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Prevalence and pattern of traditional medical therapy utilisation in Kumasi Metropolis and Sekyere South District, Ghana

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Research Paper Prevalence and pattern of traditional medical therapy utilisation in Kumasi metropolis and Sekyere south district, Ghana

Razak Mohammed Gyasi n, Lawrencia Pokuah Siaw, Charlotte Monica Mensah

Department of Geography and Rural Development, Faculty of Social Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana article info abstract

Article history: Ethnopharmacological relevance: Whilst over three-quarters of the world's population continues to use Received 26 August 2014 traditional medicine (TRM) with an increasing trend globally, limited data exist in the Ashanti Region Received in revised form regarding TRM utilisation. This study espoused a retrospective cross-sectional quantitative approach to 30 November 2014 examine the prevalence and pattern of TRM use among the general population in the Kumasi Metropolis Accepted 1 December 2014 and Sekyere South District, Ghana. Available online 15 December 2014 Materials and methods: A sample of 324, drawn through systematic random sampling was used. The Keywords: main instrument for data collection was formal face-to-face interviewer-administered questionnaire. Biologically-based therapy Data were analysed using Chi-square and Fisher’s exact tests from the PASW (V.17.0) with pr0.05 as Ghana significant. Indigenous knowledge Results: The survey found that TRM use alongside conventional medicines was pervasive with prevalence Materia medica Therapeutic pluralism of 86.1%. Biologically-based therapies (88.5%) and distant prayer interventions (58.4%) were commonly Traditional medicine used modalities through the influence of families (50.3%), friends (19.4%) and the mass media (18.0%). Whilst self-administration and purchases from pharmacy shops remained important sources of TRM, TMPs' consultation was less credible (po0.005). The disclosure rate of TRM use to health care professionals remained low (12.2%; po0.001). Conclusion: Concomitant TRM use with conventional therapies without disclosure may interfere with the potency of treatment regimen and result in drug interactions. Inclusion of alternative medicines on the National Health Insurance Scheme’s drug plan will fortify monitoring and professional administration of TRM. Information as regards TRM use needs to be incorporated into clinical and medical practice, hence the need to prioritise patient-physician communication. & 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction desired effects for the diagnosis, prevention or elimination of imbal- ances in physical, psychological and social wellbeing (Gyasi et al., The use of traditional medicine (TRM) in the diagnoses, prevention 2011). These partly elucidate the current unprecedented increase in and treatment of a plethora of diseases is pre-historic and dates back TRM utilisation the world over. Moreover, the lingering course of into antiquity. Virtually every culture globally has relied on it to treat perpetual anguish of diseases and threatening death associated with it and prevent one ill-health or another. Plants, animal products and and the dissatisfaction of conventional medical care have called for the mineral substances have been a source of medicinal agents for upsurge trend in TRM use. thousands of years and still continue to be an abundant source of Evidence from studies carried out globally has established novel therapeutic agent (Sen et al., 2011; Pan et al., 2014). TRM is beyond reasonable doubt that TRM use is widespread and the characterised by a holistic approach to the spirit–mind–body concept prevalence varies widely among populations (Ezeome and of health, embracing people, living and inanimate objects in an Anarado, 2007; Oshikoya et al., 2008; Barnes and Bloom, 2008; inseparable whole from which all beings derive their living and World Health Organisation WHO, 2011; Gyasi et al., 2011, 2013, healing forces. TRM practice involves a multifaceted combination of 2014; Okoronkwo et al., 2014). In her introductory remarks of the activities, order of knowledge, beliefs and customs to generate the World Health Organisation (WHO) Traditional Medicine Strategy 2014–2023, the Director-General of WHO, Dr. Margaret Chan, reiterated that the use of TRM has expanded globally and has n Correspondence to: Department of Geography and Rural Development, Faculty gained popularity during the last decade. TRM is either the of Social Sciences, Private Mail Bag, University Post Office, Kwame Nkrumah mainstay of health care delivery or serves as a complement to it University of Science and Technology, Kumasi, Ghana. Mobile: þ233 20 854 5052. E-mail addresses: [email protected] (R.M. Gyasi), (WHO, 2013:7). The World Medicines Situation has reported [email protected] (L.P. Siaw), [email protected] (C.M. Mensah). unequivocally that between 70% and 95% of the population in http://dx.doi.org/10.1016/j.jep.2014.12.004 0378-8741/& 2014 Elsevier Ireland Ltd. All rights reserved. R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146 139 developing countries consume TRM and that every culture in the Whilst most patients access TRM concomitantly with the world thrives on certain TRM modality (WHO, 2011:3). In Africa, conventional therapies for specific ailments (Leonard et al., various studies found that up to 90% Ethiopians and Burundians, 2004; Kuan et al., 2011; Chang et al., 2011; Hughes et al., 2012; 85% South Africans, 75% Malians, 70% of people of Rwanda, Benin Yeon et al., 2014), limited proportion divulge TRM use to their and Ghana rely on TRM for their primary health care needs (UNDP, general health care professionals. In a study of traditional medi- 2007; WHO, 2011:5; Kasilo et al., 2013; Apt, 2013). cine use among HIV/AIDS patients in Kumasi Metropolis, Gyasi TRM use remains universal in countries where conventional et al. (2013), found that 93.9% of respondents did not disclose TRM medicine is predominant in the national health care system. In use to their orthodox medical providers. Egede et al. (2002) found Singapore and the Republic of Korea, the WHO (2013: 27) fewer than 40% of Americans with diabetes informing their estimates that about 76% and 86% of the respective populations physicians about CAM use. In Taiwan, Hsu et al., 2008 found that still commonly use TRM. Other national reports posit that almost 35.4% of depression patients had discussed CAM use with their every Chinese has ever used at least one form of TRM with more psychiatrists. Similar results were observed in South Africa (Babb than 90% prevalence. It is estimated that 68.9% of the adult et al., 2007; Peltzer et al., 2008), China (Ma et al., 2008), Uganda Australian population use various forms of traditional medical (Langlois-Klassen et al., 2007) and UK (Vickers et al., 2006). remedies (WHO, 2012a). Similar trends are also occurring in Although some reasons for non-disclosure of TRM use are cited economically advanced countries including Canada (65%) (Wiles as non-inquiry by the health care providers, previous experiences and Rosenberg, 2001; McFarland et al., 2002; Andrews and Boon, or fear of physicians' reactions (Vickers et al., 2006; Ezeome and 2005; Esmail, 2007) and USA where surveys found that almost 45% Anarado, 2007; Chang et al., 2007), limited discussion of these of American adults use some form of complementary and alter- reasons are offered. native medicine (CAM) (Bell et al., 2006; Bercovitz et al., 2011; Many Ghanaian studies on TRM use have focused on disease- WHO, 2011). In Europe, TRM use ranges from 42% of the popula- and population-specific dynamics (Kretchy et al., 2013; Gyasi et al., tion in Belgium to 90% in the United Kingdom (Metcalfe et al., 2013). A better understanding of the prevalence and the pattern of 2010; Kasilo et al., 2013). According to European Information TRM use among the general population have become critical Centre for Complementary and Alternative Medicine, over 100 following a global upsurge of TRM utilisation. Moreover, there is million Europeans are currently CAM users, with one fifth reg- chronic dearth of research into the extent of TRM use, sources and ularly using CAM and the same number preferring CAM-related forms of TRM and disclosure of TRM use to health care profes- health care. The most common complementary health approaches sionals in the Ashanti Region. The current population-based study, used among the Europeans include non-vitamin, non-mineral therefore investigated the prevalence, patterns of TRM use and dietary supplements, chiropractic or osteopathic manipulation, concomitant use of TRM with conventional treatment among adult yoga and massage therapy. Others are homoeopathy, phytother- population in Sekyere South District and Kumasi Metropolis of apy, herbal medicine, anthroposophic medicine, naturopathy, Ashanti Region, Ghana. traditional Chinese medicine, osteopathy and chiropractic inter- ventions (Barnes and Bloom, 2008). Despite the difficulty in accessing the market size for TRM partly 2. Methods due to the diversity of regulations and regulatory categories for products, available data suggest that the market for TRM is sub- 2.1. Study design and participants selection stantial. van Andel et al., 2012 found that there has been an increased international trade in herbal medicines; a significant world market This retrospective cross-sectional study employed quantitative worth an estimated $83 billion in 2008 (Van Andel and Havinga, approach to analyse the prevalence and patterns of TRM use in 2008; WHO, 2011). According to National Development and Reform Sekyere South and Kumasi Metropolis of Ashanti Region, Ghana, Commission of China (2013), the output of Chinese materia medica between March, 2013 and January, 2014. To reflect the vast was estimated to amount US$83.1 billion in 2012, an increase of differences in urbanity1, population characteristics, demographic more than 20% from the previous year. In the Republic of Korea, and socio-economic discrepancies, rural and urban settings were annual expenditures on TRM were US$4.4 billion in 2004, rising to included in the survey. Settlements that met the rural or urban US$7.4 billion in 2009 (WHO, 2012b). Out-of-pocket spending for criterion were enumerated and numbered: “yes” or “no”.A natural products in the United States was US$14.8 billion (Nahin, continuous probability selection without replacement was then 2009). TRM, therefore, reserves a great deal of economic importance. carried out until the 10 settlements labelled “yes” were obtained. However, loss of biodiversity, over-exploitation and unscientificuse For rural Sekyere South District, the study settlements selected of medicinal plants, industrialization, biopiracy, globalisation toge- were Akrofonso, Bedomase, Bepoase, Boanim and Domeabra ther with lack of regulation and infrastructure are the major impe- whilst Atonsu, Ayigya, Nhyiaeso, Old Tafo and Suame were diments to the growth of herbal medicine (Sen et al., 2011; selected from the Kumasi Metropolis (see Fig. 1). Community Vandebroek and Balick, 2012). members who had attained 18 years or older (who are capable A considerable proportion of TRM up-takers frequently consult of choosing treatment options) and had used TRM and the services traditional medical practitioners (TMPs) of different categories for of TMPs or not during the past 12 months were eligible to be various forms of medicinal products and therapies (Peltzer et al., recruited for the study. 2008). In a study of complementary and alternative medicines use in Given the overall population of the study area as 2,129,073 children with chronic health conditions, Oshikoya et al. (2008) (GSS, 2012), and the estimated proportion of this population that observed in Lagos, that nearly 85% of consumers of TRM in Nigeria depends on TRM for their primary health care, a representative consult TMPs for social and psychological needs partly because of sample size of 324 was drawn from the target population based on dissatisfaction with conventional medical care. In Ghana, TMPs are the Lwanga and Lemeshow's (1991) formula for sample size accorded the quintessence of psychosocial and spiritual wellbeing and estimation for health research: n ¼ ðÞZα 2 ½Ρð1ΡÞ =d2; where mostly are the first point of call for all forms of diseases (Mensah and Gyasi, 2012; WHO, 2013). Notwithstanding, majority of the TMPs have 1 The classification of localities into ‘urban’ and ‘rural’ was based on population not registered their practices and products by the Food and Drugs size. Localities with 5000 or more persons were classified as urban while localities Authority and the Traditional Medicine Council. Indeed, this raises with less than 5,000 persons were classified as rural (Ghana Statistical safetyandpublichealthconcernsinthepracticeofTRM. Service, 2012). 140 R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146

Fig. 1. Maps depicting the study prefecture. Source: Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi. n¼estimated required minimum sample size; Zα¼5% level of final section of the survey instrument looked at the reasons for significance which gives the percentile of normal distribution¼1.96; TRM use, pluralistic administration of TRM and conventional d¼level of precision or margin of error, estimated to be 0.05; and treatments and the decision to divulge TRM use to physicians p¼estimatedprevalenceofTRMuseintheAshantiRegion(70%) and other health care professionals. (Apt, 2013; Ghana Statistical Service [GSS], 2012). The sample was A reconnaissance survey was conducted to help test the validity distributed among study settlements based on their respective and reliability of research instruments and to inform any neces- population sizes so as to ensure full representation of the universe sary changes. Primary data were collected from the respondents by whipping down selection bias. Systematic random sampling was via formal face-to-face interviewer-administered questionnaires in employed to select houses from which households and respondents order to improve response and completion rates. Research assis- were drawn. tants were recruited and trained to assist in the data collection process using the same prepared visual aids to further enhance 2.2. Outcome measures and data collection processes comprehension of some questionnaire concepts. The first author monitored data collection processes during field interviews. Also, TRM use was the outcome variable operationalised as dummy the questionnaire was translated into Twi (the main dialect in the variable indicating use or no use of TRM within a 12-month period study area) and translated back into English so as to ensure preceding the survey. The survey instrument was divided into content validity. Each interview and/or completion of a question- three sections, viz, demographic and socio-economic data, pattern naire lasted an average time of 45 min. of TRM use and combined use of TRM and conventional therapies and disclosure decision. The baseline characteristics were col- Ethical consideration lected in relation to age, sex, educational status, household income level, religion, residence, marital status, employment status, work The study protocol was approved by the Committee on Human experience, household size, and health insurance status. In the Research Publication and Ethnics, School of Medical Sciences at second section, data were obtained about prevalence and fre- Kwame Nkrumah University of Science and Technology (KNUST) quency of TRM use, knowledge, forms and sources of TRM. The and Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146 141

Study participants were briefed on the objectives of the research to the survey (see Table 1). On a multiple response scale (see and their permission was sought before the fieldwork. Informed Table 2), about nine in ten of the respondents used herbal-based consent was also obtained from both household heads and products and therapies, 58.4% accessed prayer healing and a fourth individual respondents before data collection. Participation in reported use of divination and other spiritual therapeutic inter- the research was therefore voluntary and respondents were ventions. The frequency of use of TRM by participants is shown in assured of strict confidentiality of the responses they provided. Table 2. The majority (68.2%) utilised TRM for two or more times, about 17.9% noted use of traditional treatments once. The study 2.3. Statistical analysis again found that respondents were more likely to use TRM in shorter intervals for curative, rehabilitative and preventive pur- Data were verified and coded for analysis. The data were entered poses. This was statistically significant [χ2 (3, N¼324)¼0.000, into an electronic database and analysed statistically through the po0.001] from Pearson’s chi-square analysis performed. Predictive Analytics Software (PASW) for Windows application programme (version 17.0) and Microsoft Excel 2010. Bivariate 3.3. Knowledge and decision-making regarding TRM use techniques of analysing data were employed. Descriptive statistics were carried out to describe the background characteristics of the Out of the participants who reported use of TRM (n¼279), study sample, sources of knowledge and forms of TRM accessed and 69.7% accessed TRM because people around them had strong belief the prevalence and frequency of TRM use. A non-parametric in TMPs and their medical practices. The major sources of knowl- Pearson’schi-square(χ²)andFisher’s exact (FET) tests were edge and information about TRM were respondent's family performed to compare the demographic and socio-economic inde- (50.3%), friends (19.4%) and the media (18.0%). pendent variables, inter alia, sex of respondents, educational status, Books (3.7%) and health care professionals (4.3%) of various health insurance status, residential status, etc, and the TRM utilisa- categories (physicians, nurses and midwives) were rather less tion. These models were appropriate amongst others, given the important information sources of TRM (see Fig. 2). Regarding the categorical nature of the independent study variables. The inter- sources of TRM, it was reported that nearly 72% of the participants pretation of test results took into consideration the interaction term prepared and applied TRM themselves normally. Herbs and other of less or equal to 0.05 (pr0.05) as significant. Data were organised substances involved were obtained from backyards or neighbour- and presented by frequency tables and proportionate counts. A bar hoods and farms within and around the community. Other sources chart was also used to depict and present data. of TRM included pharmacy and chemical shops (57.4%), drug peddlers or open market (39.5%), consultation with TMP (29.6%) 3. Results and less importantly, health care facilities (6.8%).

3.1. Characteristics of the sample 3.4. Combined TRM use with conventional therapies and disclosure decision The background characteristics of the study participants are presented in Table 1. The majority of the respondents were Among the consumers of TRM who participated in this section females (59.9%), within the age bracket of 20–29 years (25.9%), of the survey (n¼278), approximately 31% (n¼86) reported married/cohabitated (62.0%), with a basic school educational practising pluralistic therapy; combining both TRM modalities status (47.5%). Most of the respondents were Christians (81.5%), and the conventional interventions in the treatment of specific employed (86.5%) in the informal sector (69.4%) with monthly diseases (see Table 3). Nevertheless, an overwhelming 87.8% income up to GH¢300 ($100)2 (70.6%), while 72% had a household reported non-disclosure of TRM use to their health care providers. size of up to 6 persons. Respondents offered reasons to substantiate the non-disclosure of A comparison was done between TRM users and non-users in TRM utilisation. Nearly 80% of respondents noted, health care relation to the household size. The results of the Fisher's exact test professional did not enquire any information as regards client’s revealed a statistically significant difference [df¼5; N¼324, TRM use. Other reasons included: some 51.3% deemed no impor- po0.001; FET] unlike other major characteristic variables that tance to disclose TRM use and 43.7% also feared the physician’s did not show statistically significant differences between respon- reactions based on previous bad experiences of disclosure of TRM dents who reported use and non-use of TRM including income [χ² utilisation (35.1%). (3, N¼324)¼2.889, p¼0.409], education [χ² (3, N¼324)¼3.021, p¼0.388], sex [χ² (1, N¼324)¼0.406, p¼0.524] and age [χ² (5, ¼ ¼ ¼ N 324) 3.653, p 0.600] of the respondents. 4. Discussion It was not surprising to find that more than 78% of the sample constituted Akans of various sects such as the Asantes, Fantes, The purpose of the current study was to determine the Bonos, Akuapems, Akyims and Kwahus since the study prefecture prevalence and pattern of TRM use among the general population is the home of Akan ethnic group. While the majority of the in Ashanti Region, Ghana. Contemporary documented evidence “ ” respondents perceived their health status as Good (44.4%), have suggests that TRM use is common among individuals and com- no chronic diseases (56.4%) and insured (71.6%), the differences munities. The lifetime prevalence of TRM use among the general between the TRM users and non-users were not statistically population varies from 16% to 95% according to different national fi 4 signi cant (p 0.05). and sub-national surveys (Kretchy et al., 2013; Gyasi et al., 2013; Faith et al., 2013; Demirci and Altunay, 2014; Awad and Al-Shaye, 3.2. Prevalence and pattern of TRM use 2014; Gyasi et al., 2014; Hwang et al., 2014). Our study found that more than six in seven of the participants Column totals by variables are presented for both TRM users had utilised various forms of TRM at least once for diagnosis, and non-users. Over 86% reported to have used various forms of treatment and management of specific medical and spiritual TRM or had sought services of TMPs over the last 12 months prior problems in a twelve-month period in retrospect. This trend supports results from various studies in Africa and elsewhere 2 The exchange rate between Ghana Cedis (GH¢) and United States Dollars ($) including the rate of 84.7% reported by Onyiapat et al. (2011) in as of the time of data analysis (March–June, 2014) Enugu, Nigeria, 83.7% in a Turkish gastroenterologic survey (Kav, 142 R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146

Table 1 Background characteristics of respondents by traditional medicines utilisation status.

Variables Total N (%) 324(100.0) Traditional medicine utilisation status p value

Users n (%) 279(100.0) Non-users n (%) 45(100.0)

Age o20 9 (2.8) 9 (3.2) 0 (.0) 0.600 20–29 84 (25.9) 74 (26.5) 10 (22.2) 30–39 77 (23.8) 65 (23.3) 12 (26.7) 40–49 59 (18.2) 48 (17.2) 11 (24.4) 50–59 46 (14.2) 39 (14.0) 7 (15.6) 60 and above 49 (15.1) 44 (15.8) 5 (11.1)

Sex Male 130 (40.1) 110 (39.4) 20 (44.4) 0.518a Female 194 (59.9) 169 (60.6) 25 (55.6)

Residential status Urban 162 (50.0) 138 (49.5) 24 (53.3) 0.630 Rural 162 (50.0) 141 (50.5) 21 (46.7)

Marital status Single/widow/divorced 123 (38.0) 106 (38.0) 17 (37.8) 0.978 Married/cohabitant 201 (62.0) 173 (62.0) 28 (62.2)

Educational Status Never-been-to-school 53 (16.4) 48 (17.2) 5 (11.1) 0.388a Basic education 154 (47.5) 135 (48.4) 19 (42.2) Secondary 79 (24.4) 64 (22.9) 15 (33.3) Tertiary 38 (11.7) 32 (11.5) 6 (13.3) Never-been-to-school 35 (15.0) 33 (16.1) 2 (7.1) 0.544 Basic Education 100 (42.9) 86 (42.0) 14 (50.0) Secondary 73 (31.3) 65 (31.7) 8 (28.6) Tertiary 25 (10.7) 21 (10.2) 4 (14.3)

Religious Background ATR 8 (2.5) 8 (2.9) 0 (.0) 0.218a Christianity 264 (81.5) 228 (81.7) 36 (80.0) Islamic 39 (12.0) 34 (12.2) 5 (11.1) Other 13 (4.0) 9 (3.2) 4 (8.9)

Employment status Employed 276 (86.5) 239 (86.6) 37 (86.0) 0.922 Unemployed 43 (13.5) 37 (13.4) 6 (14.0)

Nature of occupation Trading 112 (34.6) 92 (33.0) 20 (44.4) 0.178 Farming 52 (16.0) 43 (15.4) 9 (20.0) Government 43 (13.3) 41 (14.7) 2 (4.4) Artisan 61 (18.8) 56 (20.1) 5 (11.1) Schooling 13 (4.0) 10 (3.6) 3 (6.7) Others 43 (13.3) 37 (13.3) 6 (13.3)

Working experience 1–5 years 97 (34.2) 85 (34.6) 12 (31.6) 0.611 6–10 years 65 (22.9) 53 (21.5) 12 (31.6) 11–15 years 48 (16.9) 44 (17.9) 4 (10.5) 16–20 years 33 (11.6) 29 (11.8) 4 (10.5) 21 þyears 41 (14.4) 35 (14.2) 6 (15.8)

Tribe/ethnicity Akan 253 (78.1) 219 (78.5) 34 (75.6) 0.789a Ewe 17 (5.2) 14 (5.0) 3 (6.7) Ga-Dangme 19 (5.9) 17 (6.1) 2 (4.4) Mole-Dagbani 23 (7.1) 18 (6.5) 5 (11.1) Guan 7 (2.2) 6 (2.2) 1 (2.2) Gurma 5 (1.5) 5 (1.8) 0 (.0)

Household Size r3 persons 100 (30.9) 91 (32.6) 9 (20.0) o0.001*a 4–6 persons 135 (41.7) 119 (42.7) m (35.6) 7–10 persons 67 (20.7) 52 (18.6) 15 (33.3) 11–15 persons 12 (3.7) 10 (3.6) 2 (4.4) 16–19 persons 3 (.9) 0 (.0) 3 (6.7) 20 and above persons 7 (2.2) 7 (2.5) 0 (.0)

Household monthly income rGH¢100 76 (34.4) 64 (33.3) 12 (41.4) 0.409a GH¢101–GH¢300 80 (36.2) 68 (35.4) 12 (41.4) GH¢301–GH¢500 40 (18.1) 36(18.8) 4 (13.8) GH¢ 501–GH¢1000 25 (11.3) 24 (12.5) 1 (3.4)

Perceived health status Poor 17 (5.3) 3 (6.7) 14 (5.1) 0.416 Satisfactory 54 (16.8) 10 (22.2) 44 (15.9) Good 143 (44.4) 15 (33.3) 128 (46.2) Very good 108 (33.5) 17(37.8) 91 (32.9)

Chronic disease Yes 94 (29.9) 9 (20.5) 85 (31.5) 0.307 No 177 (56.4) 29 (65.9) 148 (54.8) Don't know 43 (13.7) 6 (13.6) 37 (13.7)

Insurance status Yes 232 (71.6) 34(75.6) 198 (71.0) 0.527 No 92 (28.4) 11 (24.4) 81 (29.0)

n The Chi-square statistic is significant at the 0.05 level. a Results are based on Fisher's exact test R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146 143

2009) and the 80% score observed in Morocco (Eddouks et al., The study however found a relatively higher prevalence of TRM 2002). Before the arrival of modern medicine, TRM was the use than 62% score reported in South Korea (Hwang et al., 2014), dominant medical system accessible not only to the indigenous 51.3% among HIV patients in South Africa (Peltzer et al., 2008) and people of Ghana but across Africa and other developing regions. In 31% in Finland (Hameen-Anttila et al., 2011). These discrepancies Ghana, TMPs are important figures that occupy a pivotal position in TRM use may be as a result of the differences in research design, in the community‘s knowledge of medicine, disease prevention methods of data collection, sample characteristics, response rates, and management. The Ghanaian rain forests and semi-deciduous the study setting, the operational definition of what constitutes a forests are vast repository of medicinal plants and therefore TRM and the period of TRM use preceding field work. constitute a rich source of knowledge for medical field. Most It is interesting to note that whilst the prevalence of TRM use is high Ghanaians resort to TRM for their first line primary health care in our study, no statistically significant difference was observed in TRM needs despite the current advances of conventional treatments. use as regard sample baseline characteristics apart from household size. Furthermore, the growing interest in TRM is attributed to the This finding is congruent with previous studies reporting no relation- widespread traditional health shops, and pharmacy shops. ship between TRM utilisation and income levels, age and sex (Lim et al., Recently, few health centres offer a wide choice of herbal medi- 2005; Aydin et al., 2008). It is however inconsistent with other studies cines for diverse ailments in both rural and urban settings. that reported statistically significant difference between TRM use and socio-demographic variables (Chuma et al., 2012; Osamor and Owumi, 2010; Bishop and Lewith, 2010; Dog, 2009; Shih et al., 2010). Therapeutic pluralism is almost indispensable among popula- Table 2 Forms, sources and pattern of traditional medicine utilisation. tions. Our study has demonstrated that co-medical administration is common. A third of the participants reported concomitant use of Category Frequency Per cent p-value TRM and the conventional healing interventions as a means of curing ¼ (N 279) (%) not only medical conditions but spiritual ailments. Nevertheless,

Forms of traditional medicine a accessed Table 3 b Spiritual therapy 71 25.4 0.125 Concomitant use, advent reactions and disclosure of TRM use. Biologically-based therapy 247 88.5 Faith healing 163 58.4 Variables and classes Frequency Per cent χ2 P- Body-mind therapy 86 30.8 (N) (%) value Others interventions 21 7.5 Sources of Traditional Medical Combined TRM use with Conventional drugs 278 a Products Yes 86 30.9 o0.001n n Self-application 232 71.6 0.004 No 192 69.1 Buy from pharmacy/chemical shops 186 57.4 Open markets/drug peddlers/buses 128 39.5 Disclosure of TRM use to health care 279 Consult TMP 96 29.6 professionals o n Hospital/clinic/health centre 22 6.8 Yes 34 12.2 0.001 How frequent do you use TRM No 245 87.8 Daily 130 41.8 0.171 Adverse events of co-TRM and OM Use 278 Weekly 66 21.2 Yes 157 56.5 o0.001n Monthly 39 12.5 No 62 22.3 Annually 32 10.3 Don't know 59 21.2 Others 44 14.1 a How many times have you utilised Reasons for non-disclosure 279 n TRM Health care professionals did not enquire 222 79.6 0.032 None 45 13.9 o0.001n It is not important 143 51.3 Once 58 17.9 Fear of response of the health care 122 43.7 2 times 86 26.5 professional 3þTimes 135 41.7 Previous bad experience 98 35.1 Others 42 15.1 n The Chi-square statistic is significant at the 0.05 level. n a More responses were possible; sum of percentages is over 100%. The Chi-square statistic is significant at the 0.05 level. a b Results are based on Fisher's exact test Two or more responses were applicable; sum of percentages is over 100%.

Fig. 2. Sources of knowledge and information about TRM. 144 R.M. Gyasi et al. / Journal of Ethnopharmacology 161 (2015) 138–146 nearly one in ten reported disclosure of TRM use to health care care needs of most people call for a sentient attention in its professionals. This is in agreement with other studies (Kessler et al., development and sustainability. Biologically-based medicines were 2001; Babb et al., 2007; Langlois-Klassen et al., 2007; Peltzer et al., commonly consumed by the study participants. The MOH and its 2008; Hughes et al., 2012; Gyasi et al., 2013). Owing to the fact that agencies should ensure the enrolment of these medicines on the traditional and modern medicines evolved from different philoso- NHIS medicine plan. This will toughen monitoring of TRM utilisa- phical assumptions and with different methodological approaches, tion by medical professionals. TRM is mostly self-administered and conflicts are bound to arise when the two systems are simulta- medicated with no professional advice. The propensity of compro- neously used. The biologically-based products and therapies are the mising the efficacy and more importantly, the safety of use of TRM most frequently used TRM in the treatment of array of diseases. This is high. Employing clinical trials to determine the safety and efficacy compares the findings of a Nigerian study on adverse effects of CAM of TRM products is golden. use among adults (Okoronkwo et al., 2014). Concomitant regimen of TRM and orthodox drugs is popularly Wallis (1996) also found that 82% of Americans believed in the demonstrated by the respondents. This may have the impetus to healing power of prayer and over 64% felt that biomedical practi- cause drug interactions that in turn may lead to advent side effects tioners ought to pray with patients who request it at the time of through increased toxicity after initiation of treatment. In accor- medical administration. In contrast, the significance of divination is dance with the basic principle of non-maleficence and benefi- dwindling as most people are now embracing Christianity and cence, clinicians should enquire about TRM use by their patients to Islam. The study identified family members/relatives, friends and protect them from harm. Advent side effects can result from lack the media as the most important sources of knowledge on TRM. of communication between patient and health care provider. Traditional knowledge of indigenous medicine is mostly acquired Physician-patient relationship is therefore critical. It is important through inheritance and training based on oral tradition from and exigent that more open and effective patient-physician com- elderly members of the community. Both print and electronic media munication is prioritised. By expressing genuine interest, clinicians are emerging sources of information and knowledge on TRM. This can elicit more accurate information about their patients' TRM use. finding affirms the current observed ascendency of television and Information in relation to TRM therapies utilisation needs to be radio panel discussions and advertisement as a marketing tool for incorporated into clinical and medical practice. various herbal medicines and energy therapies. Books were less credible due to high level of illiteracy. Health care professionals are poor sources of TRM knowledge. This confirms the sort of rivalry, Acknowledgements scepticism, mistrust and suspicion that have lingered between the TMPs and OMPs in the medical practice (Buor, 2004). This study was funded by the Council for the Development of A preponderance of participants self-administers TRM; purchase Social Science Research in Africa (CODESRIA), Senegal (Grant no. TRM from pharmacy/chemical shops and from drug peddlers. Most SGRT.46/T12). Institute for Research in Africa (IFRA-Nigeria) and TRM-users are knowledgeable about herbal medical practice French Embassy in Ghana Grant Programme (Grant no. IFRA- handed down from older generations through informal training, Nigeria/2012). We are most grateful to Prof. Dr. Dr. Daniel Buor folklores and verbal communications. This is consistent with the (Valley View University, Accra, Ghana), Prof. Kassim Kassanga observations of other studies (Twumasi, 1975; Okunlola, 2007; (Department of Land Economy and Centre for Land Studies, Kwame Mafimisebi and Fakoya, 2007; Mafimisebi and Oguntade, 2010; Nkrumah University of Science and Technology, Kumasi, Ghana) and Vandebroek and Balick, 2014). The management of diseases in Dr. Anokye Mohammed Adam (School of Business, University of Cape many households usually begins at home outside health care Coast, Cape Coast, Ghana) for their exceptional review of the manu- facilities. Worldwide, a community pharmacy is generally the most script. Mr. Samuel Twumasi Ankrah (Head of General Arts Depart- common point at which the public accesses medicines, as well as ment of T.I. Ahmadiyya High School, Kumasi) deserves no mean an health advice. In support of previous studies, the importance of appreciation for his fatherly understanding and unremitting support. TMPs and health facilities as sources of TRM are declining (Peltzer We acknowledge the efforts of our language editors, namely, Mr. et al., 2008; van Andel and Carvalheiro 2013; Peltzer, 2009). These Fidelis Acquaah-Harrison and Miss Ayisha Tetteh. differences are statistically significant. 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