Zimbabwean diabetics' beliefs about health and illness : an interview study


Zimbabwean diabetics' beliefs about health and
illness: an interview study
Katarina Hjelm and Esther Mufunda Linköping University Post Print
N.B.: When citing this work, cite the original article. Original Publication: Katarina Hjelm and Esther Mufunda, Zimbabwean diabetics' beliefs about health and illness: an interview study, 2010, BMC International Health and Human Rights, (10), 7. Copyright: BioMed Central Postprint available at: Linköping University Electronic Press Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
http://www.biomedcentral.com/1472-698X/10/7
Open Access
Zimbabwean diabetics' beliefs about health and illness: an interview study Katarina Hjelm*1 and Esther Mufunda2 Background: Diabetes mellitus (DM) is increasing globally, with the greatest increase in Africa and Asia. In Zimbabwe a
threefold increase was shown in the 1990s. Health-related behaviour is important in maintaining health and is
determined by individual beliefs about health and illness but has seen little study. The purpose of the study was to
explore beliefs about health and illness that might affect self-care practice and health care seeking behaviour in
persons diagnosed with DM, living in Zimbabwe.
Methods: Exploratory study. Consecutive sample from a diabetes clinic at a central hospital. Semi-structured
interviews were held with 21 persons aged 19-65 years. Data were analysed using qualitative content analysis.
Results: Health was described as freedom from disease and well-being, and individual factors such as compliance with
advice received and drugs were considered important to promote health. A mixture of causes of DM, predominantly
individual factors such as heredity, overweight and wrong diet in combination with supernatural factors such as fate,
punishment from God and witchcraft were mentioned. Most respondents did not recognize the symptoms of DM
when falling ill but related the problems to other diseases, e.g. HIV, malaria etc. Limited knowledge about DM and the
body was indicated. Poor economy was mentioned as harmful to health and a consequence of DM because the need
to buy expensive drugs, food and attend check-ups. Self-care was used to a limited extent but if used, a combination of
individual measures, household remedies or herbs and religious acts such as prayers and holy water were frequently
used, and in some cases health care professionals were consulted.
Conclusions: Limited knowledge about DM, based on beliefs about health and illness including biomedical and
traditional explanations related to the influence of supernatural forces, e.g. fate, God etc., were found, which affected
patients' self-care and care-seeking behaviour. Strained economy was stated to be a factor of the utmost importance
affecting the management of DM and thus health. To develop cost-effective and optimal diabetes care in a country
with limited resources, not only educational efforts based on individual beliefs are needed but also considering
systemic and structural conditions in order to promote health and to prevent costly consequences of DM.
has been reported as the fifth among the ten most com- Diabetes mellitus (DM) affects millions of people world- mon diseasesFrom 1990-1997 the prevalence of dia- wide and its related complications continue to be of great betes increased from 150 to 550 per 100,000 pe concern hose diagnosed with DM, 90-95% have Thus, the overall prevalence increased threefold. Accord- type 2 DM. The number of affected people is estimated to ing to the Zimbabwe National Health Profiles (1996- double by 2025, with the greatest increase occurring in 1998) the number of new cases recorded in the ages 15 developing countries []. The regions with the greatest years and above rose from 2734 cases in 1996 to 5114 potential increase of DM in the future are Africa and cases in 1998, which is an increase of 87% of recorded Asia, where diabetes is estimated to become two to three casehe increase of DM is related to changes of times more common than todaimbabwe DM societies because of urbanization and industrialization,leading to changes in lifestyle from a 'traditional' and * Correspondence: katarina.hjelm@lnu.se active life to a 'modern' sedentary life with unhealthy 1 School of Health and Caring Sciences, Linnaeus University, Växjö, S-351 95 dietary habits and obesity in combination with increased Växjö, SwedenFull list of author information is available at the end of the article longevDM is thus a result of the collision between 2010 Hjelm and Mufunda; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com- mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc- tion in any medium, provided the original work is properly cited.
Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
the modern lifestyle and our ancient genes built for a life larly to freedom from disease, in Swedes, Ex-Yugoslavians as hunter-gathe main consequences of DM are and Arabs, three different self-care behaviours were dem- reduced life expectancy, increased mortality and morbid- onstratewedes were active and had a healthy ity associated with development of complications with and controlled lifestyle. Ex-Yugoslavians highlighted enormous costs, and thus DM will constitute a heavy bur- enjoyment of life and had a passive self-care attitude.
den for individuals as well as societ Arabs focused on mental well-being, adaptation to DM, The outcome of DM depends mainly on the patient's and actively searched for information and had a lower self-management, which is guided by individual and cul- threshold for seeking care [oreign-born per- turally determined beliefs about health and illness [,].
sons perceived DM as less serious and knew less abouttheir body and DM compared to Swedes.
Literature review
The literature search has not revealed any studies explor-
The study
ing the individual's own beliefs about health and illness in The aim of the present study was to explore beliefs about persons diagnosed with DM living in African countries health and illness that might affect self-care practice and with the exception of a comparison of Ugandan men and health-care-seeking behaviour in persons diagnosed with imited knowledge about DM and the body diabetes mellitus living in Zimbabwe.
was indicated, and the majority did not know the cause ofDM. Many attributed it to the influence of supernatural forces, which meant that limited self-care measures were used and health professionals were not consulted about An exploratory study design was used. Data were col- health problems. Men focused on socio-economic fac- lected through semi-structured interviews, in 2004 and tors, particularly the affordability of drugs, sexual func- 2006, in order to give respondents freedom to express tion and lifestyle, while women valued well-being, their views to reach a deeper understanding of the topic support in daily life and household activities and had a higher risk awareness of DM. The indication of limitedknowledge was in accordance with findings shown in pre- vious investigations focusing on knowledge of DM in A consecutive sampling procedure was used. Set criteria people in Cameroon and South Africaand little for inclusion were: diagnosis of DM, duration of DM >1 understanding of the nature of DM, with reporting of a year, age >18 years, and without known psychiatric disor- spectrum of different causes of DM in an investigation of der. All respondents were managed in an outpatient dia- the impact of the disease in Nigerians with DM [, betes clinic, at a governmental central hospital in an while in Ghanaians diagnosed with DM a blend of com- urban area also managing cases referred from rural areas.
monsense, scientized, and religious knowledge modalities The staff included a leader who was a physician special- that merged with biomedical goals, specifically drug and ized in internal medicine and a team of general physi- diet management ].
cians, general nurses and nurse aides. The respondents When investigating health beliefs and stress with a were recruited by a nurse (the principal investigator) quantitative approach] it was found that a number of when visiting the clinic.
patients suffered from considerable psychosocial stress The sample comprised 21 persons (11 females and 10 mainly related to leisure time and physical complications males) aged 19-65 yrs (Md 48 yrs, see Taborn and resulting from the disease and sometimes associated with living in Zimbabwe. The majority were treated with oral poor diabetic control. They concluded that health care agents and reported complications related to DM from staff needed to consider the self-perception of compli- the eyes. Most were married, had gone through second- ance held by patients in order to consolidate progress.
ary school, and about half of the group were gainfully Previous studies comparing beliefs about health and ill- ness in persons of different origin with DM have shown that Europeans cite various and more medically oriented The study was approved by hospital ethics committee.
causes of disease, for example heredity, obesity Written informed consent was obtained from respon- eas non-Europeans, e.g. North Afri- dents in accordance with the Helsinki Declaration.
cans, cited either stress or fate [. Middle-Easternersshowed a similar pattern of beliefs to North Africans, with a more fatalistic view of DM in terms of factors lying The interview started with standardized questions (15 beyond one's own control, such as fate and supernatural minutes) focusing on socio-demographic and medical influence through the will of God or Allah (external locus variables. Then a thematic interview guide with open- of conthough health was described simi- ended questions, including descriptions of common Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
Table 1: Characteristics of the study population.
the interview guide was carried out with six persons (notincluded in the study), and minor changes to the wording and meaning were made.
Interviews were mainly held in Shona (n = 18) but also in English in some cases (n = 3) and led by a bilingualfemale nurse (second author) not involved either in the clinic or in management of the respondents. Shona andEnglish are official languages in Zimbabwe The interviews were held in secluded rooms outside the clinic. The interviews lasted for 1-1.5 hours, were audio- taped and transcribed verbatim in English.
Combination with insulin Collection and analysis of data proceeded simultaneouslyfor respondents until theoretical saturation was achieved Number of years spent in school* [. After the interviews, the tapes were listened to and Educational level (n) notes were taken about general findings, ideas and emerging themes. The endeavour in the analyses was to be open to as much variation as possible, and themes,patterns and contradictions were searched for . By Upper secondary (College) reviewing each line of the texts, topics were identified University >2 years and the material was condensed into content categories(See example in Table s previously described Current working conditions (n) he lay theory model of illness causat Gainfully employed and the model for health-care-seeking behavi were introduced and used as the main analytical catego-ries []. Illness can be experienced as caused by factors in the individual, natural, social relations or in the super- natural sphere, and explanations of disease guide strate-gies for self-care, treatment of diseases and health-care- Family circumstances (n) seeking behavialth care can be sought from the popular, professional or folk sector (i.e. family, friends or relatives, professionals, or folk-healers; To increase the trustworthiness of the results, the tran- scripts were analysed independently by two researchers a diabetes specialist nurse and a general nurse (firstand second author) and the comparison showed high Complications related to DM (n) agreement. Content of categories were also checked by the first author.
Feet/lower extremity Beliefs about health
Health was described in terms of individual factors. The content was mainly focused on well-being, expressed in * Median (range).
terms of freedom from disease and bodily pain, and beingstrong and fit health problems related to DM, was used (for more .free of disease.looking after oneself well. Involves details se Themes investigated were: content of a feeling of well-being with no bodily pain. (6) health; factors of importance for health; causes, explana- .to be strong and fit.someone is strong without any tions and perceived consequences of DM; health-restor- ative activities; and care-seeking behaviours. The Measures used in order to feel well and experience interview guide was based on findings and experiences good health were also described as individually related from previous investigationsand peer-reviewed by factors, and the two subcategories of lifestyle factors and GPs and nurses working in diabetes care. A pilot test of looking after oneself emerged. Lifestyle factors mainly Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
Table 2: Causes of DM.
Main analytical categorya
Numbers (n)
Factors related to the individual '.both of my parents are diabetic. I inherited it from them' '.especially foods that contain too much sugar' Treatment with drugs: '. the hydrochlorothiazide that I was taking' '.maybe anti-hypertensive drugs' Diseases of the pancreas: '.problems with the pancreas' Wrong dietary habitb Disease of the pancreasb Factors related to the social sphere Disturbances in relations to othersb Factors related to the supernatural sphere Supernatural thoughtsb Punishment from God, or godsb aAnalytical categories according to the lay model of illness causation by Helman (2007).
bExplanations of causes of DM evolved in discussions of a list of potential causes of DM.
included conforming to the correct diet, but some others All respondents, with the exception of one, considered mentioned exercise. Hygiene, personal and environmen- instrumental tangible support from their family mem- tal, compliance with drugs and diabetic diet, and avoiding bers. Assistance mentioned was mainly in terms of mate- factors with negative influence on health such as injuries, rial support with provision of money to buy food and were included in looking after oneself: drugs, equipment for self-monitoring of blood glucose I make sure that I get good body-building foods, (SMBG), and help with preparation of food and supervi- maintain good body hygiene, make sure that my envi- sion of meals. Acceptance of a sick person as a diabetic ronment is clean and follow doctor's instructions on and psychological support to live positively were also Respondents predominantly talked about individual .help me to live positively, help with different factors in terms of compliance with diet, drugs and fol- things.provide money to buy medications and right lowing doctor's instructions and having check-ups as being important for their health as far as DM was con- .understand my condition so that they will be able to cerned. There were also some who talked about lifestyle assist when I fall sick. (11) factors such as regular exercise and maintenance of good Health professionals were considered important for personal hygiene.
health mainly because they give information supportabout the disease, food preparation and medications.
Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
Many also discussed a combination of material and social association, to share information and disease experience support concerning health maintenance, expressed as with others, and there they received support and assis- control of the disease and screening for potential health tance in problem solving from experts, but some did not problems, and counselling, e.g. encouragement and know about its existence (social factors): reminders to maintain good health. Finally, a few talked .prayers are useful and can have a healing power (6) about emotional support in understanding the needs of a .natural herbs, garlic to lower blood pressure and sal- icylate ointment for painful joints (17) .give information.teach me those things that I am .people with diabetes come (to the diabetes associa- supposed to and not supposed to do.give more tion) and share information and ideas concerning advice on food, especially alternatives that I can solutions to their problems.get assistance from eat.inform on how to give injections. (1) experts and health practitioners (3).
.these people understand me and my needs as a dia- To maintain health and prevent complications related betic patient. (6) to DM, all respondents brought up individual factors.
.give advice on how to look after myself, food prepa- The majority talked about compliance, mainly in terms of ration and taking of drugs.monitor my blood sugar diet with reduction of sugar intake and avoidance of over- levels regularly (3) eating, but also about medication and check-ups. Avoid- Concerning factors harmful to health, it was mainly ing stress and working hard to earn a living were also social factors in terms of a poor economic situation resulting in lack of food, money, expensive or unavailable .avoid foods that contain too much sugar,.live a life drugs, and over-working that were mentioned. Some that conforms to one with diabetes, go for regular stated social relations such as being single or divorced check-ups, test my blood sugar levels and take pills and others discussed other diseases. One person talked and injections on time. (10) about a harmful lifestyle with smoking.
.everything is just too expensive these days. (20) Beliefs about illness
.many factors.the way I am living these days.lack of All respondents, except one, had not suspected DM when food, lack of money to buy drugs and to come for they fell ill with the disease. Most described how they felt they were going to die, others suspected witchcraft and a Awareness of bodily signs was the predominant way to few suspected other diseases such as malaria, HIV and know whether health became worse, e.g. mainly general AIDS. Several symptoms, for example, drinking a lot of body weakness or tiredness or passing too much urine, water, passing a lot of urine, feeling of dying, general body but also headache, loss of appetite, and drinking too weakness and being tired had been experienced. Most much water were stated. Some talked about check-ups at went to the professional sector, to see a physician, either hospital as a possibility to monitor health status: at clinics, doctors' surgeries or hospitals, while a few .some symptoms that are noticed, for example pass- sought help from the popular sector, such as husbands, ing lots of urine, feeling tired and having headaches.
wives or friends, and two went to the folk sector to see n'angas (traditional healers).
.can only tell when I come for reviews at the hospi- .experiencing a feeling of tiredness, loss of weight, dryness of the mouth and passing lots of urine.I got When discussing the influence of economy on health, confused because I failed to understand what was all respondents unanimously expressed negative effects happening.feeling of dying.went to seek advice as they were unable to buy food or drugs or to go for from a sister-in-law (a nurse).tested my urine.then reviews at the hospital.
taken to a private doctor. (9) .the present situation has become too hard to buy .started by excess loss of weight, drinking large medications and food.I minimize coming for reviews amounts of water.and I thought I had been because the situation forces me to. (1) bewitched.was taken to a n'anga but I got Measures claimed to improve health when diagnosed worse.Taken to the doctor.later referred for admis- with DM were mainly prayers or a healing power (super- sion to hospital. (5) natural factors) and household remedies such as various DM was perceived by some, and expressed in answers herbs (garlic, zumbani (green leaves from a plant), teas, to open-ended questions, as being caused by heredity aloe) or cough remedies, paracetamol etc. (natural fac- (individual factors), other drugs such as anti-hyperten- tors). However, there was also a group of people who said sives (natural factors) or wrong food (individual factors), they had never used nature cure medicine or were not while others related it to problems of the pancreas (indi- allowed by their church to use them. More than half of vidual factors), and some didn't know (see Ta the respondents had been in contact with the diabetes a list of potential causes of DM was presented, most Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
talked about individual factors such as heredity, wrong Most respondents reported that advice had been given diet and obesity, inactivity and diseases of the pancreas.
concerning the importance of SMBG in terms of using Supernatural factors such as fate or the influence of God, bodily signs, e.g. passing urine, drinking a lot, feeling witches or evil spirits were added as well as social factors sleepy, bitterness in the mouth etc., to know about blood such as stress. Thus, a mixture of causes were mentioned, glucose to avoid sudden changes in sugar and minimizing although predominantly focused on individual factors complications such as coma. Only one had the equipment such as heredity, overweight and wrong dietary habits in for monitoring their blood glucose at home. Some had combination with supernatural factors lying outside the not received any advice at all.
individual's own control in terms of fate, punishment When discussing recommendations for diet, most cited from God and witchcraft.
the importance of reducing the intake of carbohydrates, When discussing what happens in the body when one mainly sugar, and increasing the intake of vegetables. A gets DM and the function of the pancreas, in general lim- few talked about reduction of fat and regular meals. Four ited knowledge was demonstrated. Most knew about the persons had received initial information from a dietician.
function of insulin in reducing blood sugar.
Food without much sugar, less carbohydrates and lots The majority of respondents perceived DM to be life- of fruit and green vegetables. (10) long and persisting until death and only one person indi- .not to eat sugary foods, take fats in small amounts, cated that it could be controlled.
have snacks in between. (14) Knowledge about the action of drugs was limited. Most As regards advice about exercise, most had been of the respondents were treated with oral agents and the informed of the importance of regular exercise: 'to exer- others with insulin. Those who discussed the main effects cise regularly.to lose weight by walking or jogging' (4) of treatment in general stated regulation of blood sugar and 'drugs to be taken as directed'(16).
levels and a few talked about correction of eye sight or All respondents in general reported they mainly fol- lowed advice received, as it prolongs life. Reasons for not Major problems as a consequence of DM were reported following advice could be: by about half of the studied group. These consisted of .I try but it's rather difficult.don't have money to varying physical matters such as 'reduced vision', 'coma', buy drugs and necessary monitoring equipment. (7) 'swollen joints', and 'difficult deliveries', financial prob- When discussing different common health problems lems in terms of 'too expensive drugs' and in one case related to DM, such as hyperglycaemia, repeated epi- 'taking too frequent meals' (individual and social factors).
sodes of hypoglycaemia, gastrointestinal infection, com- All respondents, with the exception of three persons, mon cold and pharyngitis, urinary infection, problems expressed fears related to DM because of different com- with the feet (crawling, burning, decreased sensitivity), plications, mainly coma but also loss of sight, heart fail- spasm in the calf, hypertension, and albuminuria, most ure, stroke and diabetic foot ulcers, and in one case respondents had used self-care measures related to the inability to buy drugs because of high costs (individual individual sphere (e.g. changes of food intake, rest, wait- and social factors).
and-see), nature (medications or herbs) or the supernatu- Most respondents experienced problems in their con- ral sphere (mainly prayers, sometimes holy water). When tact with health care staff who checked their DM. These necessary, help was sought from the professional sector, were related to delays by doctors, not coming on time or mainly from doctors and in some cases from nurses at a having lack of time to explain things, and delays at the hospital based clinic. Most respondents indicated diffi- pharmacy or dispensary.
culties in identifying the causes of the problems and said .doctors start their clinics late.see a lot of people at they were unsure or gave a variety of causes but often a time and are always in a hurry, so one does not get included an association with DM.
enough time to ask questions.delays at phar- .I think it was because of my diabetes.I used herbal macy.something has to be done. (10) leaves to rub over painful joints, smoked theherbs.also prayed for relief of my body pains.it Self-care and care-seeking pattern
worked. In the second instance I visited my doctor. (8) Respondents spoke of being informed about the impor- When discussing the occurrence of wounds on the feet, tance of reviewing the progress of DM by regular check- a pattern was evident where most respondents had ups of sugar levels and drug doses by a physician.
sought help from the professional sector at hospitals About half of the group had been informed about foot (social factors) and related the problem to injuries.
care but with a limited content: .advised that diabetic wounds take a long time to heal.should keep blood sugar low, avoid injuries and This study is unique as it explores beliefs about health keep feet dry. (6) and illness in a group of Africans originating from Zim- Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
babwe. The main results showed limited knowledge avoided collecting the frequently criticized superficial about the body and DM, health was expressed from a knowledge obtained by using only structured interviews pathogenic point of view as freedom from disease, and or questionnaires [.
individual factors such as compliance with advice Results from qualitative studies might be seen as lim- received and drugs were considered important to pro- ited as regards the possibility of generalizing data from mote and maintain health as well as to prevent deteriora- them However, the aim of the present study was to tion of DM. When people experienced health problems explore beliefs in a group of people diagnosed with type 2 related to DM, they used self-care measures to a limited DM and the focus was on disclosure of different perspec- extent, but when they did it was frequently a combination tives and not on finding results generalizable to the whole of individual measures, household remedies or herbs and population. Carefully collected and analysed qualitative prayers or holy water, and in some cases health care pro- data are transferable to other populations, or contexts fessionals were consulted for help. Poor economy was similar in characteristics mentioned as being harmful to health, and perceived as aconsequence of DM due to the need to buy expensive drugs and not being able to follow the recommended In this study beliefs about health were expressed from a treatment regimen.
pathogenic point of viewsimilar to what has beenfound in previous studies concerning beliefs about health and illness in Ugandan men and A consecutive sampling procedure was used, giving all migrants with DM living in SwedEconomic men and women visiting the clinic the same opportunity factors were emphasized as a major influence on health to participate in the study. The studied group mainly and the ability to comply with advice received about the comprised persons with a secondary level of education, of management of DM. Underlying living conditions might working age, coming from both urban and rural areas of thus be a barrier to adequate management of the disease, the country. Zimbabwe is considered to have one of as well as an underlying cause to it , and need to be Africa's best educational systems and thus the population considered in diabetes care. A conflict between willing- is relatively well-educated imary school is for- ness to comply and ability to comply was demonstrated, mally mandatory and followed by further education in and this is related to the current economic crisis in Zim- secondary school. According to reports by UNESCO, babwe. The crisis started in the late 1990s and has four out of ten children started secondary school in 2002.
entailed a social deterioration with increasing poverty, About two thirds of the population live in rural areas but poorer public health, lack of food etc 2006 about there is extensive migration into the bigger cities. Thus, 80% of the population of working age were unemployed, the studied group appeared to represent the general pop- 70-80% of the Zimbabweans are estimated to live in pov- ulation of Zimbabwe. Gender is not problematized in this erty, and about 4.3 million people were in need of food first explorative step but will be further elaborated in an aid according to the United Nations World Food Pro- extended study.
gramme in 2005. Similar findings have been shown Interviews were held mainly in Shona (n = 18) but also among Ugandans. The diabetes epidemic, particu- in English (n = 3), which are two of the three official lan- larly its distribution, is arguedo be produced by guages in Zimbabome 70-80% of the population poverty. The cumulative effects of structural constraints belong to the Shona-speaking group and this is spoken in on healthy lifestyles and lack of a right to adequate medi- everyday life by the majority, but many also speak Eng- cal care, are results of poverty leading to diabetes and its lish, particularly in the cities. Ndebele is the third lan- complications, and to disparities among social groups.
guage, spoken in the south and western part of the However, the differences are avoidable, unjust and unnec- country. The site where the study was carried out is situ- essary. The roots of the pandemia lie in inequalities in ated in the central part of Zimbabwe.
social power and the solutions required are structural.
In order to minimize the influence of different lan- Beliefs about health and illness were mainly related to guages, the interview guide was pilot-tested in both lan- factors in the individual combined with factors in nature guages, the interviews were conducted by a bilingual and the supernatural sphere as regards ways to improve nurse, and the participants were offered a choice as to the health or measures to restore health after having prob- language they preferred to use during the interview.
lems or being ill. Health care was consulted to a limited Triangulation of data by using different methods to extent and with few exceptions in the professional sector gain knowledge by open-ended and closed questions, when needed.
with probing for detailed beliefs and knowledge, made an Health-related behaviour thus did not correspond to in-depth understanding possible [nd possibly also what has previously been described in persons of non- revealed more or less unconscious beliefs and thus western origNon-westerners have been Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
described as focusing on the social or supernatural continuity of care, and limited time for consultations spheres to explain illness causation, and contacting family affecting the encounters with physicians and the ability to or friends in the popular sector first when in need of care pose questions and receive information about the man- and then turning to traditional healers in the folk sector, agement of DM. Another factor influencing knowledge in contrast to westerners who emphasize factors in the might be the fact that staff managing the clinic were not individual or nature and mainly consult the professional specialized in the area of diabetes care, which has previ- health care sector in the event of problems. As in previ- ously been shown to affect beliefs about health and illness ous investigatthe results do not corre- in persons with DM [study in South Africa, lack spond to the theoretical models chosen for of knowledge and need for further education related to analysing data. The differences might be explained by, for diabetes care have been identified as barriers to optimal example, dissimilarities in health care systems in different diabetes care ]. The health care system in the present countries and restricted empirical testing of explanatory study did not serve the diabetic persons and introduced models h further emphasizes the need to barriers to health. Structural conditions in the health care avoid crude generalizations about people's beliefs and system and the society thus, influenced individual beliefs instead to probe for and verify the individual's own per- about health and illness and the results confirm the spective. However, the models do play an important role importance of considering that population health is not as a framework when searching for different perspectives.
only related to life-style but is also tied into concrete con- Findings from open-ended questions showed that many ditions of existence and a broader socio-economic con- respondents were unsure of the cause of DM, while some text Health promotion is an activity concerned with stated biomedical explanations (antihypertensive drugs, improving living conditions and empowering communi- pancreatic disease). When adding results from discus- ties to gain control over the determinants of health.
sions of a list of potential causes, respondents mainly Reports from Havarate that a different mentioned individual factors such as obesity and approach to care in terms of empowering patients with unhealthy diet but also supernatural causes such as fate, skills and perceptions to cope with diabetes in a Continu- punishment from God, spirits etc. lying outside the per- ing Interactive Education in group discussions, cultural son's own control. Thus, the pattern appears to be more activities, dining out, and the like can be effective in an similar to what has been found in Europeans citing medi- impoverished situation. The patients might need a com- cally oriented causes, e.g. heredity and obesity plete new setting to learn to live with the disease under but also a fatalistic view discussing factors their conditions.
beyond a person's own control such as fate, the will ofGod etc. (an external locus of control; shown in Ugan- Although limited knowledge was demonstrated there [hus, a mixture of explanations was found that were indications of a potential to develop an attitude for might be related to limited knowledge about DM, also improving knowledge and self-care if this is supported by evident in discussions concerning the pathophysiology of relevant information about DM and improved socioeco- DM, action of drugs, and many were unable to identify nomic conditions, as many respondents emphasized a the disease at the onset and suspected other diseases such willingness to comply with advice received, knew that the as HIV, AIDS, malaria etc. The results confirmed previ- disease is life-long and had adequate fears of developing ous findings in Ugand concerning limited complications related to DM. Thus, it is important is to knowledge about DM in Africahe limited organize health care in a way that elicits individual beliefs knowledge about DM is also reflected in self-care mea- about health and illness in persons with DM and then sures undertaken to restore and maintain health, as many supports and provides the individual with appropriate had problems in identifying the causes of their health information to strengthen the patient's self-care capabil- problems and frequently used supernatural measures ity to become an active participant and partner in diabe- (prayers, holy water) and natural factors (herbal reme- tes care . In a country and life situation with a highly dies). Frequent use of folk medicine and visits to tradi- strained economic situation, as for example in Zimbabwe tional healers have previously been shown in Nigerians todan many other developing countries, [nd the use of complementary alternative medicine health care needs to switch from predominantly focusing might be explained by its accessibility in countries where on disease control and compliance with medication to a this is part of and recognized in the existing health care holistic attitude starting from an individual perspective system, as e.g. in Zimbabwe. However, knowledge def- but also considering social determinants of health icit might be related to the organization of diabetes care, to promote health and prevent DM and complications as many expressed dissatisfaction in contact with health related to DM in order to decrease the burden of the care related to delays by doctors and disruptions in the disease in light of the overarching pandemic of DM .
Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
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nations related to the influence of supernatural forces Zimmet PZ, Alberti GMM, World Health Organisation Report: Introduction: Globalization and the non-communicable disease such as fate, God, spirits, witchcraft etc., that influence ep Obesity 2006, 14:1-3.
health-related behaviour and thus self-care measures and Hjelm K, Bard K, Nyberg P, Apelqvist J: Religious and cultural distance in care-seeking behaviour. A factor of the utmost impor- beliefs about health and illness in women with diabetes mellitus of
different origin living in Swed. International Journal of Nursing Studies
tance affecting management of DM was the strained eco- 2003, 40:627-643.
nomic situation, and in order to develop cost-effective 10. Hjelm K, Bard K, Nyberg P, Apelqvist J: Beliefs about health and illness in and optimal diabetes care in a country with limited eco- men with diabetes mellitus of different origin living in Sweden Journal of Advanced Nursing 2005, 50:47-59.
nomic resources and 'the double burden of disease' 11. Hjelm K, Nambozi G: Beliefs about health and illness: a comparison not only educational efforts based on individual beliefs between Ugandan men and women living with diabetes mell Int are needed. Also the influence of structural factors in the Nurs Rev 2008, 55:434-441.
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The authors declare that they have no competing interests.
15. De-Graft Aikins: Living with diabetes in rural and urban Ghana: A critical social psychological examination of illness action and scope for KH and EM performed the study concept and design; EM did the data collec- interventi J Health Psychol 2003, 8:557-572.
tion; EM and KH analysed and interpreted data; KH drafted the manuscript; EM 16. Bopape M, Peltzer K: Health beliefs and stress among non-insulin and KH made final critical revisions for important intellectual content of the dependent diabetes outpatients in a rural teaching hospital in South manuscript. All authors read and approved the final manuscript.
Africa. Health SA Gesondheid 2002.
17. Dechamp-Le-Roux C, Valensi P, Assad N, Sislian P, Attali JR: Croyances des diabétiques sur l'étiologie de leur maladie. Influence de l'éthnie. We are grateful to Senior Tutor Ms Grace Nambozi, Mbarara University of Sci- (Aetiological beliefs in diabetic patients. Influence of ethnic or Diabete-Metab 1990, 16:207-212.
ence and Technology (MUST), Mbarara, Uganda, and Senior Lecturer Dr Björn 18. Hjelm K, Nyberg P, Apelqvist J: Beliefs about health and illness essential Albin, School of Nursing and Social Care, University of Växjö, Sweden, for help- for self-care practice: a comparison of migrant Yugoslavian and ful criticism and stimulating discussions. We are also grateful to Dr Alan Crozier, Swedish diabetic fema Journal of Advanced Nursing 1999, professional translator, for reviewing the language.
This work was supported by grants from The Research Committee at the 19. Patton MQ: Qualitative research and evaluation methods 4th edition. School of Health Sciences and Social Work, University of Växjö, and The Lin- London: Sage Publications; 2004. naeus-Palme Foundation, Swedish International Development Aid (SIDA), Swe- 20. SIDA: Landguiden Uganda, Afrika. (The land guide of Uganda, Africa) 2007 den, enabling joint international collaboration in Sweden and Zimbabwe.
21. Mayring P: Qualitative Content Analysis. Forum: Qualitative
1School of Health and Caring Sciences, Linnaeus University, Växjö, S-351 95 Sozialforschung/Forum: Social Research 2000, 1(2): Växjö, Sweden and 2Department of Health Sciences, Zimbabwe Open University, Harare, Zimbabwe ]. On-line journal 22. Helman C: Culture, Health and Illness London: Butterworth & Co Received: 27 October 2009 Accepted: 12 May 2010 (Publishers), Ltd; 2007. Published: 12 May 2010 23. Kleinman A: Patients and healers in the context of culture London, University of California Press, Ltd; 1980. Hjelm and Mufunda BMC International Health and Human Rights 2010, 10:7
24. Stuart L, Wiles PG: A comparison of qualitative and quantitative research methods used to assess knowledge of foot care among
people with diab. Diabetic Medicine 1997, 14:785-791.
25. Antonovsky A: Unraveling the mystery of health San Francisco: Jossey-Bass 26. Chaufan C: What does justice have to do with it? A bioethical and sociological perspective on the diabetes epidemic. Advances in Medical
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27. Mammah Popoola M: Living with diabetes. The holistic experiences of Nigerians and African Americans Holistic Nursing Practice 2005, 19:10-16.
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organisations. Midwifery 2008, 4:168-82.
29. Haque M, Emerson Hayden S, Dennison C, Navsa M, Levitt N: Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape To SAMJ 2005, 95:798-802.
30. Raphael D: Grasping at straws: a recent history of health promotion in Canada. Critical Public Health 2008, 4:483-495.
31. García R, Suárez R: Diabetes education in the elderly: a 5-year follow-up of an interactive approach. Patient Education and Counselling 1996,
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