Tswana traditional health practitioners’ perspectives on the management of diabetes and hypertension: a qualitative study using focus group discussions

Introduction The literature suggests the involvement of Traditional Health Practitioners (THPs) perspectives in treating diabetes and hypertension in Africa. This study sought the perspectives of Tswana THPs in the management of both diabetes and hypertension. Methods Using a semi-structured interview guide, four Focus Group Discussions (FGDs) sessions were held with 40 THPs; FGD1 (12) FGD2 (6); FGD3 (13) and FGD4 (9) who were purposely selected from Bojanala and Dr. Ruth Sekgopomati Districts in the North-West Province of South Africa. Results Tswana THPs perceived diabetes as a “sugar” disease and described hypertension as a disease associated with the abnormal flow of blood in a patient's body. In addition, some of the signs and symptoms of both diabetes and hypertension mentioned by Tswana THPs agreed with scientific literature. Tswana THPs employed the use of the following plants: borago officinalis, ziziphus mucronata, hypoxis hemerocallidea, sutherlandia frutescens, senna italica, urginea sanguinea and eucalyptus globulus in the management of diabetes and hypertension. Conclusion Some of the medicinal plants employed by THPs in the management of both diabetes and hypertension has been proven scientifically to be effective against these chronic conditions.


Introduction
In most African communities where access to hospitals and clinics remains a challenge, patronage of Traditional Medicine (TM) with the help of Traditional Health Practitioners (THPs) offer people the opportunity to manage certain diseases affecting their wellbeing and health in general [1]. According to the World Health Organization (WHO), "traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques, and exercises applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being" [2]. Furthermore, WHO defines Traditional Health Practitioner(THP) as, "a person who is recognised by the community where he or she lives as someone competent to provide health care by using plant, animal, mineral substances and other methods based on social, cultural and religious practices" [3].
In South Africa, a study reported that there were four groups of THPs recognized by the South African traditional healers act, namely: herbalists (izinyanga or amaxhwele), diviners (izangoma, umthandazi or amagqirha), traditional surgeons (iingcibi) [4]. The role played by THPs in the treatment and management of these two diseases (diabetes and hypertension) across the African continent has been documented [5,6]. A research carried out in South Africa revealed the treatment of diabetes among THPs and faith healers in the northern province of South Africa [5]. Similarly, a study conducted in Zambia reported the treatment of hypertension among THPs in Zambia [6]. The two leading causes of cardiovascular diseases and their complications are diabetes and hypertension. Globally, it has been estimated that 1.39 billion people are affected by hypertension [7] while 300 million people are estimated to be diabetic by the year 2025 [8]. The present study sought Tswana THPs perspectives about the management of diabetes and hypertension.

Methods
Study design and setting: an exploratory descriptive study, using four FGDs, was conducted among THPs in urban, traditional and farmland areas in the Bojanala and Dr. Ruth Sekgopomati Districts of North West district in South Africa to obtain quantitative and qualitative data. It is significant to point out that FGDs are used to gather opinions in qualitative research [9]. In the Bojanala District, Study population and sample: purposive sampling was used to identify THPs who could provide information based on their availability and willingness to co-operate [10]. The four FGD sessions (12 in FGD1); (6 in FGD2); (13 in FGD3) and (9 in FGD4) had no more than 14 subjects based on the recommendation of Gill P et al. [11].
The inclusion criteria for participants was a minimum of aged 18 years with more than one year experience in managing diabetes and hypertension. Those eligible THPs with less than one-year experience in the management of both diabetes and hypertension were excluded.
With regards to recruitment and selection of THPs leaders of various associations of THPs in the area of study (North West Province, South Africa) were contacted to obtain their support and assistance in making contact with appropriate practitioners. Furthermore, they helped to recruit eligible THPs to join FGDs held during business hours in the respective districts. Data analysis: there were simultaneous data collection and analysis with the help of two research assistants who were fluent in the Tswana language, the FGDs were audiotaped and transcribed verbatim. The raw transcribed data were analysed following Tesch's recommendation for identifying themes and sub-themes as presented in a table below with the help of independent qualitative research experts. A meeting was held between the principal researchers to discuss the codes identified after data analysis [12]. The quantitative data were analysed using SPSS version 2.0 and thematic content analysis was used to analysed qualitative data [13,14]. Descriptive statistics were used to present socio-demographic characteristics of participants expressed in frequency and percentage; mean values with standard deviation were used for age and years of work experience.  sub-themes emerged from the study ( Table 2).

Tswana
THPs perceptions towards diabetes and hypertension: THPs perspectives in the management of diabetes and hypertension are based on their understanding of these two diseases whether it is curable or manageable. Besides, how they were able to identify a patient affected by diabetes and hypertension was also taken into consideration. Last but not the least, Tswana THPs emphasized on the perceived causes and major complications of these two diseases.

Understanding diabetes and hypertension: most Tswana THPs
believed that diabetes is a "sugar disease" and described hypertension as a disease associated with a patient having an abnormal flow of blood in a patient's body. "It is a sugar disease; the basic level of sugar is not the way is supposed to be in one's blood." Female 1, GP1. "It is a sugar disease…" Female 3, GP4. "Hypertension is when there is a lot of pressure in your blood system, your blood is not flowing according to a normal way." Female 2, GP4.
Diabetes and hypertension are they curable or manageable? Most of the THPs were of the assertion that diabetes and hypertension could be cured following an appropriate treatment regimen. "Yes, both diseases are curable, with relevant treatment." Female 2, GP2. It is significant to point out that all the participants in (GP2) voiced out that they agreed with what she said. "Yes. They are curable." ***All the THPs in GP4. "Yes, these two diseases are curable." ***All the THPs in GP 3. "Both sugar diabetes and hypertension can be brought under control." *** All the THPs in GP1.

The need for a two-way referral system of patients: Tswana
THPs suggested the implementation of a two-way referral system of patients in the management of both diabetes and hypertension. They believed that BHPs were the ones against the two-way referral system. "The clinic and western doctors seem to be the ones who have problems to refer patients to us." Female 2, GP3.

Endorsements and recognition from the government: Tswana
THPs appealed to the government to give them the same attention as the BHPs working in the hospitals. "Government must also intervene because we are realizing that western doctors are highly respected as opposed to us, African healers. We always give solutions to some of the health problems in this country, but we hardly get any recognition or credit." Female 3, GP1.

Discussion
Tswana THPs in this study description of diabetes as a "sugar disease" agrees with a similar study conducted in the Northern Province of South Africa where THPs described diabetes as a sugar disease [5].
Regarding hypertension, Tswana THPs associated the disease with a patient having an abnormal flow of blood in his or her body. This is in agreement with a research carried out by Goma et al. in Zambia where some of the THPs in Lusaka described hypertension as a disease associated with blood flowing fast in a patient's body [6].
Tswana THPs in this study had varied opinions on whether hypertension and diabetes were curable or could only be managed.
The assertion about the curability of diabetes and hypertension by

THPs in FGDs 2, 3 and 4 is in agreement with the statements of THPs
in the Northern Province of South Africa which indicated that diabetes was curable using African Traditional Medicine [5]. In a similar study conducted in Nigeria, THPs believed that hypertension was curable [15]. However, in FGD 1, the THPs stated that diabetes and hypertension could only be managed but not cured completely. THPs in FGD 1 assertion that these two diseases cannot be cured completely is in agreement with scientific literature as opposed to the statements made by THPs in FGDs 2, 3 and 4 which seem to suggest that these two diseases could be cured completely following appropriate treatment regimen [16,17]. It is therefore worth noting that participants were confident in their submissions regarding the management of diabetes and hypertension.  [19,20]. Some of the THP's in this study stated with regards to a spiritual diagnosis that, upon receiving patients to their shrine "bidime" in "Tswana language" during consultations, ancestors revealed to them the problem troubling an individual and appropriate measures to be undertaken to improve his or her condition. This finding above is in agreement with another study which stated that ancestors have the power to heal [21]. Furthermore, indigenous epistemology suggests that an individual becomes ill as a result of weaknesses in his or her protective (spiritual) immunity [22].
Perceived causes (too much sugar and salt, excessive consumption of red meat and alcohol, and lack of regular exercises) of diabetes and hypertension described by THPs in this study are in agreement with the scientific findings commonly reported for diabetes and hypertension [23,24]. Regarding perceived complications of diabetes and hypertension, the THPs specifically mentioned the following: erectile dysfunction, poor eyesight, wounds associated with diabetic patients that do not get healed, leading to stroke and amputation, this being the last intervention for limb preservation in diabetic patients with foot ulcers [25]. A multi-ethnic cohort study in the USA revealed a diabetic retinopathy prevalence rate of 33.2% among the studied population [26]. Erectile dysfunction, as stated by THPs in this study, is one of the major complications associated with diabetic patients and agrees with scientific literature. The prevalence rates of erectile dysfunction reported among diabetic men conducted in the following countries were as follows: USA (more than 50%), Saudi Arabia (80-90%), Netherlands (41%) and Mexico (30-80%) [27].
Although most of the THPs were not ready to disclose information about the herbal formulation they used to manage the two diseases, Approximately sixty type 2 diabetic patients in India who were administered with a supplement (aloe vera gel powder, 100/200mg) daily over three months recorded a significant reduction in their blood glucose and blood pressure levels [28]. Crude leaf extracts of starflower (borago officinalis) administered in rabbits caused a decrease in both atrial force and rate of contractions in their hearts [29]. Experimental results revealed a decrease in intestinal glucose uptake (p<0.001 at 1-hour intervals) in diabetic wistar rats when the animals were administered with sutherlandia frutescens for over eight weeks [30]. In a similar study, an aqueous extract of African potato (hypoxis hemerocallidea) (100-800 mg/kg p.o) administered to streptozin diabetic rats caused a reduction in the animal's blood glucose concentrations (30.20% and 48.54%) [31]. In vitro studies using 0.2% 2, 2-diphenyl-2-picrylhydrazyl (DPPH) assay Africa to manage diabetes and hypertension [33][34][35].
THPs in this study revealed that lifestyle modifications on the part of patients were a major contributor to manage these two diseases, with brisk walking having been established to be effective in reducing arterial blood pressures [36]. A study reported that hypertensive patients (under 8 weeks stress management programme) recorded a significant reduction in systolic blood pressures, even without taken their antihypertensive medications within that period [37]. THPs expressed confidence in their prescribed TM and were not aware of any side effects, with the dosage given depending on the severity of a patient's condition. This is in agreement with a similar study conducted in Kenya, where THPs stated that their prescribed herbal mixtures had no side effects [38]. Some of the THPs in this study were not against the concurrent use of TM and conventional orthodox medication by their patients. However, instructions were given regarding different times their prescribed medications should be taken to achieve the best possible health outcomes. Interestingly, studies reported that to avoid adverse effects regarding the use of both TM and conventional medications, these forms of medications should be taken at different times by a patient [39].   Collaboration with biomedically health professionals The need for a two-way referral system of patients Endorsement and recognition from government