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1 CHAPTER ONE ORIENTATION to the STUDY 1.1 INTRODUCTION the Nursing Profession Needs a Knowledge Base Or Science on Which to B 1 CHAPTER ONE ORIENTATION TO THE STUDY 1.1 INTRODUCTION The nursing profession needs a knowledge base or science on which to build its practice (Perry & Jolley 1992:24). Nursing science is considered to be “the creative study of nursing phenomena which reflects the systematization of knowledge using rigorous and explicit research methods” (Leininger 1991:30). The field of transcultural nursing is committed to developing a knowledge base related to cultural care; this knowledge of cultural care differences and similarities helps nursing to develop its theoretical and practical bases (Leininger 1991:31). Through this study the transcultural nursing knowledge base is expanded by knowledge on the urban Pares living in Moshi, Tanzania. 1.2 BACKGROUND TO THE STUDY 1.2.1 Tanzanian social economy Tanzania is a country of great beauty and geographical variety. It is situated in East Africa, a few degrees south of the equator (see Figure 1.1). A democratic country which became independent in 1961, Tanzania is divided into 20 regions. It is the tenth poorest country in the world when judged by GNP per capita (Haub & Cornelius 2000:3). The economy is based on agricultural production; coffee, cotton, sisal, tea, tobacco and cloves are among the major exports. It has been estimated that 51% of the population are Christians, 35% are Muslims and 13% follow traditional religions (Johnstone 1993:527). 1.2.2 Tanzanian tribes The population of Tanzania is made up of heterogeneous groups of people, a result of “colonial land carving”. There are said to be “more than 120 loosely defined ‘tribes’ ” (Amin 1992:28). The estimated population in the year 2000 was 35.3 million people (Haub & Cornelius 2000:3). 2 Figure 1.1 Tanzania administrative map Figure 1.1 Tanzania administrative map (newafrica.com/maps 28 May 2003) Among the largest tribal groups, with more than a million persons, are the Sukuma of southern Lake Victoria and the Chagga of Kilimanjaro Region. The main tribes of Kilimanjaro Region are the Chagga and the Pare. Chaggas are mainly resident in the northern districts of this region in Hai, Rombo, Moshi urban and Moshi rural districts, while the Pares are mainly resident in Same, Mwanga and Moshi rural districts (see Figure 1.2). There has been considerable migration of Chaggas to other districts and regions, and some migration of Pares. Extrapolating from the census figures of 1988, it was 3 estimated that there would be about 1.1 million Chaggas and 300,000 Pares in 2001 (United Republic of Tanzania 1994:9) (see paragraph 2.6.3 and Table 2.1). Figure 1.2 Map of Kilimanjaro region (United Republic of Tanzania, President’s Office, planning commission, Bureau of Statistics 1994: cover page) These estimates appear to be fairly accurate according to the results of the 2002 census which are shown in Table 1.1. The population of Mwanga and Same districts was 327 945; this population is predominantly Pare by tribe. The population of the other districts in Kilimanjaro was 1 053 204; this population is largely Chagga by tribe. The net losses and gains of population from migration into and out of the region are not accounted for in this estimate of tribal groups. Dar-es-Salaam (the region which includes the largest city in the country) is the only region to have more males than females, suggesting that there is a net gain of males by migration to this area. 4 The data presented in Table 1.1 also suggest that there are differences in household size between rural and urban areas in Kilimanjaro Region. Table 1.1: Population by sex, number of households and average household size in Kilimanjaro Region of Tanzania, 2002. DISTRICT POPULATION POPULATION POPULATION HOUSE- HOUSE- NUMBER, NUMBER, NUMBER, HOLDS, HOLDS, MALES FEMALES TOTAL NUMBER AVERAGE SIZE ROMBO 116 859 129 620 246 479 50 123 4,9 MWANGA 55 666 59 954 115 620 24 326 4,8 SAME 103 520 108 805 212 325 44 474 4,8 MOSHI 192 998 209 433 402 431 84 862 4,7 RURAL HAI 127 782 132 176 259 958 58 056 4,5 MOSHI 71 040 73 296 144 336 35 598 4,1 URBAN TOTAL 667 865 713 284 1 381 149 297 439 4,6 (United Republic of Tanzania, Bureau of Statistics 2002:189) The 1967 Arusha declaration de-emphasized tribal differences, and aimed to promote a national identity (Jerman 1993:32-34). The first ruling party, the Tanganyika African National Union (TANU), opposed tribalism and all practices that were considered to lead to isolation amongst Africans (Cliffe & Saul (eds) 1972: 127,134). 1.2.3 The Pare tribe The home of the Pares (pæ-reIs) is in northeast Tanzania bordering on Kenya. Before the nineteenth century, there was at least one centralised kingdom in north Pare and about seven identifiable tribal units in the middle and southern parts (Kimambo 1991:1). Before 1928, the Germans administered the area in two parts, north and south Pare. The Pare district and the Pare tribe were “created” in 1928 during British colonial rule to promote smooth development of an area where common factors were “the highland homeland, the Chasu language, and the lifelong experience in ritual” (Kimambo 1991:173). Local people still speak of the Pare district, although since 1978 administrative boundaries have been changed so that the northern area is called Mwanga District and the southern is called Same District (Kimambo 1991:174) (see 5 Figure 1.2). The Pare tribe appears to have retained its identity. In the late 1960’s, the ‘tribal’ identity was said to be “growing, developing and increasing” (O’Barr, cited in Kimambo 1991:173), and on questioning individuals living in Moshi, they readily describe themselves as belonging to a particular tribe such as Chagga, or Pare. In July 2002, it was found that of the new patients attending Kilimanjaro Christian Medical Centre in Moshi, the largest health care institution in the region, 20,6% were Pares and 56,5% were Chaggas (Mwanswila 2002:30). This suggests that Pares are a significant proportion of the health consumers in this institution, and of the population of Kilimanjaro Region. 1.2.4 Tanzanian health Tanzanian life expectancy at birth is only 53 years; the infant mortality rate is 99/1000 live births and total fertility rate is 5,6 (Haub & Cornelius 2000:3). Health problems in Tanzania still include malnutrition, high rates of communicable disease, including HIV infection and diseases of poor sanitation and water supply, while non- communicable diseases are increasing (Mwaluko, Swai, & McLarty, in Mwaluko, Kilama, Mandara, Murru, & Macpherson 1991:219-234). According to Ministry of Health statistics from 1997, malaria was the most common disease to be treated in outpatient facilities in all age groups, and was the leading cause of admission to health care facilities. Outpatient statistics suggest that 4 895 487 cases of malaria were reported in one year, while upper respiratory tract infection accounted for 1 822 847 cases, and diarrhoeal disease for 1 008 115 cases. In comparison to these three commonest reported conditions, cardiovascular diseases accounted for 26 235 outpatient cases (0,2% of the total cases). These figures may be substantially lower than actual figures since regional statistical response rates are from 8–80%. Clinical AIDS was the leading cause of deaths in health facilities for patients over five years of age. Protein energy malnutrition accounted for more than 5% of deaths in under five year olds. The most frequent cause of an outbreak of notifiable disease was typhoid. Table 1.2 shows the proportions of cases notified of the five most frequent causes of an outbreak of notifiable disease in Tanzania, January 1997 (United Republic of Tanzania 1999:1–26,59). 6 Table 1.2: The five most frequent causes of notifiable disease in Tanzania, January 1997. NOTIFIABLE DISEASE PROPORTION OF DISEASE CASES NOTIFIED Typhoid 37% Measles 29% Relapsing fever 20% Plague 7% Cholera 5% (United Republic of Tanzania 1999:59) 1.2.5 Tanzanian health care 1.2.5.1 History Health care in Tanzania has a long and fascinating history. Traditional medicine has been practised for centuries, and it is claimed that even in the year 2001 “about 70 – 80 % of the population use traditional medicine for social and health problems” (Goergen 2001:2). Medieval Arab medicine spread to East Africa after the tenth century; later Portuguese and French Navy surgeons practised at the coast. During the German colonial rule of 1889 – 1916, dispensaries were set up in the coastal areas, and later a network of nine dispensaries was set up inland. During the period of British colonial rule from 1916 – 1960, Western medical facilities became available to more of the population (Goergen 2001:5–15). From 1900, Lutheran missionaries were actively introducing Christianity and western style medicine in north Pare and later in south Pare. “The Pare people did not embrace the modern institutions introduced by the missionaries as readily as the Chagga. The stronger position of local healers meant that traditional medicine was never rejected as an inferior or backward tradition …” (Moland 2002:37). Nurse training began in the 1930’s in mission hospitals, and the first government nursing certificate was awarded in 1943. By 1960 there were 13 nurse training institutions (Sanga 1994:36). 7 The way Western medical care was introduced into Africa has been criticized for being inappropriate and involving maldistribution, neglect of health promotion and preventive care and overdevelopment of curative services (Sanders 1985:135). 1.2.5.2 Current provision of health care In 1999 there were reported to be 5 284 health facilities nationwide including 416 in Kilimanjaro region (United Republic of Tanzania 1999:2–8).
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