionsoffamily

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(buildingnewhome, remodelling,deterioration ofhomeorneighbourhood) ‐0.19 ‐0.19 0.03 0.0402

38. Divorce 0.01 ‐0.02 ‐0.06 NS 39. Seriousinjuryorillness

ofclosefriend ‐0.28 ‐0.18 ‐0.25 NS 40. Retirementfromwork ‐0.01 0.01 0.04 NS 41. Sonordaughterleaving

home(duetomarriageor college) 0.06 0.12 0.01 NS

42. Endingofformalschool 0.14 0.07 0.19 NS 43. Separationfromspouse

(duetoworkortravel) ‐0.10 ‐0.10 ‐0.08 NS 44. Engagement 0.08 0.02 0.19 0.0317 45. Breakingupwith

boyfriend/girlfriend ‐0.30 ‐0.27 ‐0.13 NS 46. Leavinghomeforthe

firsttime ‐0.03 ‐0.03 ‐0.03 NS 47. Reconciliationwith

boyfriend/girlfriend 0.39 0.27 0.14 0.0326 48. Unrestinyourarea* ‐0.53 ‐0.41 ‐0.83 0.0019 49. Boycotts/strikes/

protest* ‐0.30 ‐0.26 ‐0.34 NS 50. Housedamaged/burnt

throughunrest* ‐0.20 ‐0.19 ‐0.22 NS

*newitemsaddedtotheoriginalscale

Amultivariateanalysisofthetotallifeexperiencesbetweenthegroupsshowasignificant

difference(TableXLII).TheDuncan'smultiplerangetestrevealsthatthedifferenceoccurs

intheUmlaziGroup(TableLII),thatistheUmlaziGroupontheaveragehadsignificantly

lesserlifeexperiencesorchangesthantheothergroups.

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TABLELII MANOVAOFTOTALLIFEEXPERIENCESBETWEENGROUPS

df SD F p Group 2 15209.03 22.68 0.0001

TABLELIII DUNCAN'SMULTIPLERANGETEST

Duncan's GroupingMean N Group

TotalLifeExperiencesA 49.73 376Hospital

A 47.84 154 KwaMashu B 40.88 362 Umlazi

Amultivariateanalysisofthenegativeandpositivelifeexperiencesbetweengroupsalso

showasignificantdifferencebetweengroups(TablesLIVandLVI).TheDuncan'smultiple

rangetestonnegativeandpositivelifeexperiences(TableLVandLVIIrespectively)reveals

thatthesubjectsintheUmlaziGroupexperiencedtheleastamountofchangecompared

totheothergroups.TheseresultssuggestthatalthoughtheHospitalGroupexperienced

morepositiveandnegativelifeexperiences,itwasnotsignificantlydifferenttotheKwa

MashuGroup.Lifeexperiencesare,therefore,notasingulartriggerfactortohelpseeking

behaviour.

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TABLELIV MANOVAOFNEGATIVELIFEEXPERIENCESBETWEENGROUPS

df SD F p Group 2 2234.48 18.37 0.0001

TABLELV DUNCAN'SMULTIPLERANGETESTONNEGATIVELIFEEXPERIENCES

Duncan's GroupingMean N Group

NegativeLifeExperiences

B ‐12.53 343 Hospital B ‐12.13 135 KwaMashu A ‐9.05 331 Umlazi

TABLELVI MANOVAONPOSITIVELIFEEXPERIENCESBETWEENGROUPS.

df SD F p Group 2 1722.99 9.70 0.0001

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TABLELVII DUNCAN'SMULTIPLERANGETESTONPOSITIVELIFEEXPERIENCES

Duncan's Grouping Mean N Group

A 8.76 294 Hospital A 7.87 117 KwaMashu B 5.42 299 Umlazi

Thediscussionoftheseresultsfollowinthenextchapter.

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CHAPTER6

DISCUSSION

Therewasnosignificantsexoragedifferenceinallthreegroups,althoughtherewere

thirteenpercentmorefemalesthanmalesrepresentedinthesample(TableIand

Figure5).Thisisinkeepingwiththesexratiointhepopulationaccordingtotheofficial

censuscarriedoutin1990.WithregardstotheHospitalGroupthehighernumberof

females(12.76%)iscomparabletootherstudiesonsexdifferencesinhospitalutilisation

whichshowagenerallyhigheruseofmedicalcarefacilitiesbyfemalesthanmales.The

differencesrangefrom30%betweentheages17to44and10to20%over45years

(Nathanson,1977;Verbrugge,1985,1979,Umberson,1992).Themainreasonforhigher

utilisationofmedicalfacilitiesbyfemaleshavebeenattributedbyVerbrugge,(1979)and

HibbardandPope(1983)tothegreaterawarenessamongwomenofsymptoms.

Mostofthesubjectsinthisstudy(90.71%)werebetween20to49yearsold.Itis

interestingthatintheHospitalGroup46.50%werebetweentheages20to29years(Table

III).ThissuggeststhatalmosthalftheAfricanadultpatientsseenatthehospitalareyoung

adults.Thisphenomenonisprobablyrelatedtotheacculturationofthiscommunity,

whereyoungeradultsaremoredisposedtousingmorereadilythemedicalfacilitiesthan

themoreelderlywhostillaremoreinfluencedbythetraditionalideasofillnessand

health.Aswouldbeexpectedthemajorityofthesample(85.09%)wereZulu(TableIV).

TherewasasignificantdifferencebetweenthelevelsofeducationoftheHospitaland

communitygroups(TableV).ThesedifferencesaredepictedinFigure7.Therewasa

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higherlevelofeducationinthecommunitygroupsthantheHospitalGroup.Ahigher

percentageoftheHospitalGrouphadnoformaleducation(14.10%)orprimaryeducation

(18.88%).Thisdoesnotnecessarilyconflictwiththeavailableliteraturethatsuggeststhat

thereisacorrelationbetweenhighereducationandgreaterutilisationofmedicalfacilities

(Okafor,1983).Thereasonforthisdifferenceisprobablyduetothefactthatthemore

educatedearnbetterand/orareonamedicalaidschemeandmakeuseofprivatehealth

carefacilities.Thosepatientsthatusethestatehospitalsaregenerallythosethatcannot

affordprivatefacilities.

TherewasasignificantdifferencebetweentheHospitalGroupandthecommunitygroup

regardingthenumberofyearsofresidenceinanurbanarea(TableVI).Ahighernumber

ofthesubjectsinthehospitalsamplehadbeenlivinginanurbanareaforlessthan10

years(24.73%)comparedtoUmlazi(10.77%)andKwaMashu(14.95%).Thismaysupport

theviewthatthesubjectsintheHospitalGroupmayhaverecentlymovedintotheurban

areaandthereforemorelikelybeunemployedorwithoutasteadyincome.Theresulting

financialconstraintswouldforcethemtoseektreatmentprovidedbythestatehospitals

whichcostconsiderablyless.

ThesubjectsthatattendedthehospitalwerereferredfromareasthroughoutNatal

(TableVII)althoughthemajorityofthesample(80.31%)wasfromtheareasclosesttothe

hospital.ThereasonsforsuchabroadreferralbaseorcatchmentareaisthatKingEdward

istheonlyteachinghospitalintheprovinceanditisalsoregardedasthehospitalthat

providesthebestserviceforAfricanpeople.Insomeinstances,eventhosethatcanafford

privateservicesprefertoattendKingEdwardtheVIIIHospitalbecauseitisbelievedthat

beingateachinghospital‘specialist’physiciansaremorereadilyavailable.Thisperception

isnotonlyonthepartofthepatientbutisalsofosteredbythelocalclinicswhoreferfor

specialistopinion.Inaddition,thelackofproperlocalfacilitiesfurtherfostersattendance

atthehospital.Krige(1990)pointsoutthatsomeoftheservicesprovidedbylocalclinics

areinadequate;patientsareexpectedtoattendonlyoncertaindays,someservices,such

as,dentalandpsychiatric,arenotprovidedandinsomecasesthedemandforblack

servicescannotbemetandpatientsareturnedaway.

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However,thefactthatmostofthesampleatthehospitalattendedfromareas,suchas,

UmlaziandKwaMashusupportsthevalidityofcomparisonsbetweensamplesofthe

presentstudysincethesetownshipsarerepresentativeofthecommunityfromwhichthe

HospitalGroupcomes.

Therewasasignificantdifference(p<0.01)intheoccupationsbetweenthethreegroups.

Thesubjectsattendingthehospitalwerefoundtobelessskilledthanthoseinthe

communitygroups(TableVIII).Anoverwhelminglyhighnumberofthesubjectsinthe

hospitalsample(72.34%)wereunskilledcomparedto42.82%intheUmlazigroupand

18.18%intheKwaMashu.Thisagainisinkeepingwiththeviewthatthosewhocannot

affordprivatemedicalhealthfacilitiesorwhodonothavemedicalaidwouldmostlikely

usethestatehealthcarefacilities.Itisalsofoundthat42.60percentofthehospital

samplewereunemployed.Thereareseveralstudiesthatshowthatunemploymenthasa

negativeimpactonanindividualshealth.LeebandRadford(1987a,1987b)andRadford

andLeeb(1986)haveshownthatdismissalfromworkcorrelateswithanxietyanddistress

aftersixmonthswithoutworkandisassociatedwithhelplessnessanddespondency.

Moller(1988)alsohasshownthatunemploymentdirectlyaffectssocio‐psychologicalwell‐

being.

Costs(includingallconstraintsplacedonthepatientsuchastimeorinconvenience)

incurredbypatientshavebeenknowntoaffecttheutilisationoffacilities(Mechanic,

1978).Thepatientsinthisstudyreportedthattheamountpaidintraveltothehospital

rangedfromR1.00toR52.00.Ofcoursetheamountisdependentonthedistancethatthe

patientstravelled.Mostofthepatientsinthestudycamefromareasinandaroundthe

hospital(71.27%)andthereforethecostoftravelonaveragewasR6.27.However,when

oneconsidersthat42.60%wereunemployedandthatthepatientsstillhadtopaya

treatmentfee(minimumofR10.00forthosewithoutincomeandunemployedanda

minimumofR22.50forthoseemployed)thefinancialimplicationsarenotnegligible.In

addition,47.60%hadtotakeoftimeofffromworkinordertoattendthehospitalofwhich

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23.46%ofthemwillnotbepaid.Fortheseindividualsattendingthehospitalresultsinloss

ofincomeaswell.

Thecostintimevariedgreatlydependingonthedistancetravelled.Somepatientsleft

homeasearlyas2h00toattendthehospital.Theaveragetimespenttravellingtothe

hospitalwasonehourandfortythreeminutes.Inadditiontothetimespenttravellingto

andfromthehospital,timecostsarealsoexperiencedinwaitingfortreatmentatthe

hospital.Althoughthispresentstudydidnotassessthecostoftimeinwaitingfor

treatmentatthehospital,somepatientsdidindicatetheirdispleasurewiththelongdelays

experiencedatthehospital(TableXVIII).Timecostisanimportantfactorsincepatients

leavehomeveryearlyandoftenarrivewellbeforetheMedicalOutpatient'sClinicopens.

Theythereafterwaitinaqueuetobeseenbyadoctor.Afterthisscreeningtheyaremost

oftenreferredtothedispensaryformedicationand/orforspecialinvestigationsand

opinionsfromotherspecialistdepartments.Thisprocesscouldtakethewholeday.

Certainprocedures,forexample,aComputerisedAxialTomography(CAT)Scan,

Electroencephalogram(EEG)orElectrocardiogram(ECG)maynotbeabletobedoneon

thesamedayorinthecaseofotherproceduressuchascertainbloodtestsorlumbar

puncturestheresultsmaynotbeavailablethesameday.Asaresultthepatientmayhave

toreturntothehospitalanotherday.Anotherreasonforpatientshavingtoreturnisthat

sometimesotherdepartmentsinthehospitalmaynotbeabletoseethepatientona

particulardaybecauseoftheirfullclinicprogrammeandgivesthepatientanappointment

foranotherday.Thesefactorsfurtherincreasesthecostforpatients.Accordingto

FitzpatrickandScambler(1984),thosewhoexperiencehighcosts,particularlythrough

lossoftime,beingdependentonpublictransport,orlosewagesfortimetakenofffrom

work,aredemotivatedinseekinghelp.

6.1HELPSEEKINGBEHAVIOUROFHOSPITALSUBJECTS

Thepresentstudyshowsthatthedominantreasonforthechoiceorpreferenceofa

particularmedicalfacilityisthequalityoftheserviceprovided.Inthehospitalsample59%

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feltthattheservices,facilitiesand/ortreatmentswereverygood,thatthehospitalhad

plentyofdoctorstoattendtotheirneedsandthatthehospitalwasalsowellrecognised

foritsgoodtreatment.Thisviewisconsistentwiththeviewsofthecommunitygroupsas

wellregardingtheirreasonsforthechoiceofservices,suchas,choiceofdoctor,the

choiceofhospitalandthechoiceofapharmacy(seeTablesXI,XIIIandXV).Boththe

communitygroupschooseserviceswhichtheyperceivetobegoodandwhichwere

closesttothem.Coppoetal(1992)havepointedouttheimportanceofunderstandingthe

influencethatdistanceplayonhelp‐seekingbehaviourandcitestudiesthatsuggestthat

thecriticaldistanceisbeyond5kms.

Theotherreasonthatpeopleseekhelporutilizehealthcarefacilitiesarethereferralsby

otherhealthfacilitators,suchas,generalpractitioners(12.00%)andperipheralhospital

andclinics(10.30%)orlayreferrals,suchas,employers,friendsandfamilymembers

(7.00%).Itisinterestingthatthelayreferralsweremadebecausethoseindividualsaswell

believedthatthehospitalprovidedabetterservice.Layreferralswerealsomadeby

employers,friendsandfamily.Suchman(1966)andHouseetal.(1988)haveshownthat

thehealthseekingbehaviourisasocialprocessinvolvingatleastoneotherperson,that

layconsultationinfluencespatternsofhelp‐seekingandthattherewasapreferenceto

consultothers,suchas,thepolice,bystanders,neighboursandfriendsbeforeconsulting

family.

Only2.20%acknowledgedthatthemainreasonforcomingtothisparticularhospitalwas

thatthecostofthetreatmentatthehospitalwasfarlowerthanthatofothermedical

availablefacilities.Ofcoursethecostreferredtohereisthecostoffeesatthehospital

andnotoftime,inconvenienceortransport.Severalstudieshaveshownthatcostisa

crucialdeterminantofhelp‐seekingamongpatients(Lewis,FeinandMechanic,1976;

Mechanic,1986;Mechanic,1992)

Anotherfactorinhelp‐seekingthatisequallyimportanttounderstandiswhatmakesan

individualchooseaparticulartimetoobtaintreatment.Inthisstudy,themajorityofthe

subjectsattendedthehospitalbecausetheybelievedthattheirconditionwas

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deteriorating(50.34%).Otherreasonsforattendanceonaparticulardaywasavailability

ofappointmentsatthehospital(29.05%);nomoneytoattendearlier(7.77%);

arrangementmadebyotherhealthorganisationsordoctors(7.10%);notime(2.70%)and

notransport(2.4%).Thesefindingsaresignificantsincetheyshowthatthemajorityof

patientswhoseekmedicalhelpmonitortheirstateandonlywhentheybelievethattheir

conditionisgettingoutofcontroldotheyutilisehospitalservices.Hencebarrierssuchas

availabilityofappointments,financialrestraintsandtransportmaypreventtheindividual

fromobtainingmedicalhelpwhentheyactuallybelievetheyneedit.Besidetheundue

stressandanxietythatthiswillcause,itmayevenfurtherdelayaconditionthatshould

havebeenattendedtomuchearlier..Mechanic(1992)hasreportedontheimportanceof

layappraisalofillness,theeffectofvariousbarriers,suchas,money,timeandtransport,

andtherelationshipwiththedoctorininfluencinghelp‐seeking.

Themajorityofthepatients(65.40%)soughthelpfromthehospitalwithinamonthof

suspectingtheywereill.Thisagainsupportstheviewthatindividualsallowaperiodof

timeforselfassessmentbeforeseekingmedicalhelp.Accordingtoourfindingsthisperiod

forselfassessmentismostlikelytotakeplacewithin5.85weeksofthefirstsuspicionof

illness.TableIXandFigure9provideabreakdownofthetimetakenfromthefirst

perceptionsofillnessandtheactualattendanceatahospital.Wecaninferfromthese

resultsthatfollowingself‐assessmentmostindividualswillseekhelpwithinsixweeksof

firstexperiencingtheirsymptoms.

Themostcommonreasongivenbythesubjects(43.50%)fornotattendingearlieror

immediatelyfollowingtheirfirstperceptionsofanillnessisthattheyfeltthattheillness

wasnotseriousenoughtowarrantmedicalhelpseeking,thattheywerenotbotheredby

thesymptoms.Somedidnotattendearlierbecausetheyhadalreadysoughtmedicalhelp

fromageneralpractitioner(19.90%),hadnomoneytoattendthehospital(14.80%),

treatedthemselvesbypurchasingmedicinesfromapharmacy(2.20%),hadnotransport

(1.90%)andbeingtooilltoattend(1.60%).Asmallpercentage(1.90%)wantedtoattend

earlierbutcouldnotgetanearlierappointment.Thesubject'sresponsesforattending

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earlierareconsistentwiththeearlierresponseswhichendorsetheimportanceofthe

patientsself‐assessmentoftheseriousnessoftheirsymptomswhichprecipitatesmedical

helpseekingbehaviour.Theirresponsesalsoendorsetheseekingofotherservicesbefore

theiruseofthehospital.Pharmaciesandgeneralpractitionersarealsosoughtafterfor

medicalhelp.Forthosewhofeeltheyhavemadenoimprovementhelpissoughtfromthe

hospital.Similarcircumstanceshavebeenfoundtoinfluenceothersocietiesregarding

decision‐makinginhelp‐seekingandtreatmentchoice(Garbo,1986;Good,1986).

Anotherimportantfactortounderstandinmedicalhelpseekingbehaviourconcernsthe

feelingsandexperiencesthatindividualshaveaboutillness.Thesefeelingsand

experiencesarereferredtoassymptomsbymedicalcareproviders.Accordingtothe

respondents63.30%feltthattheywereillbecausetheyexperiencedonlyphysical

symptomswhile20.80%experiencedonlypsychologicalsymptoms.Aboutseventy‐nine

percenthadexperiencedacombinationofphysicalandpsychologicalsymptoms.Itis

interestingthatsubjectsareabletoassociatepsychologicalsymptomswithindicationsof

illness.ItiscommonlybelievedthatAfricanpatientsusuallypresentwithphysical

symptomsandveryrarelypresentwithpsychologicalsymptoms.Apossiblereasonforthis

isthattheymaynothavethepsychologicalvocabularytoreportsuchsymptoms.Another

reasonisthatpatientsreportingpsychologicalsymptomsmaynotbetakenseriouslyand

theirpresentationmaybediscreditedasafactitiousdisorderormalingering.Thelatteris

verylikelytohappeninovercrowded,busyhospitalslikethoseprovidingcareforthe

disenfranchisedinSouthAfrica.Thefailuretotakepsychologicalsymptomatology

seriouslyis,therefore,averycommonphenomenon((Eisenberg,1986;Kellner,1986;

Mayou,1986;Pilowsky,1986).

Themajorityofsubjects(87.00%)wereconcernedorworriedabouttheirsymptomsyet

46.20%didnotknowwhatwaswrongwiththem.However,someattributedtheir

symptomstoainfluenza(13.40%),aformofinfection(12.50%)oraterminalillness

(8.10%).Otherlaydiagnoseswerealsosuggest,suchas,'somethingwrongwiththe

blood',thebladderdirtyandwaterinthehead(5.30%).Culturaldiagnosesofsymptoms

arealsomadeandtheseincludetheworkofthetraditionalhealers,crossingapathwhere

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someritualwasperformed,inhalingofabadspiritandbeingpoisoned(3.70%).This

seemstosuggestthatalthoughpatientsareabletoperceivesymptomstheyareunableto

accuratelyascribethesefeelingandexperiencestoaparticularcondition.Itisprobably

moretheanxietyexperiencedinordertointerpretthesesymptomsthatprecipitateshelp

seekingbehaviourratherthanthebeliefthattheyhaveaparticulardisorder.Itis,

however,interestingthetypesoflaydiagnosesmade.Thereisanemphasisonorgansor

systemsbeingdirty.Duetothisbeliefitisnotsurprisingthatdetergentsareusedasa

formoftreatment.Acaseinpointisaparasuicide,21years,whichwasreferredfora

psychologicalevaluationfollowinganoverdoseofvinegarandjeyesfluid(cattledip).It

hadbecomesubsequentlyevidentthatthepatienthadnottakenanoverdosebut

believedthatshewaspoisonedbyoneofhercolleagueswhohadgivenhersomefoodto

eatandshehadsubsequentlyfainted.Whenshewasbroughthome,theneighboursand

familygaveherthesesubstancesinordertowashoutthepoison.Theconsequenceof

suchbeliefs,however,mayhavedisastrouseffects.Hereagainweseetheinfluencesof

cultureinattributingmeaningtosymptomsandremainsacrucialdeterminantinhelp‐

seeking.(FreemanandMotsei,1992;SultanaandHunte,1992).

Thereisevidenceofahighlevelofselfdisclosurebypatientsabouttheirsymptoms.

Eighty‐sixpercentreportedthattheydiscussedtheirsymptomswithothers.Mothersand

spousesaremostoftenconfidedin.Itwouldappearthenthesuggestionsand

recommendationsmadebytheseindividualsplayanimportantpartinthedecisionofthe

patientstoseekappropriatehelp.Suchman(1966)andHouseetal.(1988)haveshown

thattheseekingofhealthbehaviourisasocialprocessinvolvingatleastoneotherperson

andthatlayconsultationinfluencespatternsofhelp‐seeking.Peoplemostlikelytobe

consultedarefamily,neighboursandfriends.

6.2USEOFSERVICESBYCOMMUNITYGROUPS

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Patientsmostoftenchosedoctorsthatweresituatedorlocatednearesttothem(TableX).

Theirmainreasonsforchoosingadoctorwereproximityandthequalityofservice(Table

XI).Asimilarpatternemergedforthechoiceofanhospitalorapharmacy.Subjectschose

toattendthehospitalclosesttothem,forexamplethesubjectsinUmlazichosePrince

MshiyeniMemorialHospital(42.50%)andKingEdwardVIIIHospital(35.30%)andthose

fromKwaMashuchoseKingEdwardVIIIHospital(58.40%).Apossiblereasonforahigher

numberfromUmlazinotattendingPrinceMshiyeniMemorialHospital(whichisinUmlazi)

isthepoliticalaffiliationofthesubjects.ItisgenerallyfeltthatthoseinUmlazihavean

affiliationtotheANCandthatthePrinceMshiyeniMemorialHospitalisadministratedby

theKwaZulugovernmentwhichisaffiliatedtotheIFP.HenceANCsupporterswouldavoid

theuseofsuchahospital.Thisdistrustofmedicalcaresystemshavealsobeenfound

amongstminoritygroupselsewhere,suchas,Jews,PuertoRicansandBlacksintheUSA

(Geertsen,etal.1975;Lendt,1960).

Theresponsesgleanedsuggeststhatthequalityoftheserviceandconvenienceoflocation

playaconsiderablepartintheutilizationofhealthservicesandfacilities.Itis,therefore,

importantthattheseservicesbelocatedwithinthecommunitiestheyareintendedto

serve.Thisisanoverhangofthepoliticalsystemofthecountrywhichprovidedracially

segregatedservicesandwhichnotonlyprovidedinferiorservicesfortheBlackbutalso

relocatedorreservedresidentialareasforthemawayfrombasicandessentialfacilities.As

aresultindividualshavehadtoovercomethesesocio‐economicbarriersinordertoseek

medicalhelpwhichhasdirectlyinfluencedhelp‐seekingbehaviour.Inthisregard,oneof

thehospitalsample'sreasongivenfornotattendingearlier“becausetheydidnotthink

thattheirillnesswasseriousenough”couldalsomeanthattheindividualhadtodecide

whethertheillnesswasseriousenoughtowarrantovercomingthebarriersofdistance

andcost.Lewis,FeinandMechanic(1976)andMechanic(1986)haveemphasized

especiallytheimportanceofaccessibilityofmedicalservicesinhelp‐seeking.

Mostsubjectswerepleasedwiththemedicaltreatmentreceivedfromtheirdoctorsorthe

hospitalstheyattended(TableXVI).However,agreaternumberofthecommunitygroups

werepleasedwiththetreatment(Umlazi83.9%andKwaMashu84.7%),thantheHospital

170

Group(53.2%).Thegreatersatisfactionexpressedbythecommunitygroupswould

probablybeduetotheirabilitytochooseprivatedoctorsandclinicsfortheirtreatment

wherethefacilitiesarebetter,moreaccessibleanddonothavetowaitlongfor

treatment.Hospitalsubjects,ontheotherhand,havenoalternativebuttoacceptthe

servicetheyobtainfromtheovercrowdedstatehospitals.Thewriterdailyobserves

patientsattendingtheKingEdwardVIIIHospitalandspendthewholedaywaitingwithout

grumblingorexpressinganydissatisfactioninordertobetreated.Thesepatientsmost

oftenbelievethattheserviceatthehospitalisaprivilegeandthattheyarenotallowedto

complainorbeassertive.

Thefactorsthatsubjectsusetoassesstheirsatisfactionoftreatmentisthequalityofthe

serviceandcaregiven,andthecuretheyhavehad.Afewassessedtheirsatisfactionby

themethodoftreatment(TableXVII).TableXVIIIliststheaspectsoftreatmentthat

subjectswerenotpleasedwith.Theseincludethequalityofthedoctor‐patient

relationship,thequalityofthefacilities,thetimespenttoobtaintreatment,the

ineffectivenessofthetreatmentandthecostincurred.Itisinterestingthatthecommunity

samplesexpressedmoredissatisfactionwiththequalityofthedoctorpatientrelationship,

thequalitywiththefacilities,timeandcostthanthehospitalsample.Thereasonforthisis

thatthecommunitysamplehaveachoiceofprivatetreatmentandthereforeexpectthe

treatmenttobeofanacceptablestandard.Thehospitalsample,ontheotherhand,

expecttheselimitationsatthestatehospitalbecauseofovercrowdingandover‐utilization

ofthelimitedservicesavailable.Itwouldseemthatchoiceofservicesplaysanimportant

partinpatientsatisfaction.Inaddition,ifpeoplehaveachoicetheywillalsodemand

betterservices.ThisisseenintheresponsebytheHospitalGroupwhoexpressed

dissatisfactionwiththebenefitsofthetreatmentreceived.Inotherwords,peoplewhodo

nothavethechoiceareunabletodemandabetterserviceandhencetheservice

providersarenotpressurizedtoprovideabetterservice.

Awaytorectifythissituationisthathealthshouldbearighttoall,thatpatientsbe

allowedchoiceofservicesandthatthepeoplebeempoweredandeducatedsothatthey

willbeabletodemandareasonablygoodhealthcareandservice.Thiswillalsoleadtoan

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improvementinthehealthservicesprovidedbytheState.However,areasonforapoor

serviceatthestatehospitalsisthelimitedservicesandbudgetsavailablewhichinturn

leadstoover‐utilisationofcertainstatehospitals.Forexample,inSouthAfricathe

provinceofNatalhasalwaysbeengivenaconsiderablylowerhealthbudgetthanthe

otherprovincesinthecountry.WhileKingEdwardVIIIHospitalhasbeenover‐utilisedand

overcrowded,frequentlyrequiringtheneedforfloorbeds,GreysHospital(constructedfor

whitepatients)hasalwaysbeenunder‐utilised.Againthisimbalancewascreatedbythe

previouspoliticalpolicyofthecountryandpresentpoliticalreforms,itishoped,will

addressthesefundamentalproblemsofinequalityinordertoimprovebothhealthand

illnessbehavioursincethesedirectlyaffectthehealthstatusofthewholesociety.

Mostinterviewees,however,reportedthattheywouldseekmedicaltreatmentinthe

future(92.2%).Thisindicatesthattheurbanpopulationhavecometoseeandacceptthe

needtoobtainmedicaltreatment.Asmallpercentagedidnotwantto(3.1%)orwerenot

sure(4.7%).Itisprobablythissmallgroupthatwouldseekalternateformsoftreatments.

Obviouslytheseindividualsarenottotallyconvincedthatwesternmedicineworks.Such

beliefsmayhavealsoresultedeitherfromtheirnegativeexperiencesofmedical

treatment/sortheirnotexperiencinganybenefitsfromsuchtreatmentsbesidestheir

possibledistrustofwesternmedicine.

Theuseofmedicationisanimportantissuepresentlybecauseofthewidespreadmisuse

orabusethattakesplace.Ofsignificanceisthemisuseofmedicationinsuicidalbehaviour,

agrowingproblemintheAfricancommunity(Schlebusch,1988;Pillay,Naidoo,Tlou,

1992).TableXIXliststhesourcesfromwhichsubjectsobtainedtheirmedication.Most

subjectsobtaintheirmedicationfromprivatedoctors,clinicsorhospitals.Littleself‐

prescribingtakesplace.Self‐medicatingoccurredamong5.1%becausetheyfelttheyhad

thefluand7.7%becausetheyexperiencedpain.Theseresultssuggestaloweruseofover‐

the‐counterdrugsthaninotherpopulations(Schlebusch,1988).However,because

medicationisobtainedfrommedicalpractitionersitisimportantthatthesedoctors

prescriberesponsiblyandeducatepatientsabouttheproperuseofmedications.Since

thesecommunitiesseemnottorelyheavilyonmedication,afactoralsoseeninpatient's

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dissatisfactionoftreatmentweretheresponse‘nomedication’featuredlow,proper

prescriptionwillalsoteachappropriatemedicatingbehaviour.Thisisimportantsinceonly

40.4%understoodwhytheyweretakingmedicines.Whereas46.8%tookmedication

becauseitwasprescribedwithoutunderstandingthenatureoftheillness.

Therewasasignificantdifference(p=<0,01)inthewaythehospitalandcommunitygroups

respondedtotheperceivedbenefitsofwesternmedicines(TableXX).MoreofHospital

Groupfoundthemlessbeneficialorwerenotsureabouttheirefficacy.Therecouldbe

severalreasonsforthisdiscrepancy.Itisveryunlikelythatthisistheresultofthequality

ofmedicationsbeingusedbythehospitals,sincethestandardofmedicationisequally

goodalthoughthehospitalstendtousegenericmedicationbecauseofthecostof

recognisedtradenamemedicinesThemostlikelyreasonsare,inaccuratemedicationuse

and/ornon‐compliancewiththeprescribedtreatment.Thiscouldbetheresultof

patientsnotbeinggivenproperexplanationsabouttheirillnesses(46.8%didnot

understandwhytheyweretakingmedication),notbeinggivenproperinstructionsonhow

totakethemedication(thewriterhasseennumerouspatientswhohavetaken

suppositoriesorally;vaginalsuppositoriesrectally;eardropsorallyorpatients,whohave

takentabletsprescribedthreetimesdailyonlythreetimes).

Poordoctor‐patientrelationships,sideeffectsofthemedicationandculturalandlanguage

differencesarekeycontributingfactorstothesekindsofmisinterpretations.Thelarge

numbersseenatthehospitals,overcrowding,inabilitytospeakthepatient'slanguage,

lackofunderstandingofthepatient'sperceptionsofillness,orthepatient'sunderstanding

ofillness,andtimeconstraintsdirectlyinfluencethequalityofinstructionandinformation

providedbymedicalpersonnel.Newmethodsofprovidingsuchinformationshouldbe

considered.Thesecouldincludeaudioandvideoeducationwhilepatientsarewaitingat

thehospitals;printedinstructioninAfricanlanguageswiththeuseofstepbystep

graphicalillustrationsotheilliteratewillalsobeabletounderstand;medicalpersonnel

learningthelanguageofthepeopleoremployingskilledinterpreterstodisseminate

information;theestablishmentofinformationcentreserectedinconvenientspots,

mannedbyindividualswhocanspeakthelanguageofthepeopleandarefamiliarwiththe

cultureofthepeople,wherepatientscanobtaininformationandhelpwithoutfeeling

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intimidated.Implementationofsuchserviceswilltaketheloadoffdoctorsandnurses,

helpimprovecomplianceandlowertheincidenceofpsychologicalproblemsrelatingto

healthandillnessbehaviour.

Theuseofvitaminssupplementsdifferedbetweenthegroups(TableXXI):55.70%ofthe

KwaMashugroupand40.40%oftheUmlazigroupusedsupplements.Thevitamin

supplementswereusedmainlyto'increasestrength',cureortreatanillness,makeone

activeorserveaprotectivefunction.Somealsotookvitaminsupplementsto'strengthen

theblood'orontheadviseofnon‐medicalpersons.Thereisahigheruseofvitamin

supplementsthanmedicines.Thisneedtousesuchsupplementsmaybetheresultofthe

aggressivemediaadvertisementswhichpromotetheuseofvitaminsupplementsaspart

ofthehealth,dietandexercisefadpresentlyinvogue.

Intheearlierchapterstheimportanceofreligiousandculturalbeliefsandtheir

relationshiptohealthbeliefswerediscussed.Ahighpercentageofthesubjects(89.2%)

wereChristian,2,8%belongedtoAfricanreligiousgroupswhile1.4%saidtheybelongedto

bothChristianandtraditionalAfricanreligions.Itisimportant,howevertonotethatthe

largenumberthatclaimedtobeChristianincludesthosethatbelongtoAfrican

independentchurchesaswell.Thesechurches,forexampletheShembeChurch,

integratesbothAfricantraditionsandcultureswiththeChristianfaith.

Mostofthesubjectsdenieduseoftraditionalmedicinesorhealers(55.37%).Subjectsin

thehospitalandUmlazigroupstendtodenytheuseofthesemethodsthanwasthecase

inKwaMashu.Apossibleexplanationforthisisthatgreateracculturationhasprobably

takenplaceamongthethoseattendingthehospitalandintheUmlaziCommunity.Faith

healersareusedmoreoftenthantraditionalhealers.Thisistobeexpectedsinceitwould

bemoreinkeepingwiththerereligiousbeliefs.Wessels(1987,1989)toofoundthatfaith

healerswerebecomingincreasinglypopularintheAfricancommunity.Ourfindingsarein

keepingwithWessels(1987b,1989)studies,regardingthecombinationofmethodsused

inthetreatmentofpatientsbyfaithhealers.Holywaterandherbsareusedmoreoften

thanprayer.Prayerisusuallyobtainedfromwomanprayergroups,family,friendsand

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neighbours(TableXXVIII).AhighernumberintheKwaMashugrouprespondedthatthey

hadusedprayerasamethodoftreatmentfortheirillness.

Ontheaverage,thesubjectsfrequentedtraditionalhealersthreetimesandthereafter

theirattendanceoffaithhealingdeclined(TableXXIV).Thisisoddbecausetherewas

generalconsensusamongthosethatsoughtsuchtreatmentthatthetraditionalhealing

washelpful(60.9%).Infactmoreinthecommunityperceivedthiskindoftreatmentto

bebeneficialthanthosewhoattendedthehospital.Apossiblereasonforthisdeclineis

eitheracculturationoranawarenessthatconsultingtraditionalhealersisnotregardedas

acceptablebehaviourandasaresultthereisareluctancetoreportsuchbeliefs.

Ontheaverage21.00%reportedconsultinganherbalist.Itwouldappearfromtheresults

thatsubjectsinthecommunityconsultedherbalistmoreoftenthanthosewhoattendthe

hospitals(TableXXIX).Apossiblereasonforthisisthatthosewhoattendthehospitalmay

haveagreaterbeliefintheefficacyinwesternmedicinesoralternativelybelievethatthe

illnessrequiresmedicalintervention.

Nevertheless,itisimportanttobearinmindthatahighpercentage(60.9%)dobelievein

theefficacyoftraditionaltreatmentandasignificantnumber(23.3%)wereambiguous

aboutitsefficacy.Inaddition,47.40%indicatedthattheywillcontinuewithtraditional

treatments(TableXXVII).Thissuggestthattraditionaltreatmentwillstillbesoughtand

thataconsiderableamountofhealthbehaviourtakesplaceoutsideofthemedicalsystem.

Thereforethissituationhastobecarefullyconsideredwhenplanningandprovidinghealth

servicestourbanAfricans.Failuretoacknowledgetheirunderstandingandbeliefsin

traditionalhealerswillresultinadualistapproachtothetreatmentoftheirillness.

Individualswillusemedicalservicesbutwillprobablyalsosecretlyattendtraditional

healers.Thefearofappearingignorantorprimitiveiftheyexpressadesiretosee

traditionalhealersmayleadtoadelayinhelp‐seekingbehaviourandmaybe

counterproductiveifdoctorsarenotawareofothertreatmentspatientsmaybetakingor,

especially,iftheyareaskedtostopmedicaltreatmentbytraditionalorreligioushealers.

Theauthorhasseenseveralcaseswerepatientshavebeenaskedbyreligioushealersto

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stoptakingmedicationbecausetheirtakingofmedicationindicatesalackoffaithinGod

tohealthem.Therehavealsobeenothercaseswherepatientshavebeengivenherbsand

othersubstances,suchas,intelezi,thathavevariouspsychological,psychiatricand

physicalsymptoms.Ifpatientsdonotfeelcomfortablesharingtheirbeliefsabout

traditionalandreligiousmethodsoftreatment,thedoctorwillnotbeabletoassistthe

patientpromptlyorefficiently.Ifpatientsdonotfeelthatthedoctorunderstandstheir

beliefsorthattheirbeliefswillbefrowneduponandridiculed,thepatientwillnotshare

thisinformationandthiswillleadtonon‐compliancewithtreatmentsprescribedbythe

doctor.

Subjectsalsoreportedtheuseofseverallayorfolkmedicines(TableXXIX).Laxativesor

purgativeareusedveryfrequently(88%).Warmwaterorseawaterisoftenusedto

inducevomiting.AreasonforthisisthatthereisbeliefamongAfricansinthecleaningof

thebodyanditssystems.Thebeliefisthateithertheorgansaredirty,thebloodnotclean

orthatsomethingpoisonoushasbeeningested.However,thedangersoftheuseof

purgativesuchasepsomsalts,castoroilandotherlaxativehavebeenfrequentlyobserved

inblackhospitals.Thecaseofthe21yearoldparasuicidecitedearlierdemonstratesbelief

thatcleansingisneeded.‘Strengtheningmedicines’areespeciallypopularbecausethey

protecttheindividualfromvariousomens(Wessels,1989).

6.3HEALTHANDILLNESSBELIEFS(QUALITATIVE)

Thesubjectsusedavarietyofsymptomsorlackofsymptomsandfeelingstoexplaintheir

understandingandmeaningofbeingillorwell(TableXXXI,XXXII,XXXIIIandXXXIV).In

mostcasesbeingillmeansthatonedoesnotfeelgoodorwellphysicallyand

psychologically,i.e.onedoesnotfeelnormal,isworried,feelsuncomfortableandnot

relaxed.Associatedwiththisispain.ItisworthnotingthatpainratedlowerintheHospital

Group(15.7%)thanthecommunitygroups(32%and39%).Thisprobablyisaresultof

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desensitisationtopainorthatthoseattendthehospitalbearpainstoically.Hencetheydo

notusepainasasignofillnessbutrathergeneralwellbeing.

Illnessisalsoassociatedwithbeingineffectiveorbeingunproductive,havingadysphoric

mood,lookingillphysically,psycho‐motorretardation,symptomaticandbeing

dependent.Sleepandappetiteareusedtoassessillnessaswell.

‘Wellness’isconsideredtheoppositeofthe‘ill’condition.Anindividualwhoiswellis

expectedtofeelgoodandnormalbothphysicallyandpsychologically.Hisorhermoodis

expectedtobeelated,painfree,productiveandefficient,lively,active,lookinggood

physicallyorhealthyasymptomaticandindependent.Thisviewofhealthandillnessis

similartothoseinotherculturesaswell;forexample,Diaz‐Guerrero(1984)studywhich

includedthirtydifferentcultures.Thereiscross‐culturalagreementthathealthis

characterisedas“good”,“potent”and“active”(Diaz‐Guerrero,1984).However,hedoes

pointoutthatadjectivesvaryfromoneculturetoanother.

Itisveryclearfromtheresponsesofthoseinterviewedthattheyadoptaholisticconcept

ofhealthandillness.Thisisveryimportantsincethereisastrongmovementinwestern

medicineaswelltoadoptanholisticapproachtohealthandillnessespeciallyinviewof

thedichotomousrelationbetweenthemindandbodyassumedbythemedicalmodel

(Engel,1977;Engel,1980;Schlebusch,1990).Ifhealthworkersdonotrecogniseand

promotethisholisticconceptthattheAfricanpossessthentheyruntheriskofteaching

themanarrowviewofillnessandhealthoutofkeepingwiththeirtraditionalworld‐view

whichlastsbeyondseveralgenerationsofacculturation.Unfortunately,theover‐

utilisationofservices,lackoffacilities,overcrowdingandtimeconstrainsandpoordoctor‐

patientcaremayactuallypromoteabiologicalmodelofillnesswhichmayhavetobe

unlearnedlater.Further,doctorswillhavetounderstandandtreatAfricanpeople

holistically,otherwisetheirpatientswillnotcomplywiththetreatmentsprescribed.

Theholisticunderstandingofhealthandillnessisalsoseeninthereasonsprovidedbythe

subjectswhypeoplegetsick(TableXXXV).Themostprominentreasonsarepoornutrition

anddiets;socialstresssuchaspoorlivingconditions,poverty,infectionanddiseases,

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alcoholandsubstanceabuses;psychologicalstress;environmentalstress,suchas,

violence,warunrestandoccupationalstresses;inheritedillnesses;bodymalfunctioningor

atrophy;preventativemeasures,suchas,checkups;andtraditionalideas,suchas,

bewitchment,badtermswithneighboursandfamily,seasonalandweatherchanges,and

dirtyorgans.

Althoughallgroupsindicatedthattheywouldgotoadoctor,someoftheillness

behaviourssignificantlyvariedamongthegroups;.Thesewereforhospitalattendance

(p=<0.05),useofapharmacy(p=<0.01),useofprayer(p=<0.05),denial(p=<0.01),self

medication(p=<0.01)andreadingaboutillnesses(p=<0.01).TheKwaMashugroupwas

lesslikelytoattendthehospitalthantheothergroupsbutmorelikelythantheother

groupstogotoapharmacy,self‐medicateordenytheillness.Thisisprobablytheresultof

therenotbeingahospitalnearKwaMashuwhereasUmlazihasthePrinceMshiyeni

MemorialHospital,theKingEdwardVIIIandClairwoodHospitalscloseby.Thisagain

endorsestheviewthatthelackoffacilitiesforceindividualstoseekalternateillness

behaviours.Further,theHospitalGroupendorsedprayermorethanthecommunity

groupsasaformoftreatment.TheUmlazigroupreportedthattheyreadaboutillnessin

ordertounderstandtheirillness.Ontheotherhand,theHospitalGrouprespondedthe

leasttoreadingabouttheirillness.Thisisunderstandableintermsofthelowerlevelof

educationandlowersocio‐economiclevelsoftheHospitalGroup.

6.4THEHEALTHANDILLNESSBELIEF(QUANTITATIVE)

Thereliabilityofthisquestionnaire,whichwasdevelopedtomeasurehealthandillness

beliefsforanAfricanpopulation,was0.76.Thissuggeststhatthemeasurementhashigh

internalconsistencyandisreliableforinterpretivepurposes.Acomparisonofthemeans

foreachoftheitemsshowthatthereweresignificantdifferencesinthewayeachofthe

groupsrespondedtoitems1,3,4,5,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,

24,26,27,28,29,30,and31.

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Item1assessedthebeliefthatapersongetssickbecausetheyarenotstrong.Onthisitem

theHospitalGroupagreedmorethanthecommunitygroups.Therewasasignificant

differencebetweenthethreegroups(p<0.001).Overalltherespondentsdidagreeor

sometimesagreethatifapersonisnotstrongenoughheorshewillgetsick.Wecould,

therefore,assumethatbeingillmeansthatapersonisnotstrongenoughandvulnerable

andthatthisviewwillinfluencehowtheyaccepttheirillnessandhowothersrespondto

them.Anindividualwhoperceiveshimselforherselfasstrongandwhogetsillmay

thereforedenyhis/hersymptomsforalongtimeandmay,asaresult,delayseekinghelp.

Othersassociatingwiththepersonwhoisillmaytreathimasweak.Thismayleadtoand

fosteradependentroleinthepatientormayleadtothepatientresistingthesupportof

thosearoundhim.TherewasalsostatisticallysignificantdifferencesbetweentheHospital

GroupandtheUmlaziGroup(p<0.01),andtheHospitalGroupandKwaMashuGroup

(p<0.001)Thissuggeststhatthose,whoattendthehospitalshaveastrongerbeliefthat

thosewhoareillarenotstrong.Thereweresomewhodisagreedwiththisviewranging

from22.6%intheHospitalGroupto37.7%inthecommunitygroup.

Therewasgeneralagreementbyallgroupsthataperson'sdietmayleadtoillness(item

2).Thisisinkeepingwiththereasonsthesubjectsofferedwhypeoplegetsick?

TheintervieweestendedtodisagreewiththeviewthatillnessisduetodesertionbyGod

(item3).Thethreegroupsstatisticallydifferedsignificantlyonthisbelief(p<0.001),

especiallythoseintheKwaMashuGroup(71.4%)whodifferedfromtheHospitalGroup

(p<0.001).Althoughthereisagreementsometimesthatitcouldbetrue,itwouldsuggest

thatthegeneralcommunitybelievesthismorethanthosewhoattendthehospital.

Thebeliefthatillnessiscausedbyinfectionwasoverwhelminglyendorsedbyallsubjects

(item4).Itisapparent,therefore,thattheviewofinfectionasacauseofillnessiswell

accepted.Howevertherewasasignificantdifferencebetweenthegroups'responseon

thisitem(p<0.05).Therewasalsosignificantdifferencesintheendorsementsbetween

theHospitalGroupandtheUmlaziGroup(p<0.05),andtheHospitalGroupandtheKwa

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MashuGroup(p<0.05).TheKwaMashuGroupendorsedthisitemoverwhelminglyhigher

thantheothergroups.

Item5whichrequiredthesubjectstorespondtothebeliefthatillnesswascausedby

witchcraftorsorceryyieldedmixedresponses.Therewassignificantdifferencesbetween

thethreegroups(p<0.05)aswellbetweentheHospitalGroupandtheUmlaziGroup

(p<0.05),andtheHospitalandKwaMashuGroup(p<0.05).Halfofthesubjectseither

agreed/sometimesagreeordisagreed/sometimesdisagreed.Althoughthebeliefisnota

dominantone,itisobviouslyanimportantbeliefininterpretingandunderstandingones

illness.Withitem6,thatdealswiththebeliefthatsicknessisduetoacurseor

bewitchmentbyothers,mixedresponseswerealsoobtained.Althoughtherewasa

slightlyhighertendencytodisagreewithsuchabelief.

Thereisgeneralbeliefthatlackoforinadequateregularexerciseleadstoillhealth(item

7).Asmallgroupdisagreesorarenotsureofthebenefitsofregularexercise.

Mostsubjectsdisagreedwiththebeliefthatsicknesscamefromthedevil(item8).Onthe

average,25.62%werenotsure.Asimilarpercentageagreedorsometimesagreed.

Thevisitingofdoctorsastheonlyhelp‐seekingbehaviourwhenseriouslyill(item9)wasa

dominantbelief.Although,thereweresignificantdifferencesbetweenthethreegroupsin

theiragreement(p<0.001).Allgroupsoverwhelminglyendorsedthisstatement.

Mostofthesubjectsdisagreedwiththebeliefthatonlydoctorscantreatpeoplewhoare

ill(item10),thisbeingmoresointhecommunitygroupsthantheHospitalGroup.There

wassignificantdifferencebetweenHospitalGroupandUmlaziGroupofp<0.001and

betweentheHospitalGroupandKwaMashuGroupofp<0.001.Ofthosewhoagreed,this

beliefwasmorecommonintheHospitalGroup.Thiscouldexplainwhypeopleseek

medicalhelpandmaybeausefulbelieftoconsiderincompliance.

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Item11whichassessedthebeliefthatthereisnothingapersoncandotopreventhimself

fromgettingillalsoelicitedmixedresponses.Astatisticalsignificanceofp<0001was

obtainedbetweenthethreegroups.Whilealargenumberdisagreed,16.74%agreed,

21.91%sometimesagreedand17.19%werenotsure.Thiswouldindicatethatthereare

manywhobelievethattheyhavenointernallocuscontrolinpreventingthemselvesfrom

gettingill(WallstonandWallston,1984).

Sicknessasaresultofpoorselfcareand/orhygienewasendorsedbymostofthesubjects

(item12).Asignificantdifferencewasfoundbetweenthegroups(p<0.05).Thisbeliefisin

keepingwiththesubjectsresponsesto“Whypeoplegetill”

Thesubjectsagree/sometimesagreedthatsomeillnesscannotbetreatedbymedical

doctors(item13).Thiswouldsuggestthenthatifindividualsdonotbelievethatdoctors

cantreatallillnessesthenwecouldassumethattheywouldseekhelpwheretheymay

feeltheywouldobtainappropriatetreatment.Thisbeliefmayaccountforthevaried

responsetoitem10andmayleadtoselectivehelp‐seekingbehaviour.

Thesubjectsalsoendorsedthebeliefthatsometimesillnessesareinherited(item14).The

threegroupsrespondeddifferentlyonthisitem(p<0.001).TheKwaMashuGroupagreed

lesswiththisitembutendorsed“sometimesagree”moreoften.

Item15whichlookedatselfcarebyindividualspreventingillness,wasgenerallyendorsed

bythesubjects.19,21%disagreedand15.03%werenotsure.Againtheissueofinternal

locusofcontrolinhealthbehaviourmustbeconsidered(WallstonandWallston,1984).

Thesubjectsfeltthattheywereabletoeffectacurethemselveswhenill(item16).27.36%

disagreedand16.78%werenotsure.However,theydidnotseethemselvesasculpable

forillnesses(item17).Althoughtheysometimesagreedthattheirillnesscouldbetheir

fault.Responsessignificantlydifferedbetweengroups(p<0.001).Hereagaintheconcept

ofinternallocusofcontrolmaybeacentralissuetoconsider.

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'Visitingadoctorforregularcheckupscanpreventapersongettingsick'(item18)was

agreed/sometimesagreedbymostrespondentsHowever,14.09%disagreedand16.46%

werenotsure.Asignificantdifferenceofp<0.001betweenthethreegroupswasobtained.

Inaddition,theintervieweesexpressedthebeliefthatdoctorscantreatsymptomsbutnot

thecause(item19).Hereagaintheinfluenceofculturaland/ortraditionalbeliefsof

illnessmaybediscerned.

Therewasageneralisedresponsetothebeliefthatmostillnesscanbetreatedathome

(item20).Asignificanceofp<0.001wasobtainedbetweenthegroups.24.49%agreed,

30.70agreedsometimes,26.41%disagreedand18.40%werenotsure.TheKwaMashu

Groupoverwhelminglydisagreedwiththisview.Respondentsalsobelievedthatolder

peopleknowatlotaboutillnessandthattheycanprovideappropriateadvice(item21).

Theresponsesshowthat29.91%agreedand30.70%sometimesagreedwiththis

statement.

Item22dealtwiththebeliefthatpeopleshouldpraytoGodtocurethemoftheirillness.

Theresponsevariedfrom27.64%agreeing,29.44%agreeingsometimes,22.70%

disagreeingand20.22%notsure.Thethreegroupssignificantlydifferedintheirresponses

(p<0.001).

Item23assessedthebeliefthatpeoplearelazyanddonotworkhardenough.Mostofthe

subjectssometimesagreed(35.85%).Asignificanceofp<0.05betweenthegroupswas

obtained.

Beliefsaboutthetreatmentgivenbyeldersorolderpeoplewasassessedbyitem24.The

mostcommonresponsewas'sometimesagree'(37.02%).Thesecondhighestresponse

was'notsure'(23.59%).Ontheaverage18.17%agreedand21.22%disagreed.

Asmuchas49.21%ofthesubjectsdisagreedwiththebeliefthatillnessisaformof

punishmentforthewrongorbadthingsthatapersonhasdone.However,19.41%agreed

sometimes,11.17%agreedand20.20%werenotsure.

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Thebeliefthatapersonmaygetsickasaresultofsomethinginvadingtheirbody(item25)

wasanacceptedbeliefbysubjectseitheragreeing(39.37%)orsometimesagreeing

(31.79%).Only13,46%werenotsureand15.38%disagreedwiththestatement.TheKwa

MashuGroupshowedhighestagreementwiththestatement(49.4%)andlowest

disagreement(10.4%)

Item27assessedthebeliefthatsicknessoccurredasaresultofnotperformingthe

requiredritualsorprayerstoancestorsorpriest.Thegroupssignificantlydiffered

(p<0.001).Although43.53%disagreedwiththisbelief,12.04%agreed,20.25%agreed

sometimesand24.18%werenotsure.TheKwaMashuGroupleastagreedwiththe

statement(5.2%)andshowedhighestdisagreement(59.7%).

Avariedresponsewasobtainedforthebeliefthatapersoncanbecomeilliftheywalkor

crossoverapathorplacewheresomeritualwasperformed(item28).Asignificant

differencebetweengroupswasobtained(p<0.05)'Sometimesagree'wasthemost

commonresponse(22.57%),while22.57%agreedand21.33%werenotsure.25.17%

disagreedwiththebelief.TheKwaMashugroupdemonstratedlowestagreementwith

thisbelief.

Thebeliefthatsicknessistheresultofmalfunctioningorimproperfunctionofthebody

(item29)appearstobeacommonbeliefoftherespondents.Thosethatresponded'agree'

were34.76%and'sometimesagree',36.23%.TheKwaMashuhighestagreementwiththe

statement(50.0%)andlowestdisagreement(5.8%)

Therewasahighdisagreementwiththestatementthatillnessisduetodemon,evilorbad

spiritpossession(48.48%).Ap<0.05significancewasobtainedbetweenthethreegroups.

Boththecommunitygroupsshowedlowagreement.Umlazi9.9%andKwaMashu9.7%.

AlthoughtheHospitalGroupdemonstratedmoreagreementwiththebelief(14.9%),they

alsorespondedwiththehighestdisagreement(51.9%).

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Thelastitemassessedthebeliefthatillnessisduetopunishmentordesertionbythe

ancestors.Therespondentsshowedhighdisagreementwiththisbelief(47.18%).Although

22.86%werenotsure,14.53%agreedand15.43%sometimesagreedwiththebelief.The

KwaMashugroupindicatedthelowestagreementwiththisbelief.

Whiletherehasbeensignificantdifferencesinthewaytheintervieweesrespondedon

eachitem,therewasnoconsistentdifferenceinthewayeachgroupresponded.This

suggestthattheHospitalGroupbeliefsofhealthandillnessarenotsignificantlydifferent

tothatofthecommunity.

However,itappearsthatcertaindominantbeliefsareendorsedbytherespondentsthese

are:peoplegetillbecausetheydonoteattheproperfoods;illnessiscausedbyinfection,

peoplegetsickbecausetheydonotexerciseregularly;peoplegotodoctorsonlywhen

theyareseriouslyill,peoplegetsickbecausetheydonotkeepthemselvesclean;thereare

someillnessesthatdoctorscannottreat;peopleinheritillnessfromtheirparents;if

peopletakegoodcareofthemselvestheywillnotgetill;peopleareabletocure

themselves;visitingadoctorforregularcheck‐upscanpreventapersongettingsick;

doctorscanmaketheillnessbetterbuttheycannottreatthecause;olderpeopleknowa

lotaboutillnessandcanadviseotherswhattodo;peoplegetsickbecausetheyarelazy

anddonotworkhardenough;peoplegetsickwhensomethingforeigninvadestheir

bodiesandsicknessoccurswhenthebodyisnotfunctioningproperly.Inaddition,

respondentsgenerallydisagreedwiththefollowing:illnessisduetodesertionbyGod;

sicknesscomesfromthedevil;doctorsaretheonlyonesthatcantreatpeoplewhoareill;

thereisnothingapersoncandotopreventthemselvesfromgettingill,ifapersongetsill

itistheirownfault;illnessisaformofpunishmentforthewrongorbadthingsaperson

hasdone;sicknessoccursbecauseyoudonotperformtheritualsorprayerrequiredby

thepriestorancestors;illnessisduetodemon,evilorbadspiritpossession;andillnessis

duetopunishmentordesertionbytheancestors.

Thebeliefsthatwerelessclearwere:peoplegetsickbecausetheyarenotstrong;illnessis

causedbywitchcraftorsorcery;peoplegetsickbecausesomeonehascursedordone

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somethingeviltothem;mostillnessescanbetreatedathome;peopleshouldpraytoGod

tocurethemoftheirillness;treatmentgivenbyeldersorolderpeoplecanreallybe

helpful;andapersoncanbecomeilliftheywalkorcrossoverapathorspotwheresome

ritualwasperformed.

Oftheninefactorsthatemerged,fourdealtwithaetiology,fouraddressedbeliefs

regardingtreatmentandoneillnessprevention.Theaetiologiesofillnessforurban

Africansaccordingtotheseresponsesareexternalevilandancestral,self‐blame,medical

andbodymalfunctionorweakness.Themaintreatmentbeliefsareselfmedication,

medicaltreatments,prayerandanholistictreatmentapproach.Self‐careisseenasa

methodforpreventingillnesses.

Thereweresignificantdifferencesoncertainfactors(TableXXXIX).Onfactor2,boththose

livinginanurbanareaforlessthan5yearsandgreaterthan5yearsendorsedthe

aetiologicalbeliefofself‐blame(p=0.0003)butthosewhowerelivinginaurbanareafor

lessthan5yearsendorsedthebeliefofself‐blamemorethanthosewhowerelivingfor

greaterthan5years.Apossiblereasonforthiscouldbethatthosewholivedforlessthan

fiveyearswouldhaveonlyrecentlylefttheruralareasandthereforeweremorelikelyto

attributetheirillnesstohavingabandonedtheirculturalrootsandbeliefs.

Onfactor3therewasasignificantdifferenceamongthegroups(p=0.0003)inthe

interactionwithurbanisation.Themoreurbanisedtheindividualthemorelikelyheorshe

wastoadoptamedicalaetiologyofillness.Therewasalsosignificantageeffect

(p=0.0015).Theyoungertheadultthemorelikelywasheorshetoadoptamedicalreason

forillness.Thisisprobablyduetotheprocessofeducation.

Beliefsinself‐medication(factor4)significantlydifferedbetweenthe3groups(p=0.0220).

Thesebeliefsalsovariedwithurbanisation(i.e.thenumberofyearslivinginanurban

area).Urbanisationalsoinfluencedthegroup'sbeliefsonbodymalfunctionandphysical

weaknessetiology(factor5).Thisbeliefwasalsoaffectedbytheageoftheindividuals.

Theoldertheindividualthelesslikelythebelief.Self‐careaspreventativebeliefwas

185

differentbetweengroupsandwasalsoinfluencedbyurbanisationandtheageofthe

individuals.Thissuggeststhaturbanisationandyoungeradultsbelievethatself‐carewill

preventillnesses.Theuseofprayer(factor8)variedbetweenthegroupsandwas

influencedbyurbanisationaswell.Bothurbanisationandagealsoinfluencedtheholistic

treatmentbelief(factor9).

Factor6whichdealswithmedicaltreatmentvariedbetweenthegroups.Thecommunity

groupsstronglybelievedinmedicaltreatment.Thiswouldsuggestthatahigherlevelof

education,acculturationandurbanisationcontributestothebeliefsoftheefficacyof

medicaltreatments.

Theseresultssuggestthereforethatthehospitalattendersdonothaveasetofbeliefsof

healthandillnessdifferentfromthoseofthegeneralpopulation.Nevertheless,thereare

severalhealthandillnessbeliefsheldbythiscommunity.Thesebeliefsarestrongly

influencedbyurbanisationandtheageoftheindividual.Itwould,therefore,seemthat

healthandillnessbeliefsvaryandarestronglyinfluencedbyurbanisationandageofthe

individuals.

6.5SOCIALSUPPORTANDHEALTH

Thisquestionyieldedaveryhighlevelofreliability(0.91).Hereagain,thismeasurement

hadhighinternalconsistency.

Theresponsesofthesubjectsshowthattheyweregenerallysatisfiedwithallaspectsof

socialsupport(TableXLI).Regardingaccessibility,therewasasignificantdifferenceamong

thegroupsastowhethertheaccessibilitywasimmediate(p=0.0001)ordelayed

(p=0.0001).Ofthosethatindicatedthattheyhadimmediateaccessibility,theKwaMashu

Groupscoredhighest,followedbytheUmlaziGroupandthentheHospitalGroup.For

thosethatindicatedthattheiraccessibilitywasdelayed,thoseinKwaMashureported

moredelaysthantheothergroups.

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Theproximityofthesubjects'socialsupportsignificantlyvariedforthegroups

(TableXLIII).Eachgrouprespondedsignificantlydifferentlyregardingtheproximityof

theirsupport.TheKwaMashuGroupmostlyindicatedsupportnearbyfollowedbythe

UmlaziGroupandthentheHospitalGroup.However,ofthosethatindicatedthattheir

supportwasfar,theKwaMashuGrouphadgreateramountofsupportfurtherawaythan

boththeHospitalorUmlaziGroups.

Regardingthemodeofsupport,boththeHospital(80.85%)andKwaMashu(95.45%)

groupsusedthetelephoneextensivelytoobtainsupport:Supportthroughletterwriting

orpostalserviceswasobtainedby32.71%intheHospitalGroup,27.62%intheUmlazi

groupand59.74%intheKwaMashugroup.Itwouldseemthatthosewhoattendedthe

hospitalandthoselivingintheKwaMashuareahavelessphysicalcontactwiththosewho

providesocialsupportalthoughtheseindividualsdonotliveveryfaraway.Thisisin

keepingwiththeearlierresultsthatshowedthat79.26%ofthehospitalsubjectswere

unaccompanied.Thiscouldbeduetovarioussocio‐economicfactorssuchashavingtolive

separately,inrelatives'homesorbecausethosethatprovidesocialsupporteitherlive

withtheiremployers,asinthecaseofdomestics,orinhostelsprovidedbyemployers.

Withinthiscontext,theuseofthetelephoneorpostalservicesbecomepractical.The

Umlazicommunity,ontheotherhand,havemorepersonalsupportandrepresents

familieslivingtogether.Thefactthatthesubjectsdescribedtheirsocialsupportasbeing

satisfactorydespitethevariationinthetypeofsocialsupport,suggeststhatitisnothow

socialsupportisobtainedbutrathertheavailabilityandtheperceptionofsupportbythe

individualthatisimportant.Theperceptionsofsupportareprobablyinfluencedbythe

individual'sexpectationsaswell.Inthecontextwheretheconceptoffamilyhas

deterioratedtotheextentithasamongAfricansinSouthAfrica,theindividual's

expectancyofsocialsupportisprobablynotcommensuratewiththoseofindividualsin

moreprivilegedcommunities.

Supportismostoftenprovidedbyamother,family,friendsandneighbours.Thisisin

keepingwiththehospitalsubjectsqualitativeresponseswithregardstobeing

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accompaniedtothehospital.Ofthoseaccompanied,mostwereaccompaniedbyclose

familyandfriends.Suchman(1966)andHouseetal.(1988)haveshownthattheseeking

ofhealthbehaviourisasocialprocessinvolvingfamily,neighboursandfriends.

Thefactoranalysisoftheresponsesonthesocialsupportquestionnaireyieldedtwo

factors.Factor1dealswithgeneralsocialsupportorsupportinthetimeofacrisis.Factor

2dealswithaclose,confidentialtypeofsupport.Itisinterestingthatonfactor1theway

subjectsrespondeddependedontheirsex,thelengthofstayinanurbanareaandage

(TableXLVI).Therewasnosignificantdifferencesbetweenthegroupssuggestingthat

socialsupportdidnotinfluencehelp‐seekingbehaviourintheHospitalGroup.

FemalesintheHospitalGroupsignificantlyendorsedthesupportoffactor1morethanthe

males(p=0.0072).Malesendorsedthistypeofsupportinthecommunitygroupsmore.

ThismaysuggestthatfemalesintheHospitalGrouparemoresatisfiedgenerallywith

socialsupportorsocialsupportincrisesthanthoseinthecommunity.Inaddition,those

livinglessthanfiveyearsintheurbanareaweresignificantlymoresatisfiedwiththetype

ofsocialsupportinfactor1exceptinthecaseoftheUmlaziGroup(p=0.0178).Thismay

suggestthatthosenewintheurbanareaaresatisfiedwiththesocialsupport.Asthey

residelongerinanurbanareathefactor1typesocialsupportisperceivedasbeingless

satisfactoryorthesocialsupportactuallydwindles.Anotherreasonforthoselivinginan

urbanarealessthanfiveyearsfindingthesocialsupportsatisfactory,isthattheymay

havecomefromruralareaswherethequalityofsocialsupporthadbeenpoorornon‐

existent.Therewerealsosignificantdifferencesinthewaylivinginanurbanareaaffected

male'sandfemale'sperceptionoffactor1socialsupport(p=0.0289).Thelengthofstayin

anurbanareadoesnotseemtoaffectthemalesperceptionoffactoronesocialsupport.

Afterfiveyearsresidenceinanurbanarea,thefemalesperceptionimproved.Thiswould

suggestthatfemales'levelofsocialsupport(factor1type)oratleasttheirperceptionofit

improveswhentheymoveintoanurbanarea.

Onfactor2thereweresignificantdifferenceswithregardstolengthofstayinanurban

areabetweenthegroups(p=0.0160)andthesexofthesubjectsbetweenthegroups

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(p=0.0160).Thesedifferencesweresimilartofactor1suggestingthatthefemalesinthe

HospitalGrouparemoresatisfiedgenerallywithsocialsupportorsocialsupportincrises

thanthoseinthecommunity(exceptintheHospitalGroup)andthatthosenewinthe

urbanareaaresatisfiedwiththesocialsupport.However,astheyresidelongerinan

urbanareathefactor2typesocialsupportisperceivedasbeinglesssatisfactoryorthe

socialsupportactuallydwindles.Hereagain,anotherreasonforthoselivinginanurban

arealessthanfiveyearsfindingthesocialsupportsatisfactoryisthattheymayhavecome

fromruralareaswherethequalityofsocialsupporthadbeenpoor.However,the

perceptionofUmlaziGroup'ssocialsupport(factor2type)improvedwiththeirresidence

inanurbanarea.

Overall,theresultsshowthatthereissatisfactionwiththeavailablesocialsupports.

Femalesseemtoperceiveandexperiencebettersocialsupportthanmen.The

improvementofthefemales'satisfactionwithsocialsupportonfactor1,aswellasthe

males'perceptionsnotdeclining,appearstohavepositiveimplicationsregardingsocial

supportandurbanisationinAfricansbecausesatisfactorysocialsupportisdirectlyrelated

tophysicalandpsychologicalwell‐beingandactsasabufferbetweenstressfullifeevents

andsymptoms(Zimetetal.,1988).Ontheotherhand,theexperienceandperceptionsof

socialsupportonageneralscaleseemtodeclinewithlongerresidenceinanurbanarea.

Thisaspectraisesconcernforthefuture.Thepositiveeffectsofgoodsocialsupportin

healthandhealthbehaviourhasbeenwelldocumented(CohenandSyme,1985;

Geertsen,1988;Ritter,1988;Sarason,etal.1985).However,inthisstudytherewasno

significantdifferencesbetweenthegroups.Thissuggeststhatsocialsupportdidnot

influencehelp‐seekingbehaviourintheHospitalGroup.

6.6SYMPTOMPERCEPTIONS

Averyhighreliabilitywasalsoobtainedinthisquestionnaire(0.96).Thissuggestthatthe

measurementhashighinternalconsistency.

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TheHospitalGroupdidnotexperiencemoresymptomsorratetheirsymptomasmore

seriousthantheothergroups.Generally,theKwaMashuGroupexperiencedmore

symptomsthantheothergroups.Thesubjectsendorsedtheirexperienceofpsychological

andpsychiatricsymptomatology,suchas,depressionandanxietytogetherwithphysical

symptoms.ThisiscontrarytothepopularbeliefthatAfricanpatientsdonotgenerally

presentwithdepressiveoranxietysymptomatologybutmainlyphysicalsymptoms.Itis

possiblethattheseindividualsperceivethemedicaldoctorasbeinginterestedinphysical

symptomsandthereforeonlyreportphysicalsymptomstohimorher.Thisisa

fundamentalproblemwiththemedicalmodel;itfocusesonlyonthebiological.Asa

result,patientsaretaughttopresenttheirillnessinthismanner.Mechanic(1992)points

outtheinfluenceofdoctorsviewsandpracticesonhealthandillnessbehaviours.The

failuretoaddresstheotherdimensionsofhealthandillness,ortheself‐understanding

withinAfricanworld‐viewwillperpetuatetheseekingofalternatetreatment,thedelayin

medicalhelp‐seekingbehaviourand/orobtainingtreatmentfromothersourcesthatwill

addressthedifferentdimensions(FreemanandMotsei,1992).Thefocusonphysical

symptomatologywillalsocontributetotheviewthatpsychological,psychiatricandsocial

symptomsarelessimportantandthetreatmentofthesesymptomsarealuxury.Sucha

viewresultsintheindividualnotbeingtakenseriouslyorcontributestohisorherlearning

tosomatizeinordertoobtainhelp.

6.7STRESSANDHELPSEEKINGBEHAVIOUR

ThereliabilityobtainedinthemodifiedversionoftheLifeexperienceSurveywas0.71.

Hereagaintheinternalconsistencywashigh.Thissuggeststhatthequestionnairehas

goodconstructvalidity.

Thereweresignificantdifferencesinthewaythegroupsperceivedtheextentorimpactof

thefollowinglifeexperiences:Marriage(item1)wasregardedpositivelywiththeUmlazi

Group.Itssamplerecordedthemostmarriages(p=0.0001).TheKwaMashuGroup

reportedtheleastnumberofmarriages.However,thesubjectsgenerallyfoundmarriagea

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positiveexperience.Engagements(item44)wererecordedinlargernumbersintheKwa

MashuGroupthantheothergroups(p=0.0317).Engagementstooaredescribedas

positiveexperiences.Reconciliationwithboyfriendorgirlfriend(item47)hadagreater

impactintheHospitalandUmlaziGroupthantheKwaMashuGroup.Theimpactof

maritalreconciliation(item25)wasmorepositiveintheHospitalGroup.Theimpactof

outstandingpersonalachievement(item9)wassignificantlyhigherintheKwaMashu

Group.Thistoohadapositiveimpact.Thesignificantnegativeimpactswereduetodeath

ofaspouse(item1);changeinsleepinghabits(item4);deathofmother,father,sister,

grandmotherandotherclosefamilymembers(item5);seriousillnessofotherclose

familymembersandspouse(item15);troublewithemployer(item17);changeinthe

numberofargumentswithspouse(item26);changeinhusband'swork(item28);change

intheamountofrecreation(item29);borrowingmorethanR10000(item31);major

personalinjury(item35);majorchangesinlivingconditions(item37)andunrestinthe

areaofresidence(item48).

Amultivariateanalysisofthetotallifeexperiencesbetweenthegroupsshowasignificant

difference(p<0.001—TableLIII).TheDuncan'smultiplerangetestrevealsthatthe

differenceoccurredintheUmlaziGroup(TableL).suggestingthattheUmlaziGroupon

theaveragehadsignificantlylesserthreateningorenhancinglifeexperiencesorchanges

thantheothergroups.Amultivariateanalysisofthenegativeandpositivelifeexperiences

betweengroupsalsoshowasignificantdifferencebetweengroups(TablesLIVandLVI).

TheDuncan'smultiplerangetestonnegativeandpositivelifeexperiences(TableLIIand

LIV,respectively)revealsthatthesubjectsintheUmlaziGroupexperiencedtheleast

amountofchangecomparedtotheothergroups.Theseresultssuggestthatalthoughthe

HospitalGroupexperiencedmorepositiveandnegativelifeexperiences,itwasnot

significantlydifferenttotheKwaMashugroup.Itmaybeinferredthenthatlife

experiencesarethereforenotasingularlytriggerfactorforhelp‐seekingbehaviourinthe

hospital.However,thefactthatthesubjectsintheHospitalGrouphadmostlifechanging

experiencesmaylendsomesupporttotherelationthatsomehavearguedforbetween

stressandillness(Feuerstein,etal.,1987;HolmesandRahe,1967;RaheandLind,1971;

Selye,1956;Steptoe,1991;TurtonandChalmers,1990).

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Thisstudyshowsthatthosethatattendthehospitaldonothaveadistinctivelydifferent

setofhealthbeliefstoothersintheirsociety.Whatemergesisthatthereareseveral

healthbeliefsabouttheaetiology,treatmentandprevention.Inthisstudythefollowing

mainbeliefsemerged:aetiologicalbeliefs(externalancestral/evil,self‐blame,medical,

physicalweaknessorbodymalfunction);treatmentbeliefs(selfmedication,medical,

prayer,holistictreatment)andthepreventativebelief(selfcare).Age,sex,educationand

urbanisationstronglyinfluencethebeliefsthatapersonadopts.FortheAfricanpatient,

health,illnessanddiseaseareviewedholistically.Thebodyandmindareinseparablefrom

thedimensionsofthesocial,culturalandreligious.Medicalbeliefsarealsowellintegrated

intotheirconceptualisationofhealthandillness.Thereis,however,amuchlesser

emphasisonculturalbeliefs,whichisprobablyaresultofacculturationinthiscommunity.

However,thisdoesnotmeanthatthemedicalviewofillnessisreadilyaccepted.There

existsabeliefthatwesternmedicinetreatsthesymptomsbutnotthecause.Depending

ontheindividual'sbeliefofwhatthecausemaybe,theappropriatehelp‐seekingtakes

place.Thismayincludeself‐medication,seekingthehelpoffamily,traditionalhealers,

faithhealers,herbalistsorprayer.ThisstudyalsoshowedthattheHospitalGroupdidnot

significantlydifferfromtheothergroupsintheexperienceandperceptionofsocial

support,theexperiencesandseverityofsymptomsandthenumberoflifeinfluencing

experiences.

6.8ACOMPARISONOFTHERESULTSWITHOTHERHEALTHANDILLNESSMODELS

Theresultsofthisstudysupportmanyofthecomponentsorconceptsproposedbysome

ofthemorepopularmodelsofhealthandillness.(Areviewofthepopularmodelshas

beenpresentedinchaptertwo).Thoserelevantaspectsthatemergedfromthisstudyand

allowinferencestobemadewillbebrieflydiscussedhere.However,itmustbenotedthat

thisstudywasnotdesignedtotestthesemodels.Possibleinferencesaredrawnfromthe

resultstosupportorvalidateaspectsoftheseothermodelswherethismaybevalidly

done..

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Theresultofthepresentstudysupportstheviewthattheperceptionofsymptomsplays

animportantpartintheseekingofhelp.AccordingtotheHBM,symptomsactasan

internaldecisionmakingprocessthatactasa'cuetoaction'.KaslandCobb'sModel

(1966a)onillnessandsickrolebehaviourshypothesizesthatbehaviourundertakeninthe

presenceofsymptomsisinfluenceddirectlybytheindividual'sperceptionofthedisease

andthebeliefconcerninghealthaction.Suchman(1965a;1965b)alsopointsoutthat

symptomexperiencesalerttheindividualthatsomethingiswrongwhichisthen

interpretedandresultsintheassumptionofthesickrole.Fabrega'sModel(1973)also

suggestthattherecognitionandevaluationofsymptomsleadstorealisationofthe

presenceofillnessandinturnleadstobehaviourstoalleviatethem.Thisisalsocommon

toMechanic'sModel(1978)aswell.Inthepresentstudytooitwasfoundthatthe

presenceofsymptomsalertstheindividualthatsomethingiswrongandprecipitatesthe

processofhelpseeking.

Theseverityofsymptomsisalsoacomponentofmanyofthesemodels.Inkeepingwith

theHBM,Suchman'sModel(1965a,1965b)andMechanic'sModel(1978),theextentto

whichsymptomsareperceivedasseriouswillaffecthelp‐seeking.Thisvariablewasalso

foundtobeoneofthesixcategoriestoemergefromtheCummings,BeckerandMaile

(1980)studytoidentifycommonvariablesamongthehealthmodels.Inthisstudy,

severityofsymptomsplayedamajorpartinprecipitatinghelp‐seekingandsubjectsalso

reportedthatdelayinseekinghelpwasaresultofthemnotperceivingtheirsymptomsas

serious.

'Benefits'or'costofaction'and'barriers'isacomponentthatfeaturesfrequentlyinthe

healthmodels(HBM;KaslandCobb,1966a;1966b;Mechanic,1978).Hereagain,subjects

inthisstudysoughthelpiftheybelievedthatsuchactionwouldalleviatetheirsymptoms.

Thisstudyalsoshowedtheusageofseveralothertreatmentsinadditiontomedicalhelp‐

seeking.Thesecomponentssuchasshopping,selfmedication,homeremediesand/or

culturaltreatmentsarealsocommontoSuchman'sModel(1965a,1965b),Fabrega's

Model(1973)andYoung'smodel(1980)

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Ahighpercentageinthisstudyreportedseekingthehelpandadviceofsignificant

individualsintheirenvironment.Suchman(1965a,1965b),Fabrega(1973),Mechanic

(1978),Young(1980)andCummings,BeckerandMaile(1980)allemphasizethe

importanceofsocialsupportandsocialnetworksintheutilizationofhealthfacilities,

Consistentwithallthesemodels,healthattitudes,valuesandbeliefshavebeenfoundto

playanimportantroleintheperception,experienceandunderstandingofsymptoms,the

choiceoftreatments,thedecisiontoseektreatmentandthebenefitsoftreatments.This

studyisinkeepingwiththesemodelsalsosupportstheviewthatdemographicvariables

playsaroleintheseekingofhelp.

Theaccessibilityofservices,astheHBM,Anderson'sModel(1968)andYoung(1980)also

found,contributestotheutilizationofhealthservices.Responsestoitemssuchas5,7,10,

11,15,17,18,1924and30ontheHBQ,supportsconceptssuchas'healthlocusof

control','internalhealthlocusofcontrol','powerfulothershealthlocusofcontrol'and

'chancehealthlocusofcontrol'(WallstonandWallston,1984)

Thefactthattheseresultsvalidatesomeofthefundamentalaspectsofthecommon

healthandillnessmodelssuggeststhatthesewesternmodelsmaybeadaptedforusein

theAfricancontext.Localresearch,likethispresentone,canbeintegratedintoalready

existingmodelstoprovidemoreusefulworkingmodelsforlocalusage.

6.9TOWARDSAMODELOFHEALTHANDILLNESS

BasedonthefindingsofthisstudyitispossibletoconstructahelpfulmodelofAfrican

helpseekingbehaviourvalidatleastforcommunitiessimilartotheurbanAfrican

communitiesstudiedhere.AgraphicalrepresentationofthemodelispresentedinFigure

12.Theexperiencesofsymptomsalertstheindividualofchangestakingplaceand

commencestheprocessofhelpseeking.Thesymptomsexperiencedbythepatientsare

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bothpsychologicalandphysical.Asmuchas63%experiencephysicalsymptomsandabout

20%psychologicalsymptoms.Thesesymptomsthatareexperiencedareevaluatedinthe

contextoftheindividual'spersonalconceptionofhealthandillness.Thisstudyhas

uncoveredfurtherevidencefortheviewthattheurbanAfrican'sconceptionofhealthand

illnessisholistic.

Healthisviewedasfeelinggood,well,comfortable,freeinbodyandmindandinvolves

thefeelingofcontentmentwithlife.Theindividual'smoodindicatesthatthepersonis

well;thereisnopain;theindividualisactiveandproductive;thereisnormalvegetative

functioningandtheindividualsocializesappropriately.Changesinanyofthesewill

constituteillness.

195

196

Thesechanges,thatisthephysicalandpsychologicalchanges,aswellasthecognitive

evaluationofthechanges,alerttheindividualthatallisnotwell(thismaybereferredto

asthestageofalertness).Theindividualwilldisclosethisexperienceorfeelingtoothers.

Aboutasmanyas86%willsharethisinformationwithothers.Thissharingofsymptomsis

referredtoasillnessdisclosure.Thepurposeofillnessdisclosureistohelptheindividual

makesenseofhisorhersymptoms.Illnessdisclosuremayalsobealearnedresponsein

theindividual'sinitialassumptionofillnessbehaviourandsickrolebehaviour.Thesupport

anddisclosureismostoftentomother,familyandfriends.Thisisprobablybecause

mothersaregenerallytheonesclosesttotheindividualfrombirth.Theexperienceof

symptoms,istherefore,associatedwiththecaringandnursingofamotherormother

figureandhencesupportwillbesoughtfromsuchindividuals.Theviewthatolderfolk

knowalotaboutdiseaseswillalsoleadtotheseekingofhelporsupportfromthem.

Duringthestageofalertnesstheindividualtriestounderstandorattachmeaningtothe

symptoms.Inaddition,theviewsofothers(towhomtheindividualhasdisclosedhis

illnessto),theindividualbeliefsandpastexperienceswillalsoplayacrucialrolein

establishingmeaningforthesymptoms.

Beliefsmaybecategorisedintofourmainareas;Theseare,cultural,self‐blame,medicalor

bodymalfunction(TableXXXIX‐factors1,2,3,and5).TableXXXVprovidesexamplesof

thesebeliefs.Theexperiencesthatassistintheunderstandingofthesymptomsreferto

thoseillnessexperiencestheindividualhasexperiencedinthepastanditsconsequences,

aswellasexperiencesofotherswhowereillorexperiencesofillnessviaothermeanssuch

astelevision,newspaper,stories,oraltraditions,formaleducationandothermedia.

Onthebasisofthemeaningorunderstandingofthesesymptomsactivehelp‐seeking

begins.However,asmuchas46%willstillnotknowwhatiswrongwiththemotherthan

realisethattheyareillandrequirehelp.Theunderstandingormeaningsascribedto

symptomsmaybecategorizedintothreebroadareas,namely,medical,layand/orcultural

(TableXXXIX).

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Thehelp‐seekingbehaviourswillvary.Help‐seekingmaybeseparatedintofourbroad

areas,namely,self‐help,prayer,culturaland/ormedical.Selfhelpwillincludetheuseof

substancesavailableathome,fromsignificantothers,shopsandpharmacies.About32%

(TableXXXVI)willmedicatethemselves.Thesubstancesusedmayvaryfromhomemade

concoctionstomedicaltreatments(TableXXX).

Prayerasamethodofhelp‐seekingisbasedonthereligiousviewthattheycouldbe

healedbyGodwhohasthepowertodoso.Usuallyprayerisobtainedfrommembersof

churchesorotherreligiousorganisations.Culturaltreatmentsareobtainedfromthe

traditionalhealer,thefaithhealerandherbalist.

Theuseofmedicalservicesisthefourthtypeoftreatment.However,onlyabout20

percentwillvisitadoctorimmediately.About40%willmonitortheirsymptomsandatthe

pointthattheythinkthatitisseriousenoughwilltheyvisitadoctor.Insomeinstancesthe

delayinvisitingadoctormaybeduetootherbarrierssuchasfinancialconstraints,lackof

transport,availabilityofappointments,sickleaveandpersonalproblemssuchasnobaby

sittersornoonetoaccompanythepersonfortreatment.

Medicalhelp‐seekingisprobablytheresultoflearnedbehaviour,sanctionedsocially

acceptedbehaviourandtheresultofwesterninfluencesabouttheunderstandingof

illnessandhealth.Theinitialreason,thatismedicalhelpseekingisalearnedresponse,is

duetoseveralwaysinwhichthebehaviourcouldhavebeenreinforced.Thesedays,more

andmoreAfricanbabiesarebeingborninthehospitalandnot,asinthepast,athomeby

midwives.Asaresult,theindividualisexposedfrombirthtohospitals,doctorsandclinics.

Evenpregnancy,anormaldevelopmentalprocessismedicalisedbecauseofthe

developmentofspecialisedobstetriccareandthefactthatapregnancyistreatedasa

“disease”wherethemotherisrequiredtoattendante‐natalclinics.Thefollowupcareat

clinicsafterbirthtomonitorbirthweightandtheimmunizationofchildrenfurther

reinforcesthisview.Visitstothedoctorandtheinteractionwiththedoctorleadstoa

learnedresponsebytheindividualespeciallyinamannerthatisacceptabletothedoctor.

Inthisregard,patientsareinfluencedtopresentsymptomstotheirdoctorsinaparticular

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way.Thisprocessoflearningtakesplacesthroughtheassociationofsymptomswith

doctors,thereinforcedbenefitsoftreatmentandmodelling.

Otheraspectsthatinfluencesthechoiceandselectionofmedicalservicesarethelocation

andqualityoftheserviceprovided.Individualswilluseserviceslocatedclosesttothemor

wheretheybelievegoodservicesareprovided.Hereagain,theopinionsofsignificant

othersplayanimportantroleindeterminingwheregoodservicesexist.

Itisimportanttonotethatthevarioussourcesoftreatment,namely,self‐help,prayer,

culturalandmedicalarenotnecessarilymutuallyexclusivetreatments.Individualstendto

usethemconcurrently.However,certaintreatmentsmaybecomesociallysanctioned

morethanothers.Forexample,withacculturationmedicalhelpseekingismoresocially

acceptedthanculturaltreatments.Yettheutilizationofaparticulartreatmentmaynot

representcompleteortotaltreatmentbecausetheremayexistthebeliefthatdoctorscan

treatsymptomsbutnotthecauseorthatdoctorsarenottheonlyoneswhocantreat

peoplewhoareill(HBQitem10and19respectively).Alternativetreatmentsmaythenbe

soughtbutifthesearenotsociallysanctioneditwouldtakeplaceclandestinely.

6.10SUMMARYANDCONCLUSIONS

Thisstudyhasdemonstratedthefollowing:

1 UrbanAfricanshaveapersonalconceptionofillness,healthanddiseasethat

influencestheirmannerofhelp‐seeking.Healthisviewedasfeelinggood,well,

comfortable,freeinbodyandmindandinvolvesonefeelingcontentwithlife.The

individual'smoodindicatesthatthepersoniswell,thereisnopain,theindividual

isactiveandproductive,thereisnormalvegetativefunctioningandtheindividual

socializesappropriately.Theirpersonalorphenomenologicaldefinitionofhealth,

illnessanddiseaseisholisticandisstronglyinfluencedbytheirtraditionaland

culturalcontextandexperience.Withwesternisationandurbanisationtheprocess

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ofacculturationisrapidlytakingplaceresultingintheintegrationofwesternviews

onhealth,illnessanddiseasewiththeirexistingview.

2 Therearecertainattitudesandbeliefsthatdirectlyinfluencebothpositiveand

negativehealthbehaviour.Whatemergesareseveralhealthbeliefsaboutthe

aetiology,treatmentandprevention.Inthisstudythefollowingbeliefsemerged:

aetiologicalbeliefs(externalancestral/evil,self‐blame,medical,physical

weaknessorbodymalfunction);treatmentbeliefs(selfmedication,medical,

prayer,holistictreatment)andthepreventativebelief(selfcare).Failuretotake

thesebeliefsintoaccountwillresultinnegativehealthbehaviours.Someofthese

beliefs,suchas,bewitchment,demonpossessionandbodyfunctioningattributed

to“somethingwrongwiththeirblood”,“dirtyorgans”and“waterinthehead”may

alsocontributetodelaysinmedicalhelp‐seekingorthetakingofsubstancesthat

couldbefataltotheindividual.Self‐medicatingandseekingofprayercanalso

delaytheseekingofmedicaltreatment.

Otherattitudesandbeliefsthatcontributedtohelp‐seekingofmedicalservices

werethatthehospitalprovidedthebestservicesforAfricans,thetreatmentwas

goodanditprovidedthebestfacilities.Thebeliefsthatthehospitalisbusyand

crowded,illnessisnotseriousenough,thatonemaygetbetterwithout

interventionanddenialofillnessalsocontributetodelaysinseekinghelp.

3 TheHospitalGroupdidnotsignificantlydifferfromtheothergroupsonhealth

beliefs,socialsupport,symptomperceptionorlifeexperiences.Thissuggestthat

thosewhoseekmedicalhelpdonothaveapeculiarprofile.Rather,thereare

severalhealthbeliefswhichinteractinacomplexwayandmayleadtomedical

help‐seeking.

4 Healthactionwasfoundtobeinfluencedbysignificantindividualsinthesubject's

environment.Theyareusuallymothers,spouses,friends,familyaswellas

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employersanddoctors.Theseindividualsplayanimportantpartinhelpingthe

individualunderstandhisorhersymptomsaswellastheseekingofhelp.

5 Demographicvariables,suchas,age,sex,educationandurbanisationstrongly

influencethehealthandillnessbeliefs.Youngeradults,withhighereducationand

whohavelivedlongerinurbanenvironmentstendtousewesternmodesof

treatmentsmorereadily.Withregardstosexitwasfoundthatmorefemales

attendedthehospital.Thehospitalattendersalsohadlowereducation,moved

recentlytourbanareasandhadasignificantlyhighernumberofunemployedor

unskilled.

6 Theseresultsvalidatedsomeofthefundamentalaspectsofthecommonwestern

healthandillnessmodels.Thissuggeststhatthesemodelsmaybeadaptedforuse

intheAfricancontext.Localresearchlikethisonecan,therefore,beintegrated

intoresearchalreadydoneinordertobeusedlocally.

7 Theuseofservicesandfacilitiesaredeterminedbythelocation,accessibilityand

thequalityofservices.Individualswilluseservicesandfacilitiesthatareclosestto

themandwhichtheyperceiveasprovidingagoodservice.Generally,subjects

werepleasedwiththetreatmenttheyreceivedatthehospitals.Theaspectsthat

subjectswerenotpleasedaboutweredoctor‐patientrelationships,pooror

inadequatefacilities,timedelaysandillnessnotcured.

8 Therewerecertainbarriersthatnegativelyaffectedhelp‐seeking.Thesewere

financialcosts,time,transport,lackofcommunitysupports(suchas,creches,lack

ofplacestoleavechildreninordertoattendthehospitalandnoonetoaccompany

thosethatareveryill),noearlyappointmentsavailableatthehospitalsandother

priorities,suchas,workandschool.

9 Symptomshavebeenidentifiedasa“triggerfactor”orprecipitantofhelp‐seeking.

Bothphysicalandpsychologicalsymptomatologyareexperiencedandrecognised.

Almost50percentwerenotabletoassociatethesymptomswithadisorder.

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10 Patientsusedmedicationsthattheyobtainedfromdoctorsorapharmacy.The

subjectsalsoacknowledgedtheuseofvitaminsupplementsforincreasingtheir

strength,toimprovetheirhealth,makethemactive,protectthemfromillnesses

anddiseasesandasabloodsupplement.

11 Individualsuseotherformsoftreatmentsindependentofmedicaltreatments.A

significantlyhighnumberareChristianwhouseprayerandsoconsulttraditional

healersand/orfaithhealersaswell.Traditionalorculturaltreatmentscost

betweenR68.23toR95.29.Subjectsgenerallyconsulttraditionalhealersforabout

threetimesandthereafterthereisadeclineinattendance.Ofthosethatused

thesetreatmentsbetween40to80percentfoundthembeneficialandindicated

thattheywillcontinuetraditionaltreatment.

12 Amodelofhelp‐seekingforurbanAfricans.Thismodelexplainstheprocess

involvedintheseekingofhelpwhenill.

Theseresultsdemonstratetheimportanceofstudyofhealthandillnessbehaviourwithin

theSouthAfricancontext.Itisobviousthatoneoftheimportantrolesoftheclinical

psychologistinSouthAfricaistheresearchandpracticeofpsychologyinhealthsettings.

Thisisespeciallyimportantsincethehealthsystemofthecountryispresentlybeing

dismantledbecausetheexistinghealthstructures,whichweredevelopedonracial

segregation,havenowbeenrejected.WiththeannouncementoftheStatePresidentthat

healthistobecomeafunctionofgeneralaffairsfromthe1April1993(DailyNews,30

January1993),itisessentialthatinthedevelopmentandre‐structuringofanhealth

systemthattheperspectivesofclinicalpsychologistsaretakenintoaccount.Clinical

psychologistscanplayanimportantfunctioninbothpolicy‐makingandinthestructuring

andplaningofhealthcarefacilities(fromwhichtheyhavebeenleftoutinthepast)by

applyingtheirknowledgeandskillsinhealthpsychology.Suchanapproachisadoptedat

theSub‐DepartmentofMedicallyAppliedPsychology,DepartmentofPsychiatry,Faculty

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ofMedicine,UniversityofNatal,Durban,wherethepsychologists,aspartofthere

functionattheMedicalSchool,areinvolvedinpolicymaking.Itishopedthatsucha

situationisexpandedtootherpartsofthecountry.

Clinicalpsychologistscanalsoplayanimportantfunctioningeneralhospitalsandmedical

schools.Inotherpartsoftheworldtherehasbeenanincreaseintheemploymentof

psychologistsinhealthrelatedfields(GentryandMatarazzo,1981;Horwardetal.,1986;

Millon,1982;Sweetetal.1991).WhilethisisstilltobecomeatrendinSouthAfrica,the

roleofpsychologyinthiscountryisalsoundergoingcriticalreview.AttherecentPASA

annualgeneralmeetingtherewasarecommendationthattheorganisationdisbands

becauseofinter aliaitslackofrelevanceforthepresentcontextofachangingsociety.

Whiletherelevanceofthetraditionalroleofpsychologistmaybequestionedthereis

evidenceinthispresentresearchthatpsychologistsinthiscountrymayhaveaspecialrole

toplayinthefieldofhealth.

Thispresentresearchsupportstheviewthat,althoughdifficult,cross‐culturalresearchin

healthpsychologycanandmustbeundertaken.Moreresearchofthisnaturecanonly

helptoprovidebettercareandtreatmenttothemanyinourcountrythathavebeen

disenfranchised.Inaddition,researchofthiskindwillcontributetorapidlyequalisethe

imbalancesthatpresentlyexist.Studiesofthiskindwillalsohelpinthedevelopmentof

newaswellasthestandardisingof,researchinstrumentsinhealthpsychologywithinthe

SouthAfricancontext.

Itishopedthatthispresentresearchwillcreateinterestintheareaofpsychologyasitis

appliedtohealthandillnessinSouthAfrica.Specificareasofhealthandillnesscanbe

selectedandstudiedwithintightlycontrolledresearchdesignsthusprovidinginsightsfor

thetreatmentofAfricansinthiscountry.

203

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APPENDIX