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Man constantly finds himself in the struggle for survival, during this process traces of his previous achievements are left at different developmental levels. He accumulates knowledge of these achievements constituting what is referred to as culture. Culture therefore refers to the sum total of the needs of man both social and biological and his adaptation to the environment. Culture incorporates whatever constitutes man’s survival whether physical or social. Africa has an indigenous culture meaning it is peculiar to the African society. The basic unit of any society is the family and this is what sums up to form the society. We therefore can refer to culture as belonging to every society (Ayisi, 1992).
Cultural practices on the other hand refer to those specific rituals that every society observes as part of their culture in their day to day life. The society requires that its members conform to these practices and often provides sanctions to those that defy. Society tends to reward those that conform and punish those that do not. Therefore the members tend to follow a particular culture in order to belong to the society. In Africa, a culture is unique to a specific people sometimes ethnic or a certain geographical area hence what is considered normal in one society may be completely bizarre in another.
In as much as culture holds a sacred place in the African society, continued cultural practices have proved to be a major challenge to the public health sector. Culture demands that those who do not conform are punished and have laid out sanctions for deviant members. Therefore members conform and religiously follow a particular culture in order to avoid punishment as well as seek rewards. Africa is rich in culture and even though some cultures have been shed off as a result of globalization, most communities in the remote areas have religiously continued to follow their cultures despite the oblivious implications this has had on their health as well as that of the society as a whole.
The public health sector is mainly concerned with the prevention of disease, prolonging of life as well as encouraging the physical fitness and efficiency of individuals. This has been done through community mobilization, promoting the personal hygiene of individuals and other areas such as sanitation and infections. Their main concern however is prevention of disease rather than cure. Over the decades, the sector has been successful in the implementation of these objectives though they also have been faced with massive challenges. Rather than lack of funds, various health problems have continued to emerge such as the Aids epidemic, massive increase in population, pollution as well as social cultural practices. It is these cultural practices that have been hardest to change especially in parts of Africa (Schneider, 2010). We will therefore look at these cultural practices in Africa and the implications they have had on the public health sector.
Rites of passage
In many African societies, circumcision is cultural. Normally the setting in which the procedure is carried out is not clinical neither is the provider trained medically. The victims of this practice are normally young men or adolescents who must undergo this practice as a rite of passage. HIV infection has taken a massive toll in Africa and this can be largely attributed to the circumcision practices especially in the remote areas. Female circumcision on the other hand has brought in a lot of controversy and has been illegalized in many countries. However, it is still being practiced in some countries. In 1991, Gambia was under pressure to eradicate female genital mutilation like its neighboring countries since the act was proving to be a health hazard to the women. Radio stations that broadcasted against or portrayed FGM as bad or hazardous were banned and it took a lot of effort and protest to help eradicate the practice. Culture proved to be a major challenge in the fight because even though the women were continually warned on the implications during child birth, a considerable number boasted of having enough children even though they had undergone circumcision (Ayisi, 1992).
Female circumcision has led to HIV infection as well as having health implications on the girl child involved. Due to the low level of hygiene observed, it is very likely that the risk of infection ups since the blades lack sterilization. In other instances where a mistake occurs the girls bleed to death as relatives and the traditional healers watch helplessly. In such instances they are quick to point out cultural reasons as the cause of death rather than their owning up to their mistake. In 2008, a civil rights group in Ghana claimed that 21 girls had bled to death as a result of FGM and filed a petition against the Ministry of Health (Winkelman).
Studies have also revealed that FGM has resulted in complications during child birth. These may include the requirement for a caesarian section, bleeding heavily and longer hospitalization after delivery. The likelihood of these implications varies and depends on how severe the FGM was. The delivery is in turn very complicated for these women and more often results in the child dying during delivery. The practice often done on girls less than 10 years normally leaves the young girl with a scar. This evidence of health implication to both mother and child has made the practice a focus of human rights activists even though the fight has been challenging (Read, 2003).
Male circumcision on the other hand has been equally challenging. Almost all African males undergo male circumcision as a rite of passage. However, only a few entrust this to a medical practitioner. Instead this rite of passage is conducted in groups and normally by an old traditional healer. The level of hygiene observed during this exercise is completely off. The blades are never sterilized and are used on almost all of the boys. This indicates that the risk of spreading HIV is considerably high if any of the boys were to be infected. Serious clinical implications have been reported on these adolescents as well as death. In as much as the health sector has continued to emphasize medical circumcision this has proved to be futile due to the cultural role the traditional circumciser holds. Therefore replacing them in Southern and Eastern Africa is no mean task.
For example a study done in South Africa searched medical records revealing that in 2008, 5% of 10,609 circumcised were admitted due to circumcision complications such as amputation, mutilation, dehydration and pneumonia. Even though data for most African countries was not taken the research revealed that three out of four boys in African countries are circumcised by a traditional healer (Uchendu).
African society regard children highly and often a woman or a particular family is valued in regard to the number of children. Unlike other cultures children are highly valued and many women are encouraged to have a lot of children. They are therefore discouraged from using contraceptives and other methods of birth control. As a result it becomes a health risk especially where a woman is unable to undergo a normal birth. Normally when a woman has a caesarian birth, she is advised to observe a period of time before conceiving again in order to recover in terms of health. However due to the place of the child in African cultures most women end up getting pregnant before the recommended time and instead advised to visit traditional healers. This has in turn resulted in high maternal and infant mortality since either the mother or the child dies during child birth.
On the other hand most African cultures consider a mother as women if she is able to successfully deliver her child at home. This practice common in many African countries has resulted in many women attending ante natal care but often chose to deliver themselves at home. In cases where the mother was infected with HIV, the risk of infecting the baby becomes far much higher as compared to when the baby is delivered in a medical facility. Besides that, the infant and maternal mortality rises as birth complications arise during home births. In a research conducted in Uganda 8 out of every 10 women who attended ante natal care chose to deliver at home. One out of these eight women died out of birth complications or the baby (Read, 2003).
Read further explains that in Malawi for example, the women prefer traditional mid wives during child birth who often are not trained while other chose them from their group of close friends. However she goes on to explain that there are other areas where women prefer midwives but do not object if they happen to be trained medically. This she says has led to at least a noticeable decrease in the maternal and paternal deaths in countries like Nigeria and Kenya. However she recommends that further intervention is still necessary.
Traditional medicine and utilization of health services
Traditional medicine normally employs the knowledge, beliefs, practices and experiences of a certain culture to diagnose, treat and prevent mental and physical sickness. A considerably high percentage in Africa depends on alternative medicine as it is commonly referred. Even though evidence in research has revealed that some of these medicines are effective, some of them have proved to be hazardous to the patient. These medicines include herbal medicine and though most people regard them as harmless they can lead to serious health problems if either the product or the therapy is of poor quality.
O’mathuna (2007) in his research on alternative medicine concluded that alternative medicine can not be dismissed as useless and continues to play a major role even in the public health sector. However, Africans need to shed off the culture of overreliance on the medicine and acknowledge the role of medical doctors where they are available.
The culture of utilizing health facilities has also been a challenge to the public health sector. This has been particularly in the fight against HIV and Aids. Generally the poor especially in Africa do not find the need of visiting a medical facility unless they are ailing. The preventive care concept is therefore new to this population and self medication is more common. Routinely testing the people may cause a decrease in the spread of HIV but their failure to seek medical attention has constantly resulted in more infections in the continent. Short term research by the Ministry of Health established that out of the patients who visit hospitals monthly, only 1% does so for normal check up (O’mathuna, 2007).
Wife inheritance and polygamy
Finally, it would be incomplete if we focused on cultural practices that have had an impact on public health if we left out polygamy and wife inheritance. Common in most African countries these two practices are linked to the value Africans have in regard to children and kinship. Even though these practices have played a role in strengthening the family, wife inheritance has lead to the spread of HIV and Aids just like polygamy. Heath workers in 2004, in Malawi warned the citizens of health implications that were arising as a result of wife inheritance. They were advised to undergo testing before engaging in the practice as well as polygamy. This practice has been dismissed in many African countries as land and property grabbing where the greedy brother in laws rushes to inherit the wives of the deceased without due consideration on their health status (Shumaker et.al 2009).
In many countries the act has been viewed as dehumanizing and undermining the dignity of women. Many widows are continually being encouraged to be more positive about widow hood rather than see it as a curse as many African countries have done. Gender activists against wife inheritance in Africa have teamed up with civil rights groups, NGO’s and the government to ensure that these widows are not forced to undergo this ‘death sentence’ as it is commonly being referred. Particularly, widows result to this dehumanizing act as a means of survival; it is only through poverty eradication that the woman can be set free of such traditions. The African culture discourages the woman from working and instead the woman waits on the husband to provide. In the event that the husband dies then she is left at the mercy of greedy relatives to be able to feed her children.
In a research by civil rights activists in Burundi, wife inheritance was found to be more common in instances where the women were illiterate. In provinces where the woman was at least educated, they were found to vehemently object wife inheritance. Some women even went ahead and filed court cases objecting the move and also rightfully claiming their husband’s property. A similar study testing the effect of education on wife inheritance was conducted in a different province and the findings were that the level of education of a woman greatly affected the possibility of her being inherited. However the shortcoming is that the African woman is not encouraged to go to school. Instead, African women are encouraged to cook and do house chores while their male counterparts are taken to school. The researchers concluded that the fight had to begin with educating the girl child (Winkelman, 2008).
A conceptual framework in simple terms is an illustration that shows how variables interact in a relationship. Often, the independent variable refers to the variable that is not affected by the changes and variations on the dependent variable. Dependent variable on the other hand depends on the independent variable. The independent variable in this case refers to the cultural practices that are practiced in Africa. On the other hand the dependent variable is the public health sector that is continually affected by the independent variable.
Independent Variables Dependent Variable
Health behavior models
Health behavior models give us a definition of what we should measure in regard to behavioral aspects of health. There are several models of behavior but this section will only focus on models linked to the behaviors already discussed. These models will provide as with an insight into our previous and also future understanding of behaviors related to health.
The social cognitive theory
This theory was the work of Albert Bandura and some scholars also refer to it as the social learning model. Bandura used this theory to incorporate both social factors and environmental factors encouraging behavior change in the health sector rather than merely focusing on individual factors. The approach in this theory is mainly clinical and has been applied in preventing and modification of risky health behaviors and in turn promoting health of individuals.
The concepts in this model emphasize on the interaction that exists between the individual, the behavior and the environment. Bandura constantly refers to this relationship as dynamic. The person is associated with several major concepts such as, individual characteristics, emotional coping, self efficacy, reinforcement, expectations and observational learning. The factors that influence the behavior in regard to the environment are cultural, social, economical, physical or political in nature. Situations in this model are used to refer to how the individual perceives the environment. Therefore as the scheme continues to interact, the behavior influences the individual and the environment simultaneously (Hayden, 2009).
This model puts a lot of emphasis on observation and insists that behaviors are learned hence it is also possible to unlearn this behavior as well. Therefore, in order to learn how to change a particular health behavior it is advisable to equip yourself with cognitive as well as behavioral skills in order to cope with a situation. Bandura is most famous for his self efficacy concept which refers to an individual’s confidence in being able to change their own behavior. This concept has been very important in the health sector especially in helping individuals change risky behaviors.
Bandura’s proposition was that the levels of self efficacy in an individual will affect their possibility of successfully undertaking a task. Individuals who have low self efficacy will poorly fair in a task while individuals whose self efficacy is low will not only be successful in the task but will also perform the task with a lot of ease. Bandura highlighted several factors as affecting a person’s level of self efficacy. Such factors include, persuasion, the feedback a person gets on the behavior, modeling through observation as well as other experiences the individual has in performing the task.
In culture for example, it is possible for Africans to stop the practices if 1)they are constantly enlightened and discouraged from doing so- through persuasion, 2)they have attempted to quit previously 3) through observing others who have managed to quit such cultural practices 4) the ability to cope with the negative concepts resulting from quitting the cultures. This model in health change has been found to be very influential and assertive.
It also has applied the concept of reinforcement through management as a way of encouraging behavior change. Reinforcement works through use of rewards whenever the desired behavior is expressed and the decrease of rewards if the behavior is stopped. In the same way punishment is used when the undesired behavior is expressed and withdrawn whenever it is stopped. The government sin Africa can employ this method by rewarding communities that quit primitive cultural practices such as FGM. In the same way practice of FGM has been illegalized in almost all African countries even though it is continually been practiced. Punishment will be demonstrated by enforcing strict laws and sanctions on those who violate them will discourage people from performing it.
Finally the model emphasizes the importance of helping the person cope with emotionally threatening situations. Since most of these cultures may not be as easy to shed for those communities involved it is important for the government to conduct training and intensive counseling on the dangers of these cultural practices to their health. This way the government can also provide alternative ways to substitute these practices in order to ease the emotional burden this might create. In conclusion Bandura’s model if applied to the latter can provide impressive results in health behavior change.
This model has been researched on for more than 20 years with results showing that it has been effective in helping change several health attitudes and behavior. Such behaviors include observing a proper diet, use of condoms, management of stress, abuse of drugs and encouraging patients to adhere to the prescribed drugs. All these behaviors are pertinent to the field of public health and increase morbidity while reducing the quality of life for individuals. This model focuses on intentionally changing behavior of individuals and has led to extensive research in the field of public health (Schneider, 2010).
The constructs in this model focus on the different stages that change undergoes, the process, and the advantages and disadvantages of change. The main strength of this model is its focus on change not as an event but a process and later breaking it down into constructs and stages then establishing whish among the stages is more concerned with making progress towards change. The explicit constructs also form a very firm foundation for this model. In this way, various populations and types of behaviors can be identified at the different levels of change.
This model has also been constantly called the stages of change model only because the stages are seen as the major constructs. Since individuals do not transform their behaviors in an instance this model highlights several stages of change. The first one is referred to as the precontemplation. At this stage are individuals unwilling to change, at least not in a period of about six months while others express a lot of commitment to their behavior and are not willing to change. This may include communities that have practiced wife inheritance for a long time and are not willing to shed the behavior. The second stage is the contemplation where they are considering changing within 6months and are more willing to listen to information regarding behavior change unlike those in the precontemplation stage. These could be communities that have acknowledged the negative effects of practicing culture in regard to health.
The third stage in TSM is the stage of preparation. Often these people are willing to change at least for duration of thirty days. The group of people in this stage has attempted to change their behavior in the past and continue to exhibit some efforts of willingness to change. The other stage was referred to as action stage to refer to people that have undergone behavior change in a period of less than 6months. To these people the change is still very raw and their chances of relapse tend to be overly high should they be faced with challenges. The final stage which they referred to as the maintenance is a stage for individuals who have changed for a period of six months. For them they have practiced the new habits and their risk of relapsing is quite lower though it cannot be dismissed.
The process of change was then defined by researchers where they defined the behavioral, cognitive, emotional as well as personal strategies as agents of change. Consciousness and the evaluation of self are classified as experimental constructs and are emphasized on the initial stages while the behavioral constructs such as reinforcement, liberation and conditioning are encouraged in the later stages of change.
In his research, Winkelman (2008) established that this model or theory has widened in scope and incorporated other behavior change such as culture though the model is most famous for cigarette quitting. The model is solely founded on the exact nature of the behavior in order to facilitate change. In Africa it is worthy to notice that the exact nature of the practices is clearly defined and the process of change is easier to establish.
There should be conscious awareness programmes in Africa to help give an insight into the causes, consequences, cure and the solution of the health behavior problems. Let there be extensive education and give an opportunity for feedback. In Kenya for example, the media played a great role in 2002 up to the present in increasing the people’s awareness on the repercussions of FGM on the girl child. International non governmental organizations with the help o the government have tried to reach the remote areas and educate the community on how to get rid of hazardous cultural practices.
The mere application of these models may not propel the African community to drop their cultural practices in an instance. The right policies need to be put in order to facilitate the process. Africans need to be liberated socially to discourage the over reliance on cultural practices. For example the over reliance on traditional healers in most African countries is as a result of failure to access medical or health facilities. In other cases the medical facilities are available but expensive compared to the traditional provider prompting them to continue relying on the latter.
In a research conducted Uganda, counter conditioning was highly encouraged. Let the community learn healthy attitudes and behaviors in order to substitute the behavior which is problematic. Africa as a whole is very rich in culture that is not at all harmful to their health. It is important to acknowledge that we are not trying to dismiss all their cultural practices as bad but rather the ones that have implications on their health. In this area certain practices such as weaving, art and decoration were encouraged. The communities were rewarded and the activities generated a lot of income. Male circumcision by traditional providers was not discarded but the traditional providers were encouraged to undergo clinical training at no cost in order to encourage adherence to medical conditions (Ayisi, 1992).
If planned and comprehensive interventions are not put into place, the population will get stuck at the initial stages of change. The only motivation that will trigger the process of change is the implementation and formulation of the right policies. Follow up is also necessary in order for the process to continue smoothly. The Ministry of Health in the African countries has a lot to work on if this is to be done in the long run. The public health sector should take note that a single model can never account for change in behavior due to its complexity. Therefore the comprehensive theory or model is likely to come from an integration of all the major theories in order to change these cultural practices. It is important to note that these cultural practices if not completely stopped will continue to be a major threat to the public health sector.