EVALUATION OF THE PERCEIVED BENEFITS OF TRADITIONAL UVULECTOMY
AMONG A COHORT POPULATION IN ILORIN, NIGERIA.
BY
DR OLAYINKA ABDULMAJEED SULEIMAN
DEPARTMENT OF OTORHINOLARYNGOLOGY
UNIVERSITY OF ILORIN TEACHING HOSPITAL, ILORIN,
KWARA STATE, NIGERIA
A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL
COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR
THE AWARD OF THE FELLOWSHIP OF THE MEDICAL COLLEGE IN
OTORHINOLARYNGOLOGY
NOVEMBER 2007
DECLARATION
I, Dr Olayinka Abdulmajeed Suleiman, hereby declare that I am the sole author of this project, and that all references has been consulted by me and this dissertation have not been previously submitted for the award of a higher degree either in part or in full and neither has it been submitted to any Journal for publication.
……………………………………………
Dr A O Suleiman
Department of O R L,
University of Ilorin Teaching Hospital, Ilorin
June 2007
CERTIFICATION
This is to certify that this work “Evaluation of the perceived benefits of traditional uvulectomy among a cohort population in Ilorin, Nigeria” was done under our supervision
………………………………………………………..
Professor C C Nwawolo Associate Professor/Consultant ENT Surgeon, ENT Unit; Department of Surgery, Lagos University Teaching Hospital, Idi-araba, Lagos, Nigeria
…………………………………………………………
Dr F E Ologe Senior Lecturer/Consultant ENT Surgeon, Department of ENT, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
ACKNOWLEDGEMENT
I give thanks to Almighty God for His mercy and grace in the completion of this dissertation.
I am grateful to Prof CC Nwawolo, and Dr F E Ologe, for their tireless supervision, guidance and support in writing this project. My gratitude goes to Prof P A Okeowo, Professor of
Otorhinolaryngology and Dr A D Dunmade, Mr. S. Segun-Busari, Dr B S Alabi and Dr A Aluko
Consultant ENT Surgeons for their support and guidance.
I acknowledge with thanks the efforts of Prof GTA Ijaduola, Professor of Otorhinolaryngology
University College Hospital, Ibadan, for some references, which were helpful.
My gratitude to Mallam Abdullahi, a tailor in Sango, for his time and assistance during the period of my data collection.
Finally I thank my wife; Medinat and my daughters; Aaliyah and Thariyah for their love and support.
SUMMARY
Background: Traditional healers are an important part of African society. They are known to cover the health needs of a substantial proportion of the population. It is unfortunate, however, that the knowledge of the extent and nature of this form of traditional healing, and the people involved in the practice is still limited.
Objective: To evaluate the perceived benefits of traditional uvulectomy among a cohort
population in Ilorin.
Materials and Methods: This study was conducted in Sango area due to the high concentration
of traditional Surgeons in this community. The control population used is from the Oja
gboroo area in Ilorin. The study was conducted between February and June 2006;
everyday of the week except Sunday from 4pm to 6pm. Sample size of three hundred and
seventy-six subjects was used for the study and three hundred and forty-four for the
control.
Results: The proportion of male that had uvulectomy done was 235(62.5%) and female
141(37.5%) with sex ratio of 1.6:1. Prevention of sore throat, treatment of sore throat,
prevention of childhood illnesses such as diarhoea, delayed growth and refusal of feeds
and elongated uvula which is causing choking feeling in the throat were major reasons for
the procedure.
Complications are rare, commonest is sore throat 34(9%), bleeding which is usually
insignificant in most cases 26(6.9%). There was no difference in the frequency of sore
throat among the two study groups. Eighty-seven percent (87%) of subjects who had
uvulectomy are satisfied with the outcome.
Conclusions:
There is no significant difference in the frequency of sore throat among the subject population compared to the control group.
There is no significant difference in the occurrence of childhood illnesses among subjects who had uvulectomy and the control group.
This community has strong confidence in the practice of traditional uvulectomy and gives it more than 85% approval rating.
CHAPTER 1
INTRODUCTION
Traditional healers are important part of African society. They are known to cover the health needs of a substantial proportion of the population. It is unfortunate, however, that the knowledge of the extent and nature of traditional healing, and the people involved in the practice is still limited 1.
Traditional medical care tends to be patronized by older people, males and those who are far from conventional medical centres 2. Traditional medical service is cheap, accessible and socially acceptable 3. Therefore they have a large patronage. In East Africa ninety percent of the population rely on traditional healers 4.
The cooperation between traditional and western medicine is still in its infancy. Efforts to synthesize both have been erratic, varying from country to country 4, 5. Health educators, Doctors and health policy makers believe that the positive aspects of what traditional healers can contribute to health care needs to be carefully studied, appreciated, and encouraged. Their high risk assessments, treatments, and practices should be outlined in each population group; and both traditional healers and those who patronise them should be taught the dangers in a friendly atmosphere devoid of derogatory comments and remarks 6.
Traditional uvulectomy is a surgical form of traditional medical practice whereby the palatine uvula is partially or totally removed by the traditional surgeons who are known to provide affordable care to under served areas 7.
Uvulectomy has been described by Byzantine Physicians as far as the Greek age
[324-1453AD], and many African countries still perform it as part of traditional medicine 8. In north-west Ethiopia it is performed at a very high rate.9
Uvulectomy is an uncommon procedure in Western Europe and North America. St
Clair Thomson and Negus, as far back as in 1948, described it as one of the rarest operations in otorhinolaryngology10, though at present the uvula is routinely removed as part of palatal surgery for snoring 8.
It is noted that uvulectomy is really part of uvulopalatoplasty for snoring and some types of obstructive sleep apnoea (OSA) 11-15 but itself is relatively infrequent operation even in Europe and North America. Laser assisted uvulotomy (uvulectomy) is an effective surgical procedure for treatment of snoring and some types of OSA11. Studies done in United Kingdom in August 2005 among Otolaryngologist showed that uvulectomy is an established surgical technique with indications for treatment of snoring and postnasal drip 16.It was reported to have been used to treat persistent chronic cough and cellulitis of the uvula 17,18,19 .
It should clear that traditional uvulectomy is in a different category. Traditional uvulectomy is noted to be one of the common negative cultural practices in Nigeria, particularly in the North 20. Other African countries where it is being commonly practiced include Chad,
Sudan, Ethiopia, Morocco, Mali, Tanzania, Niger, Eritrea, Sierra Leone and Cameroon.8
Traditional uvulectomy is also widely practiced in the middle East (especially Israel, South
Sinai, Lebanon and Yemen)8.
Traditional uvulectomy is usually indicated for prevention of throat infections, treatment of recurrent sore throat, and prevention of childhood illnesses among which include diarhoea, delayed growth, refusal of feeds etc, elongated uvula and prevention of suffocation in a child during pharyngitis .8, 10, 21-24
Traditional uvulectomy has been widely practiced in some cultures that it has acquired ethical approval among the people even with the continuous discouragement by orthodox medical practitioners 10. We tend to perceive uvulectomy and other traditional practices as useless, cruel and even medically dangerous. Yet such practices may have their benefits, even if they have deleterious complications; which may have kept these practices persistent.
The benefits or otherwise of traditional uvulectomy remains controversial. This study thus looks in to the perceived benefits of this procedure.
ANATOMY AND PHYSIOLOGY OF THE UVULA
The uvula is a fleshy part of soft palate that hangs down above the base of the tongue.
Although small sized and seemingly unimportant, it has remained an object of speculation as to its function throughout the ages8. It derived its name from the Latin word for ‘grape’. It develops from the extension of the membranous ossification of the palatine bones as a last step of fusion of the two halves of the soft palate as it zips up front to back 25. It consists of connective and glandular tissues with diffuse interdigitated muscle fibres, called muscularis uvulae.
The uvula plays a role in the production of uvula sound used by Arabic teachers, singers and criers 26. The soft palate together with the uvula has anatomic function of coordinating the movement of air and food in the pharynx 1, 10. Any congenital defect in structure or acquired tissue loss of the uvula affects respiration, deglutition, and speech. Nasal regurgitation of fluid and nasal speech may occur. These functional defects are encountered in bifid uvula and congenital defect of palate.
Partial uvulectomy does not prevent the production of uvula sounds or affect velopharyngeal status; it does affect its quality, while radical uvulectomy totally prevents uvula sounds production26, 27. Blood supply to the uvula is from the ascending pharyngeal artery while its nerve supply is from pharyngeal plexus. Lymphatic drainage is to the cervical groups of lymph nodes.
DISEASES OF THE UVULA
These include congenital defects in structure such as bifid uvula, multiple uvula, elongated uvula or complete absence. These can affect uvula speech. Acquired diseases include inflammation of remnant uvula following partial amputation of uvula from traditional uvulectomy. Allergy with associated quincke’s oedema could be life threatening. Inflammation of uvula from staph aureus, streptococcus infections or primary mycobacterial infection could cause massive enlargement and elongated uvula 8, 28-30. These can lead to respiratory obstruction or spread of infection to adjacent structures such as the tonsils, hypopharynx, and larynx; causing tonsillitis, pharyngitis, and laryngitis respectively. Other important diseases of the uvula include benign and malignant tumors 30.
INDICATIONS FOR TRADITIONAL UVULECTOMY
The indications for traditional uvulectomy vary from place to place and depend on the socio-cultural belief of the people. It includes elongated uvula, persistent sore throat, irritable cough, poor appetite, and prevention of throat problems. These throat problems include sore throat, throat swellings, elongated uvula, inability to swallow, and loss of voice8, 10, 22, 31. Some
African communities expect uvulectomy to improve general health of individuals, improve appetite, reduce airway infection and coughing; as well as being thirst quenching8,32. Other expectations include cure for diarrhea disease, vomiting, malaise, and loss of weight8, 10, 33 .
Uvulectomy could be a ritual custom8, 10, 33.
SURGICAL PROCEDURE OF TRADITIONAL UVULECTOMY
Some traditional surgeons offer prayers before commencement of surgery. No anesthesia is used for the procedure. The patient is reassured. His hands are held behind him and the head is supported by an assistant 8, 10,22,34,35. With the patient seated on a long chair and the Surgeon sitting opposite him or her; he or she is asked to open his or her mouth as wide as possible. A wooden tongue depressor is used to depress the tongue while at the same time lifting up the uvula. Thus the tongue depressor acts as a platform on which the uvula is cut with a sickle knife
10,22,34,35. Often, the operation performed is partial uvulectomy.
Post operatively, haemostasis is maintained by application of herbal extracts 8, 22, 34-36.
Some of these are made from cassava leaves; others use gin as gargle believing it to be a haemostatic agent1. Lukewarm water containing aluminum hydroxide has also been used 35
COMPLICATIONS OF TRADITIONAL UVULECTOMY
Various complications have been reported as a result of this procedure. These complications include primary and secondary hemorrhage, hypovolemic shock, severe anemia, cellulitis, peritonsilar abscess, parapharyngeal abscess, inadvertent laceration of the tongue and floor of the mouth, trismus, acute otalgia and tetanus. Nasal speech and nasal regurgitations are late complications. Others include hepatitis, and HIV infections from unsterilised instruments 8,37-40
JUSTIFICATION OF STUDY
This study could explain why the practice of traditional uvulectomy is yet to be abolished in our society. It will assist in weighing the perceived benefits of the procedure to the deleterious complications that could arise from it which may change the people attitudes to this practice.
LIMITATION OF STUDY
1 Subjects may not give accurate and correct information because the procedure may have
been done when they were infants.
2 Women in purdah could not be interviewed or examined due to cultural and religious
reasons.
CHAPTER 2
LITERATURE REVIEW
Traditional uvulectomy is said to be rare in Western otorhinolaryngological practice, though about a hundred and twenty years ago it used to be common in the West 10, 22 At present uvulectomy is an established procedure for treatment of simple snoring and mild obstructive sleep apnoea in developed countries11-15. Otolaryngologists also perform uvulectomy in the treatment of post nasal drip and persistent cough. 17,18
Traditional uvulectomy is a common traditional practice in Nigeria and other African countries. In fact, it was reported to be the most prevalent traditional practice in Ethiopia10,41
In Nigeria it is called “belubelu”, in Morocco it is called “rahrak”, while in East Africa it is called “kilimi”, “Kiswahili”, “kimeo” or “kimela”10.
Traditional uvulectomists are usually barbers by profession. Others could be Arabic teachers or petty traders 8,10,22,42. The practice is known to be common in coastal Tanzania and
Sierra-Leone. Similar findings were described in Nairobi10. It is also performed in other African countries like Ethiopia, Tanzania, Kenya, Sudan, Chad, Sinai desert and Nadir areas of Morocco
8,10,34. The areas of this practice do largely coincide with distribution of Islam 21, 41,42, although it has little to do with Islam 25. It was noted that educational status and religion do have significant influence in the practice of traditional uvulectomy in Ethiopia 41.Other studies noted that people patronizing traditional healers do so irrespective of educational status 43. A study done in Tanzania shows it is not related to sex or religion34.
The age at which uvulectomy is performed vary from population to population. Reports show that uvulectomy is performed more commonly in young children; between 1-8 years 31,34,42.
This procedure is carried out at an earlier age among Muslims than non-Muslims in Cameroon 42.
One study in Nigeria reported that uvulectomy is usually done between the age of 21 and 30 years with female preponderance 22.
The prevalence of traditional uvulectomy also varies from community to community.
Studies done in West Ethiopia and Tanzania revealed a prevalence rate of 75 and 73.3% respectively 31,34. In Nigeria, 98% of paediatric admissions among the Hausa and Fulani have been recorded as uvulectomized 34.
Indications for traditional uvulectomy vary. It is commonly indicated for prevention of throat problems. Elongated uvula is believed to be the precursor of all throat problems and it is a chief indication in this part of the world 8, 10, 23, 44.
About 60% of traditional surgeons advocate early removal of the uvula in neonates as a preventive measure against throat infection and chronic cough in later life 10. Traditional uvulectomy is indicated for prevention of childhood illnesses such as vomiting, diarrhea, measles and fever 8,45.
In Tanzania, about 98% of a study population of children were said to have had uvulectomy done for vomiting in contrast to other reports that identify respiratory tract infection and cough as chief indication for the operation 10,22,34. Traditional uvulectomy is sometimes performed as a ritual among the people of South Sinai and among East Africans, and it accounts for 1.5% of indications for traditional uvulectomy 10,33.
Irritating cough was the commonest indication in East Africa (32.7%) and pain in the throat was also common (19.1%) 10. In Nigeria, Ijaduola reported in his study that all subjects gave long uvula, persistent sore throat and irritating cough as indications, while loss of voice and prevention of throat problems in neonates was given as indications by 60% of the subjects10.
Uvulectomy has been performed for a child with diarrhea 8,46. Other indications include traditional beliefs such as the Chadians who believe that uvulectomy helps neonates to swallow well 8. In Morocco, it is believed that it will facilitate breast-feeding, speech and ensure better health throughout life8 . Batajira women in Ethiopia believe that uvulectomy prevents suffocation in children with pharyngitis36. Curative indications include dysphagia, abdominal pain, headache, weakness and insomnia 8.
The outcome of this procedure varies. In a study done in Nigeria, 17.2% of 61 children admitted with complication of uvulectomy died 8. In general, the uvula tends to heal quickly, rarely becomes infected, but studies have shown that severe hemorrhage, as well as local and general infection may result, especially in the absence of precautions38.
Hemorrhage and speech defect were reported as common complications in Ibadan38.
Septicemia, cervical cellulitis, peritonsilar and parapharyngeal abscess are some of the complication that can arise 38.In another study in Nigeria, hemorrhage accounted for 55.9%, acute otitis media 23.5%, palatal damage 13.3%, acute epiglotittis 5.5% and tetanus 1.5% of complications following traditional uvulectomy22. Aspiration of blood and lung infection post-traditional uvulectomy has been described 10.
From a study done in Dar es salam Tanzania, it was noted that three patients who had traditional uvulectomy developed insufficiency of the soft palate and rhinolalia operta which was attributed to absence of uvula and stiffness of soft palate after the procedure34. Another important set back following traditional uvulectomy is those carried out as treatment for conditions such as pulmonary tuberculosis, chronic tonsillitis, nasopharyngeal cancer and malignant lymphoma, some other potentially life threatening conditions, may lead to delay in obtaining appropriate treatment; resulting in late presentation. 10, 22,47.
A cluster survey done in Adamawa Nigeria noted that uvulectomy has a significant association with death from neonatal tetanus 48. A child was also reported to have died after been subjected to uvulectomy for diarrhea46. The death of the child was most likely due to delay in treatment of the diarrhea while parents were busy subjecting the child to uvulectomy 46.
Cases of mutilation of the uvula were reported among Bedouins of South Sinai 33.
With the continuous practice of this procedure in our environment disregarding the complications that could arise from it, especially transmission of HIV/AIDS and the fact that traditional uvulectomy has acquired social approval by those who practice it due to the perceived benefits derived from the procedure. It is imperative to scientifically evaluate the benefits of traditional uvulectomy. This will serve as basis of striking a balance between traditional and modern medicine; and bring out ways of preventing complications that could arise from the practice. The information obtained could be disseminated through health education and re-shape the practice.
CHAPTER 3
OBJECTIVES OF STUDY
GENERAL OBJECTIVE
1. To evaluate the perceived benefits of traditional uvulectomy among a cohort population
in Ilorin.
SPECIFIC OBJECTIVES
1. To determine the common indications for traditional uvulectomy among the study
population.
2. To assess whether the practice reduces the incidence of throat infections.
3. To assess whether traditional uvulectomy prevent childhood illnesses.
4. To determine the complications of traditional uvulectomy among the study
population.
CHAPTER 4
MATERIALS AND METHODS
STUDY AREA
Ilorin, the Capital city of Kwara State, is located in the middle belt region of Nigeria.
Because of its location, it is described as a link between the northern and the southern parts of the nation. Ilorin consist of three local government areas; Ilorin East, Ilorin West and Ilorin
South. Each local government area has about 11 wards. The total estimated population is about 735, 47849.
Sango area (Ilorin East), located along Jebba road, is the northern exit of the town. It has a population of about eleven thousand inhabitants49. The houses are located on both sides of the main road and they are arranged haphazardly. Most of the residents are Hausa, with little formal education. The major occupation is trading. Islam is the predominant religion.
Sango was chosen as the study area because of its high concentration of traditional uvulectomists, this will ensure an easy assess to the target population and Ooja gboroo area was chosen as the control area because of its tribal, religion and socioeconomic similarities with the control area and it is located within the Ilorin metropolis and closer to the teaching hospital.
SUBJECT SELECTION
Subjects that satisfy the inclusion criteria will be selected for the study.
The inclusion criteria:
1. All consenting adults aged 16-50years: children below the age of 15years may not be
able to give consent and elderly subjects may not have good memory of events.
2. Subjects must have had uvulectomy done before the age of 16 years.
Exclusion criteria:
1. Subjects who had uvulectomy done after 16years of age.
2. Subjects who are below 15years.
3. Subjects who do not consent to the study.
4. Women in purdah.
SAMPLE SIZE DETERMINATION
Sample size will be determined using Fisher’s formula
N = Z2PQ D2 N = the desired sample size (when population is more than 10,000).
Z = the standard normal deviate usually set at 1.96
P = prevalence=50%=0.50
Q =1-P=0.50 D = degree of desired accuracy, usually set at 0.05
N = 1.96x1.96x0.50x0.50 =384 (0.05)2
Sample size of 376 was used for the study population and 344 for the control.
SAMPLING TECHNIQUE
The houses in Sango community were already numbered in preparation for the 2006 National
Population Census. Every consenting adult in each household that met the inclusion criteria were recruited. Verbal informed consent was obtained. They were assured of confidentiality. Subjects were told they could withdraw from the study at any stage without any penalty.
DATA COLLECTION
A pre-tested structured questionnaire containing sociodemographic data, indications, complications, age at uvulectomy, occurrence of childhood illness and attitude to uvulectomy was administered by me with an interpreter who is fluent in Hausa language. Examination of the ear, nose and throat was done by me with use of battery powered head light and disposable tongue depressor to confirm the presence or absence of uvula. This was done under adequate privacy in the homes of recruited subjects.
DATA ANALYSIS
Data analysis was done using computer software programme: EPI info version 6. Frequency tables were generated and relationship between categorical variables was assessed using chi-square test. P-value ≤ 0.05 was taken as statistically significant.
CHAPTER 5
RESULTS
The sample size for the study population was 376.There were 235 males and 141 females with a male: female ratio of 1.6:1. The age range was 16-50 years, with a mean age of 30.14 years (±SD
10.57). The control group sample size was 344 with 227 males and 117 females, with a male: female ratio of 1.9:1. Their age range was 16-50years with mean age of 30.62 years (±SD 10.76).
The majority of respondents were Moslems: 89.6% for subjects and 87.7% for the controls. About 10.3% and 16.3% of the study and control populations respectively were
Christians. Hausa/Fulani was the major tribe of the subjects and control 240 (63.8%), and
210(61.1%) respectively.
The study and the control groups have some form of education, 41.6% of the subjects have primary education and 9% have tertiary education. About 48.8% of the controls have primary education and 11.9% had tertiary education. Trading is the major occupation of the subjects and the control groups, about 55.5% and 43.3% respectively are traders.
The major indications for uvulectomy were prevention of sore throat, treatment of sore throat and prevention of childhood illnesses accounting for 29.8%, 21.7% and 21.4% respectively.
Sore throat was the major complication of traditional uvulectomy accounting for 9% of stated complications. It is not clear if this was a complication of the procedure or a continuation of the pre-operative indication for traditional uvulectomy. Childhood illnesses appear to be present in both groups without significant difference with or without uvulectomy.
There is no significant difference in frequency of occurrence of sore throat among the two study groups.
Table 1
Age distribution of subjects and controls
Age No of Subjects (%) Control (%) 16-20 78(20.7) 70(20.3)
20-24 79(21.0) 80(23.2)
25-29 51(13.7) 48(13.9)
30-34 27(7.1) 25(7.3)
35-39 45(12) 42(12.2)
40-44 29(7.7) 22(6.4)
45-49 36 (9.6) 29 (8.4)
50-54 31 (8.2) 28 (8.1)
Total 376(100) 344(100)
F statistics=0.48
P-value = 0.463627
Of the 376 subjects78 (20.7%) were aged 16-19 years; 79(21.0%) were aged 20-24years;
51(13.7%) 25-29 years; 27(7.1%) 30-34 years; 45(12%) 35-39years; 29(7.7%) 40-44years;
36(9.6%); and 31(8.2%) 50-54years. The mean age was 30.14 ± 10.62. Of the344 controls,
70(20.3%) were aged 16-19 years; 80(23.2%) were aged 20-24years; 48 (13.9%) 25-29 years; 25
(7.3%) 30-34 years; 42 (12.2%) 35-39years; 22 (6.4%) 40-44years; 29 (8.4%) 45-49years; and
28 (8.1%) 50-54years. The mean age was 30.62 ± 10.83. Thus the subjects were similar in age distribution.
Table II
Gender distribution of subjects and controls
Sex No of subjects (%) Control (%) Male 235(62.5) 227(65.9) 227(65.9)
Female 141(37.5) 117(34.1)
Total 376(100) 344(100)
Chi- Square = 0.95
Degree of freedom = 1
P-value = 0.329530
The subjects consist of 235(62.5%) males and 114(37.5%) females, giving a male: female ratio of 1.6:1. The controls consist of 227(65.9%) males and 117(34.1%) females, giving a male: female ratio of 1.9:1. Thus the populations were similar in sex distribution.
Table III
Tribe distribution of subjects and controls
Tribe No of Subjects (%) Control (%) Hausa 240(63.8) 210(61.1)
Yoruba 136(36.2) 134(38.9)
Total 376(100) 344(100)
Chi-square = 0.59
Degree of freedom =1
P-value = 0.440967
Thus the populations were similar in tribe’s distribution.
Table IV
Religion distribution of subjects and controls
Religion No of Subjects (%) Control (%) Islam 337(89.6) 228(87.7)
Christianity 39(10.3) 56(16.3)
Total 376(100) 344(100)
Chi- square = 5.4
Degree of freedom =1
P-value = 0.019320
The populations were similar in their religions distribution.
Table V
Level of education of subjects and controls
Level of education No of subjects (%) Control (%) Primary 156(41.6) 168(48.8)
Secondary 109(28.9) 75(21.8)
Tertiary 34(9.0) 41(11.9)
Nil 77(20.4) 60(17.5)
Total 376(100) 344(100)
Chi- square =8.08
Degree of freedom =3
P-value = 0.044315
Majority, 156(41.6%), of the study population had only primary education; with higher number having no form of education77 (20.4%) compared with control group who had more people having tertiary education.
Table VI
Occupational distribution of Subjects and Controls
Occupation No of Subjects % Control%
Trading 208 (55.5) 149(43.3)
Fulltime house wife 18 (4.8) 24(7.0)
Artisan 55 (14.6) 68(19.8)
Driver 25(6.6) 10 (2.9)
Civil servant 16(4.2) 29(8.4)
Farmer 9(2.4) 12(3.5 )
Student 45 (11.9) 52(15.1)
Total 376(100) 344(100)
Chi- square =27.01
Degree of freedom =5
P-value =0.000057
Table V11
Reasons for uvulectomy n= 376
Reason for uvulectomy Frequency (%)
Prevention of sore throat 242(29.8)
Treatment of sore throat 176(21.7)
Prevention of childhood illness 174(21.4)
Elongated uvula 104(12.8)
Diarrhea 72(8.9)
Persistence cough 19(2.3)
Tradition 14 (1.7)
Vomiting 6(0.7)
Hoarseness/loss of voice 2(0.2)
Prevention of early death 2(0.2)
Note: some subjects gave more than one reasons
The frequent indications for traditional uvulectomy in our study population were prevention of sore throat, 242(29.8), treatment of sore throat176 (21.7) and prevention of childhood illnesses
174(21.4).
Table V111
Age at uvulectomy
Age at uvulectomy No subjects (%) Less than 1 year 235(62.5)
1-9years 46(12.2)
10-15years 95(25.3)
Total 376(100)
Almost two thirds, 235(62.5%), of the study population had traditional uvulectomy done at infancy, especially on the 8th day after birth.
Table 1X
Comparison of frequency of throat problems in post uvulectomy with control
Frequency of sore throat No of Subjects (%) control (%) 1-2 episodes/year 30(7.9) 31(9.0)
2-3 episodes /year 5(1.3) 3(0.9)
3-4 episodes //year 1 (0.2) 2(0.6)
Nil episodes 340(90.4) 308(89.5)
Total 376(100) 344(100)
Chi- square = 1.01
Degree of freedom =3
P-value = 0.798894
The difference of frequency of occurrence of sore throat among the populations is statistically insignificant.
Table X
Satisfaction with outcome of uvulectomy
Satisfaction post uvulectomy No of subjects (%) Satisfied 327(87.0)
Not satisfied 49(13.0)
Total 376(100)
About 87.0% of those that had uvulectomy done expressed subjective satisfaction with the outcome in regard to what it was indicated for, only 13% were not satisfied.
Table X1
Satisfaction post uvulectomy with level of education n=376
Level of education No of subjects satisfied No of subjects Not satisfied No formal education 230(61.2) 2(0.5)
Primary 75(20.0) 11(2.9)
Secondary 17(4.5) 8(2.1)
Tertiary 5 (1.3) 28(7.4)
Total 327(87.0) 49(13.0)
Chi- square =188.3
Degree of freedom =3
P-value = 0.000001
Majority of those with no formal education were actually satisfied with outcome even with the fact that the subjective benefits were not justified as claimed.
Table X11
Satisfaction post uvulectomy with Age at uvulectomy
Age at Uvulectomy No of subjects satisfied No of subjects not satisfied Less than 1 year 242(64.3) 10(2.7)
1-9 years 67 (17.8) 7(1.8)
10-15 years 18 (4.8) 32(8.5)
Total 327(87.0) 49(13.0)
Chi- square =133.70
Degree of freedom =2
P-value = 0.00000
Those that had uvulectomy done at an older age are less satisfied with the outcome, this could be due to the fact that they are better matured and more exposed
Table X111
Complications of uvulectomy
Complications No of subjects (%)
Sore throat 34(9.0)
Bleeding 26(6.9)
Ear ache 5(1.3)
Neck swelling 2(0.5)
Nil 138(36.7)
Don’t know 171(45.5)
Total 376(100)
Sore throat was the commonest complication complained by the respondents, 34(9.0%) which could be due to untreated throat infection or post uvulectomy infection.
Table X1V
Comparison of occurrence of childhood illnesses in subjects and controls
Occurrence of childhood illness No of subjects% Controls
Fever 105(27.9) 102(29.7)
Persistent cough 6(1.6) 6(1.7)
Vomiting 11(2.9) 2(0.6)
Convulsion 4(1.1) 7(2.0)
Diarrhea 32(8.5) 18(5.2)
Nil 218(58.0) 192(55.8)
Total 376(100) 344(100)
Chi square =9.29
Degree of freedom =5
P value =0.098006
Traditional uvulectomy is believed to reduce childhood illnesses as in this study population such as diarrhea disease, vomiting, persistent cough, convulsion, and other related disease.
Findings in this study compared with the control group shows that there is no significant difference in occurrence of childhood illnesses among the two groups Table XV
Attitude to uvulectomy among Subjects and Controls
Attitude Subjects Controls
Good practice 327(86.9) 208(60.4)
Bad practice 38(3.3) 119(34.6)
Don’t know 11 (2.9) 17(4.9)
Total 376(100) 344(100)
Chi- square = 68.26
Degree of freedom =2
P-value = 0.00000
Majority of subjects (86.9%) and controls (60.4%) claim that uvulectomy is a good practice that should be continued. On the other hand only 3.3% of the subjects want the practice to be discouraged compared with 34.6% of control. While there is some similarity in terms of acceptance which could be ascribed to the similarity in culture, religion and believe of the two groups, the differences is still statistically significant.
Table XVI
Oropharyngeal Examination finding
Finding No of Subjects(%) Control(%) Uvula
Present &Normal 0(0) 344(100)
Partially amputated 2 (0.50) 0(0)
Completely amputated 374(99.4) 0(0)
Cleft palate 0 (0) 0(0)
Soft palate
Normal mobility 374(99.4) 343(99.7)
Reduced mobility 2 (0.5) 1(0.3)
Posterior pharyngeal wall
Appeared normal 364(96.8) 339(98.5)
Granular 7 (1.9) 4(1.2)
Enlarged pharyngeal bands 2 (0.5) 0(0)
Hyperemic 3(0.8) 1(0.3)
CHAPTER 7
DISCUSSION
The number of subjects for the study was 376, 235(62.5%) males and 141(37.5%) females with a male: female ratio of 1.6:1. The control population was 344; 227(65.9%) males and 117(34.1%) females with a male: female ratio of 1.9:1.The age distribution of both the subjects and controls are similar.
The major tribe in Sango area is Hausa, and this was reflected in the tribe distribution among the study group where Hausa/Fulani were majority 63.8% compared to 36.2% that are
Yoruba. This could be because Sango is located along the northern exit of the town and has a large settlement of Hausa/Fulani’s. The control population is mainly Hausa (61.1%), though majority speaks Yoruba language probably because they were old time settlement of
Hausa/Fulani who have virtually become Yoruba’s due to mixture of Ilorin indigenes and non-indigenes that are resident in this area.
Islam is the major religion in Ilorin as reflected in both the study and control populations.
This is similar to the findings of other studies that noted traditional uvulectomy to be commoner among the Muslims than the non-Muslims 25,42.
Males appear to be predominant among the study and the control groups. The male preponderance among the subjects may be due to the practice of purdah among them. The
Hausa/Fulani culture and religion does not permit free contact or interaction with male strangers.
This is probably the reason why there was male preponderance among those that had uvulectomy done, compared to the study by Ijaduola where female preponderance was noted 22.
A large percentage (79%) of the subjects had a form of education 41.6% had primary education, 9% tertiary education and 20.4% have no formal education. Among the controls 82.5% have formal education with 48.8% primary, 11.9% being tertiary education and only
17.4% has no formal education. The difference in level of education between the two groups probably shows why traditional uvulectomy is more acceptable among the study group. This is consistent with the findings of a study in Ethiopia where it was noted that education reduces the practice of traditional uvulectomy 41.
Majority of subjects (86.9%) claim that uvulectomy is a good practice and should be continued while 34.6% of control said it is a bad practice and should be discouraged. This difference is statistically significant; the control group is better educated, closer to the university teaching hospital with access to modern health care because of its location. This observation is similar to the findings of Alene and Edris 41 that the higher the educational status the attitude to decrease traditional uvulectomy increases, while it is at variance with the findings of Bimal etal
31 noting that the head of the family is more likely to be literate in uvulectomy group than in non uvulectomy group. The latter study was hospital based, and this could contribute to this difference.
The subjects almost have a universal approval of traditional uvulectomy with 86.9% claiming it is a good practice and were satisfied with the procedure. This is expected because of the high concentration of traditional uvulectomists; which is likely to engender a high level of approval and advocacy from habit and established tradition. Any attempt to discredit the practice among them would be fiercely resisted. Such communities are suspicious of outside suggestions and influence. The way to change their attitude to this practice is to concentrate efforts on the leaders of the community and organize community education forum. Then the ills of the practice can be outlined with the intention, not only to stop it, but we introduce heavily subsidized alternative treatment for throat diseases such as antibiotics, throat lozenges, and gargles. When the benefits of the new methods are seen and enjoyed, they will willingly begin to withdraw from traditional uvulectomy. Initially efforts should be concentrated on key leaders in the community who are likely to be open to change.
INDICATIONS FOR TRADITIONAL UVULECTOMY
Prevention of sore throat and other disorders associated with the throat, and prevention of childhood illnesses in general are the major indications for traditional uvulectomy in this study.
This is a similar finding of the study done by Ijaduola 22 and JJ Manni34.This was different from the finding of Einterz etal, where prevention or treatment of vomiting in children was the primary indication 42. This preventive initiative merges into tradition, although only very few of them admit the practice is merely a ritual custom.
Treatment of sore throat is an important indication for uvulectomy. Elongated uvula causing choking symptoms is given as an indication by more than a quarter of the subjects. One wonders the criteria used for assessing the normal length of the uvula.
An interesting indication given by almost 20% was diarrhoea. The link between diarrhoea and uvulectomy is far fetched. But studies indicate it is an important indication8,46.
AGE AT UVULECTOMY Majority (64.3%) of the subjects had uvulectomy done at the age of one year or less, especially on the 8th day after birth. This gives the impression that tradition is probably an important consideration for this practice. Also it reinforces the fact that a large volume of traditional uvulectomy is done as preventive measure. This is a similar finding to other studies done by Bimal31, JJ Manni34,Einterz42 and Ijaduola44.
COMPLICATIONS OF TRADITIONAL UVULECTOMY
Majority of the subjects denied history of complications from the procedure
(36.7%). Sore throat with associated difficulty in swallowing was the commonest. It is not clear if this is a continuation of the initial indication for traditional uvulectomy or a complication of the procedure. Bleeding was generally minimal and insignificant, without need for hospital visit. This is at variance with the studies by Adekeye etal35, Ibekwe38 and Ijaduola47 where bleeding was reported to be severe. Sore throat could be an immediate postoperative pain or it could be due to throat infection. This standpoint is a great disadvantage to efforts at abolishing the practice. The population sees the practice as essentially harmless. The few complications reported could be rationalized on the grounds that even orthodox medical treatment is not devoid of complications. What is required is a proper prospective study of patients undergoing traditional uvulectomy. Immediate objective assessments of the associated complications can be done, rather than relying on subjective recollections of events of a procedure done several years before. The technical problem of this proposal however is traditional surgeons feel reluctant to expose their work to the scrutiny of orthodox practice. They may be afraid that it is a ploy intended to apprehend and prosecute them.
Although 36.7% gave no history of complication from the procedure, this figure may not be reliable. Most of the subjects had uvulectomy in infancy or shortly afterwards. They were probably unaware of the procedure and its sequelae. The parents were not always around to verify the history given. Infact some subjects who claimed to have had uvulectomy were discovered to have normal uvula and were excluded from the study, about 45.5% could not remember the event. Also, it must be clearly stated that this study was conducted among the survivors of traditional uvulectomy. So it may not be surprising that stated complications appear mild. Cases of mortality, probably due to more significant complications, were not included.
CHILDHOOD ILLNESS AND UVULECTOMY
Traditional uvulectomy is believed to reduce the incidence of childhood illnesses such as diarrhea, vomiting, cough, throat problems, convulsion, measles and other related diseases. This is an important attraction that encourages patronage of traditional uvulectomy.
Infant and childhood morbidity and mortality is high among the low socioeconomic class, to which our study population belongs. The parents may have lost a few children already. Any thing that holds promise of prevention of further childhood mortality is easily embraced. Also, because of poverty, parents cannot afford orthodox treatment for common childhood illnesses.
Thus a cheap alternative is attractive.
There was no evidence that the incidence of childhood illnesses were better in the subjects than controls. In fact while 58% of the subjects claimed to be relatively free of childhood illnesses, 55.8% of the controls made such a claim. Rather than reducing the incidence of childhood illnesses, Bimal etal31 noted a casual relationship between sickness and uvulectomy among infants.
PERCIEVED BENEFITS OF UVULECTOMY
The frequency of throat infection post uvulectomy among the subjects was 7.9% compared with 9% among the controls. This probably dismissed the believe that uvulectomy reduces the incidence of throat infection.
It is quite surprising to note that 87.5% of the subjects claimed to have been satisfied with the outcome of traditional uvulectomy in regard to the reason for which it was done. Only 13.0% claimed not to be satisfied, this is an overwhelming majority even with the fact that there was no evidence that it prevent occurrence of childhood illnesses or does it reduces frequency of throat infection. It is difficult to change a behavior pattern people genuinely belief they derive appreciable benefit from. It takes a better, cheaper and more attractive alternative, introduced in a wise and systematic fashion to break their faith in the current practice of traditional uvulectomy.
OROPHARYNGEAL EXAMINATION FINDING
More than 376 subjects who actually participated in the study claimed to have had traditional uvulectomy done. It was however noted that only 376 subjects had their uvula removed. This is likely due to the fact that early uvulectomy being prevalent in this community gave some of the subjects a feeling and belief that it must have been removed while they were infants. Manni in Tanzania34 and Einterz in northern Cameroon42 have made similar observations. The fact that there were a few cases of partially amputated uvula among the subjects raises the possibility that some who claimed to have had uvulectomy and were found with apparently normal uvula may have actually been submitted for traditional uvulectomy with less than satisfactory excision, these subjects were excluded from the study.
CHAPTER 8
CONCLUSION
Traditional uvulectomy is being practiced in Sango area of Ilorin. It is commoner among males and the major indications in this area for traditional uvulectomy are prevention of sore throat, prevention of childhood illnesses, treatment of sore throat and elongated uvula.
Complications among the survivors of this appear rare; sore throat and minimal bleeding being the commonest reported complications.
It was also noted that traditional uvulectomy does not reduce occurrence of childhood illnesses or prevent it nor does it reduce the frequency of occurrence of throat infection.
This community has strong confidence in the practice and gives it a high approval rating.
The study made it clear that traditional uvulectomy is not a valid treatment or prophylaxis for throat infection or childhood illness and should therefore be strongly discouraged.
RECOMENDATIONS
Health education to the grass roots will improve awareness on the wrong belief of the people in regards to traditional uvulectomy and improve their knowledge on other sinister conditions that could present the same way as throat infection requiring modern medical attention; this will prevent late presentations of advance throat diseases.
This process needs to be gradual, seeking the cooperation of community leaders, to win over the traditional uvuvlectomists in an atmosphere of mutual trust and understanding rather than outright condemnation.
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