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LEARNING IN A MISSION OUTPATIENT DISPENSARY
IN SIERRA LEONE - A FIELDWORK STUDY

presented by

Evvy Hay

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LEARNING IN A MISSION OUTPATIENT DISPENSARY

m SIERRA LEONE - A FIELDWORK STUDY
Bu

Ewg Hag

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Adult and Continuing Education

1967

ABSTRACT

LEARNING IN A MISSION OUTPATIENT DISPENSARY
IN SIERRA LEONE - A FIELDWORK STUDY

59

Evvy Hay

Mission outpatient dispensaries, which often operate at frenetic level of
activity, are a common source of health care services in developing countries.
It is meaningful to consider what patients are learning about the nature and
treatment of their illnesses under such conditions. Host health center
research has focused on staffing and delivery of services, an area of interest
to administrators. In contrast, this writer examined the learning experiences
that occur in an outpatient dispensary from the perspective of the patient, an
area of concern to adult educators.

An ethnographic approach was used to focus on patient learning in the
Kaseia Hospital outpatient dispensary. The study was delimited to patient
learning in outpatient settings and did not include patient learning in other
health care settings such as hospitals, Under Five clinics, and primary health
care programs. Strategies used included observations, participant
observations, interviews of staff and patients, and a survey of dispensary
outpatients. investigation focused on the learning environment, learning
opportunities, and patient recall of specific information. Three area villages
were surveyed to determine to what extent villagers were using the
dispensary and to interview villagers regarding what they had learned from

Evvy Hay

the outpatient dispensary experience. Local health authorities were
interviewed for information on health habits. in addition, 50 people were
interviewed regarding their perceptions of Western pharmaceuticals. Finally,
to understand better the Kaseia Hospital outpatient dispensary in the larger
context of outpatient services in Sierra Leone, on-site visits were conducted
at six other mission hospitals.

Study findings demonstrated that what patients learned was primarily
related to instructions about their treatments and knowledge of how to take
medications. Environmental factors, including crowding and limited time,
staff roles that did not include expectations for patient education, and a lack
of teaching protocol affected the learning environment. Findings related to
health habits of patients centered on a number of themes, including medical
pluralism, the importance of therapy-managing groups, and the
reinterpretation of Western pharmaceuticals.

For Gordon and Helen Hay

ACKNOWLEDBI‘IENTS

Several expressions of appreciation are in order at the completion of this
dissertation. The first is to Dr. Ted Ward, who invites his students to walk
alongside him and suggests doors of opportunity in life to them.

The next is to Guidance Committee members Drs. Norman Bell, Howard
Hickey, and John Hunter for their suggestions and support. The
recommendations and encouragment of Dr. Doug Campbell were valued, as
well.

Appreciation is due the Michigan State University African Studies Center,
the Sage Foundation, and the Wesleyan Medical Fellowship for their
assistance in funding the research.

A word of warm regard goes to the staff of Kamakwie Wesleyan Hospital
and the American Wesleyan Mission in Sierra Leone, who in every way
assisted during the on-site research time. Special thanks are due to Rev.
and Mrs. Don Kinde of the American Wesleyan Mission, Mrs. Marion Morgan of
the Christian Health Association of Sierra Leone, and Dr. George Sage of the
University of Sierra Leone, who administratively facilitated the research
visit. A personal word of tribute is in order for Dr. and Mrs. Charles Pierson,
who in their combined 33 years at Kamakwie have done much to keep the
doors of Kamakwie Wesleyan Hospital open to those in need.

III

Finally, there is a thank-you to my family: to Gordon Hay, a father whose
time on the computer and whose unending willingness to assist made the
dissertation write-up both possible and a warmly shared experience; and to
Helen Hay, a mother who has always been in the front row of my life,
clapping and cheering. They are parents who told us we were the most
wonderful daughters in the world, and they loved us as if that were true.

IV

TABLE OF CONTENTS

Page
LIST OF TABLES ................................................ viii
LIST OF FIGURES ................................................ ix

Chapter

I. PURPOSE ................................................. i
Context of the Problem ................................... 2
Research Questions ...................................... 5
Precedents in the Literature .............................. 5
Procedural Overview ..................................... 7
Population .............................................. B
Delimitations ........................................... 9
Limitations ............................................. 9
Definition of Terms ...................................... 9

Generalizability ......................................... i 2

importance of the Study .................................. 12

Ii. PRECEDEHTS IN THE LITERATURE ............................ i4

Ethnographic Precedents ................................... lS

Evans-Pritchard ......................................... iS

Finnegan ................................................ i7

Health in Sierra Leone ..................................... 20

Health Status and Services ................................ 20

Health Beliefs and Practices .............................. 24

Medical Anthropology ...................................... 30

Janzen .................................................. 30

Additional Medical Anthropology Literature .................. 32

Health Education ........................................... 35

Health Education Concepts ................................. 35

Health Education Considerations ............................ 37

Summary ................................................ .' 43

III. RESEARCH POPULATION AND PROCEDURES ...................... 45
Population ............................................... 46
Outpatient Dispensary Usage .......... ' ..................... 46
Outpatient Survey ........................................ 47
Village Surveys .......................................... 50
Research Questions ........................................ 54
Research Procedures ....................................... 55
Design Related to Research Questions I Through 4 ............ 57
Design Related to Research Question 5 ...................... 63
Summary ................................................. 67
IV. FINDINGS RELATED TO PATIENT LEARNING ...................... 70
The Learning Environment .................................. 71
The Facility and Services ................................ 7i
Observations Related to Patient Learning .................. 72
Learning Opportunities .................................... 76
Nurse/Patient Interactions ............................... 76
Drug Dispenser/Patient Interactions ....................... 7B
Physician/Patient Interactions ........................... 80
Staff Interviews ........................................ 62
Patient Recall of Specific Information ...................... G3
Dispensary Interviews .................................. 64
Village Interviews ...................................... 66
The Learning Environment of Other Mission Hospitals ......... 90
Summary ................................................ 93
V. FINDINGS RELATED TO HEALTH HABITS ........................ 96
Health Habits Generated From Previous Experiences ........... 97
Data From Outpatient Interviews .......................... 97
Health-Habit Information From Local Authorities ............ 102
Western Pharmaceuticals as a Health Habit ................. I05

vi

Health Habits Generated From the Outpatient

Dispensary Experience .................................. 109

Vignette 1--Papa ...................................... 109
Vignette 2--Kalimba Village Measles Epidemic ............ 1 12

Vignette 3--Dan1el ..................................... 114
Summary ............................................... I 15

VI. CONCLUSIONS and RECOMMENDATIONS ....................... 1 16
Conclusions Related to the Research Questions .............. 116
Implications and Recommendations ........................ 123
Suggestions for Further Research ......................... 124
Summary ............................................... 124
APPENDICES ................................................... 126
A. OUTPATIENT DISPENSARY USAGE ............................. 126
B. OUTPATIENT SURVEY DATA ................................ 130

C. VILLAGE SURVEY DATA ................................... 146

D. FACILITY MAPS ........................................... 146
E. OUTPATIENT INTERVIEW FORM ............................. 153
F. OUTPATIENT INTERVIEW DATA .............................. 155
G. DATA FROM STUDY OF PERCEPTIONS OF PHARMACEUTICALS ..... 156
REFERENCES ................................................... 167

VII

LIST OF TABLES

Table Page
1. Vital Events Statistics for Sierra Leone .................... 20
2. Distribution of Health Manpower and Structural Facilities
in Sierra Leone ........................................ 21
3. Wage Payments .......................................... 49
4. Attendance Figures at Nongovernment Mission Hospitals
and Outpatient Dispensaries ............................ 91
Al. Outpatient Dispensary Attendance Figures
1960 through I 966 .................................... 126
6.1. Kaseia Hospital Fee Schedule (December, 1966) .............. 130
6.2. Fees Paid by Outpatients per Illness Episode ................. 132
6.3. Distance to Kasela Hospital Outpatient Dispensary ........... 133

6.4. Distance Traveled to Kaseia Hospital Outpatient Dispensary. . . 137
CI. Basic Descriptive Information on Villages Surveyed .......... 146

C2. Outpatient Dispensary Usage in Villages Surveyed ........... 147

VIII

Figure
Al.

A2.

A.3.

A.4.
B. I.

8.2.

8.3.

B4.

85.

B.6.

B.7.

LIST OF FIGURES

Page

Outpatient Dispensary Attendance for 1960 through1966 . . . . 127
Average Monthly Outpatient Dispensary Attendance

for 1965 and 1966 .................................... 126
Average Daily Outpatient Dispensary Attendance

for 1965 and 1966 .................................... 126
Outpatient Dispensary Attendance by Day of Week ............ 129
Ethnic Groups Represented in the Outpatient Survey ........... 136
Ethnic Groups Represented by Appointment Unit

Patients in the Outpatient Survey ......................... 139
Categories of Outpatients Surveyed

(Numerical Representation) .............................. 140
Categories of Outpatients Surveyed

(Percent Representation) ................................ 141
Level of Education of Outpatients Surveyed ................... 142
Time of Day at Which Patients Completed Their

Outpatient Dispensary Visits ............................. 143
Fees Paid by Outpatients per illness Episode .................. 144
Distance Traveled to Kaseia Hospital ......................... 145

IN

C.1. Map of Kaioko Village ....................................... 146

C2. Map of Rotemne Village ..................................... 149
13.3. Map of Kalimba Village ...................................... 150
0.1. Diagram of Kaseia Hospital and Outpatient Dispensary .......... 151
0.2. Diagram of Outpatient Dispensary ............................ 152

CHAPTER I
INTRODUCTION TO THE STUDY

The purpose of this fieldwork study was to describe what patients learn
about the nature and treatment of their illnesses in a mission outpatient
dispensary, specifically the Kaseia Hospital outpatient dispensary located in
the Sela Limba chiefdom of Sierra Leone, West Africa. The study resulted in
a conceptualization of patient learning in this context. The investigation
was intended to provide insights into what patients learn about their
Illnesses and treatments In a busy outpatient dispensary, to contribute to
the knowledge of what effect a dispensary experience has on patient learning
about illnesses and treatments, to assist health care workers in considering
what constitutes an educative outpatient environment, and to bring into
focus the Issue of outpatient learning for people who have both a concern for
this area and the ability to do something about it.

In W John Dewey (1936/ 1 963) provided a
conceptual framework for learning experiences in which he described
experience as an interaction between the individual and his environment.
Experience, then, generates habits that are both available in and temper the
character of subsequent experience. That is, experience is continuous. As
described by Dewey, habits need not be executed blindly but can be carried
out intelligently with awareness of circumstances and probable
consequences. Habits are the means (or tools) by which people actively cope
with the problems posed by their environments. 'Certain sorts of habits“ are
manifestations of growth. That is, those habits that enable an individual to

clarify and cope with the problems of his environment and lead to additional
habits for understanding and coping with new problems as they occur
manifest growth. The implication of Dewey’s theory is that in a learning
environment there needs to be a knowledge of the problems participants have
(and are likely to have), together with a knowledge of the habits which are
useful in clarifying and coping with those problems, in order to provide the
sorts of experiences in that environment that will result in the development
of those habits.

Dewey's theory is germane in the context of patient learning in the Kaseia
Hospital outpatient dispensary. A patient coming to the clinic has already
had experiences related to learning about health, Illness, and various types
of treatments. Seeking no assistance when 111, turning to a traditional
practitioner, or purchasing medicines in the local market are all
"experiences,” and have resulted in particular health habits. In the
outpatient dispensary environment, an additional interaction takes place.
This writer looked at what patients learned in the dispensary environment,
while considering the influence of their previous experiences as part of that
learning process.

Context of the Problem

The need for health care services in Sierra Leone is clear. The 1974
census figures fixed life expectancy at birth as 36 to 40 years for females
and 33 to 37 years for males. The infant mortality rate at that same time
was 225 per 1000, rivaling Guinea and Upper Volta for the world's highest
rates (Okoye, cited in MacCormack, 1964). In the capital city of the Southern
Province, mothers aged 14 to 20 lost more than half the children they had
borne (Kanden at Dow, cited in MacCormack, 1964). A survey of 4,660

children under five years in 1977 judged 24: (below the 90th percentile of
the median of the standard used) to be malnourished (AID, cited in
MacCormack, 1964).

Endemic environmental diseases such as malaria, hookworm, roundwonn,
amoebiasis, schistosomiasis, and onchocerciasis affect adult health as well.
Infectious diseases such as pneumonia, leprosy, and tuberculosis also
influence health.

High morbidity and mortality rates do not exist in isolation, however.
They form only one part of the common quintet of developing countries:
poverty, Ignorance, fecundity, prejudice and disease (Fendall, 1967). Sierra
Leone's approximate per capita income of $210 per year is the second lowest
among 17 West African countries (Lamb, 1965). Health care expenditures
have steadily declined from 15.48 of government expenditures in 1963-64 to
6.23 in 1960-61, reflecting government policies which have not favored
health (Nickson, cited in MacCormack, I964).

The government alone is not able to meet the health needs of the country.
In the three provinces (Northern, Southern, Eastern), 46% of hospital beds are
provided by seven mission and three mining hospitals. 'The worst served
provincial area [is] the Northern Province' (Clark, 1969, p. 66).

Within the Northern Province, Kaseia Hospital has provided health
services in the Sela Limba chiefdom since the 19303. In 1966there were
70,953 outpatient visits and 1,761 hospital admissions. Major surgeries
numbered 511 and procedures 1,555. In the 10 monthly Under Five
immunization clinics in the town of Kaseia and surrounding villages, 5,1 16
children were seen. The four chiefdoms surrounding the hospital have a
catchment area population of 72,000 (Zampese, 1964), but in fact more
chiefdoms use the hospital.

In designing rural health care systems, planners historically have focused
on the geographic distribution of health services and the training and supply
of personnel. Evaluation of these health centers has been limited to
investigating staff work loads and patterns of time allocation, according to
a Johns Hopkins University study (cited in Akin, 1965). Analyses of work
patterns consistently have indicated a 'frenetic level of activity“ in these
health centers. A typical example described in a World Health Organization
study by Sharma and Chaturvedi in India indicated that medical officers were
seeing from 100 to 130 patients in a five-hour work day, which means that
each patient received only two to three minutes of attention (cited in Akin,
1965).

In such hurried clinic environments, staff typically spent a large
percentage of their time delivering curative services. A study by Spruyt
(cited in Akin, 1965) indicated that relatively little time was left for other
characteristic clinic services, such as preventive care, maternal and child
services, and nutrition and health education programs.

Given the need for health care services and the fact that in developing
countries clinics frequently function at a frenetic pace a meaningful
question to consider is what patients learn about the nature and treatment of
their illnesses under such conditions. As indicated, most health center
research has focused on staffing and delivery of services, an area of Interest
to administrators. In contrast, this writer examined the learning that
occurred in a health center clinic from the perspective of the patient, a topic
of concern to adult educators. '

5

Research Questions

The main question of the research study was “What are patients learning
about the nature and treatment of their illnesses in the Kaseia Hospital
outpatient dispensary?” The research questions that arose from that were
the following:

1. What is the learning environment of the outpatient dispensary?

2. How are learning opportunities organized and conducted in this setting
in terms of understanding the nature and treatment of Illnesses?

3. What specific information about the nature and treatment of their
illnesses do patients recall from their clinic visits?

4. Is the learning environment of the Kaseia Hospital outpatient
dispensary similar/dissimilar to that of other mission hospitals in Sierra
Leone?

5. What are the health habits (beliefs, practices) of those using the
outpatient dispensary?

a. What health habits (beliefs, practices) have been generated from
previous experiences?

b. What health habits (beliefs, practices) have been generated from the
outpatient dispensary experience?

Precedents in the Literature
Four bodies of literature provided meaningful precedents for this study:
the ethnographies of Evans-Pritchard and Finnegan, research information
related to health in Sierra Leone, medical anthropology research, and
literature related to health education.

Evans-Pritchard's monographs entitled Waiting];
W (1937) and IDLEIIIEE (1940) provided methodological

insights into ethnographic research, as well as substantive Insights into
beliefs regarding health and disease in a specific culture in the Sudan.
Finnegan's monograph Winona
(1965) not only provided valuable methodological suggestions, but was rich
in information on the Limba people, including their beliefs about health and
disease.

Two bodies of literature related to health in Sierra Leone contributed to
the study. The first was literature relating to health status, and the second
concerned health beliefs and practices. The usual “litany of depressing
statistics“ (Parker, 1966, p. 499) was placed in the larger context of
information related to available services and an analysis of problems in
health services. The literature on health beliefs and practices touched on
concepts of disease, traditional medicine, geophagy, perceptions of Western
pharmaceuticals, and women and health.

The medical anthropology literature illuminated several themes that
emerged in the course of the research in Sierra Leone. In MM
W Janzen (1976) highlighted the concepts of medical
pluralism and therapy-managing groups. Prins (1979) touched on the
coexistence of diverse therapy systems. Twumasi (I979) dealt with the
adaptation that occurs when diverse therapy systems coexist. Davis-Roberts
(1961) presented a case study, done among the Tabwa of Zaire, which
demonstrated that the pragmatic use of different therapy systems, including
Western therapy, did not involve engagement with an epistemological system
that contradicted the Tabwa system.

In the health education literature, attention was focused on how the
concepts of health education have changed over the years. Health education
is no longer concerned with disseminating information to passive audiences,-

rather it focuses on an educational role in which behavior changes result
through people understanding their own environment and how they can
exercise control over it (Welt, 1965). Finally, attention was focused on
factors that affect health education programs, such as administrative and
environmental considerations, the population being served, and principles and
methods of learning that influence health education efforts.

The literature provided both substantive and methodological precedents
for the study. It also provided a larger context in which to view health care
at the Kaseia Hospital outpatient dispensary. The medical anthropology
literature provided tools for analyzing the findings of the research. The
health education literature showed the stress placed on community
participation in health education today. It also highlighted specific
considerations that arise in health education in outpatient dispensaries.

Procedural Overview

Research was conducted from September 1966 through mid-December of
1966 in Sierra Leone. The ethnographic approach was used to focus on patient
learning in the Kaseia Hospital outpatient dispensary. Ten weeks of research
time were spent at the Kaseia Hospital outpatient dispensary. Methodologies
used there included observations, participant observations, interviews of
staff and patients, and a survey of dispensary patients. The fool for
investigation were the learning environment, learning opportunities, and
patient recall of specific information. The researcher visited three area
villages, as well, to ascertain to what extent villagers were using the
dispensary and to interview villagers regarding what they had learned from
the outpatient dispensary experience. To clarify the issue of health
practices, local authorities were interviewed for information on health

habits. Further, 50 people were interviewed concerning their perceptions of
Western pharmaceuticals. To understand the Kaseia outpatient dispensary in
the larger context of outpatient services in Sierra Leone, there were on-site
visits and interviews conducted at six other nongovernment hospitals, all of
which belonged to the Christian Health Association of Sierra Leone (CHASL).

Narrative data were analyzed with a view to developing a theory of what
patients learned in the Kaseia Hospital outpatient dispensary. Limited
quantitative data were obtained to support the narrative data. This
information is displayed in tables and figures.

Population

The primary population of the research study comprised persons using the
services of the outpatient dispensary at Kaseia Hospital. In 1966, 70,953
patients were seen. The major ethnic groups using the clinic were the Limba
(46.33) and the Temne (24.4%). The Susu, Fullah, Loko, Mandingo, and 10
other groups were also represented. About 573 of all patients traveled less
than 10 miles to reach the dispensary. Nearly 403 of all clinic patients paid
less than Le 15.00 (3042) per illness episode.

The population using the outpatient dispensary lived in countryside that
was cries-crossed with winding rivers, laterite motor roads, and narrow
bush paths. Villages were clusters of thatch or “pan“-roofed houses. The
majority of household heads were farmers. Rice farms were located outside
the villages, in the surrounding area. The town of Kaseia, with a pdpulation
of about 10,000, was in a rural area. It does not have running water or
electricity.

9

Delimitations
The study was delimited to patient learning in outpatient settings and did
not include learning that took place in other health care settings such as
hospitals, Under Five clinics, and primary health care programs. Some staff
interviews and a number of the interviews on the use of Western
pharmaceuticals were group interviews. Groups‘were selected because they
occurred naturally. Participants were free to interact in these interviews.

Limitations

Patients from five language groups were present on any given day in the
outpatient dispensary. The researcher conversed freely with Krio-speaking
patients and was able to ask specific questions in Temne and Limba. Other
conversations in Limbo and Temne, and all conversations with patients of
other ethnic groups, took place through an interpreter. in many instances,
the depth of conversation was more limited than is desirable in an
ethnographic study.

Reliability of responses to interviews in the clinic may have been
affected by interaction effects in a congested environment. In group
interviews the interaction among participants might have influenced the
validity of individual responses.

Definition of Terms
mm. The process of coming to share the cognitive orientation of
people in a second culture (Brewster & Brewster, 1976, p. 122).
W. A Thursday-morning clinic in which patients paid a
fee to be seen by a physician. In general, more affluent patients
attended this clinic.

I0

WW. Habits that are available in and temper the
character of subsequent experience (Dewey, 1936/ i 963, p. 44).

MM- That which fosters growth (Dewey, 1936/ 1963, p. 36).

{63.1129611216111- Whatever conditions interact with personal needs, desires,
purposes, and capacities to create one's experience.

M. An interaction between the individual and his environment
(Dewey, 1936/1963, p. 43).

My. The eating of earth, including vespid and termite clays. In Sierra
Leone, geophagy is common during pregnancy.

W. Plastic spoon containing a measuring scoop on each end,
used in mixing sugar and salt solution for oral rehydration.

m. Securing “certain sorts of habits.“ One is said to be growing (in
general) when the habits he/she is acquiring from experience do not
thwart problem solution or create new problems, but rather help
him/her to clarify and cope with present problems and make some
contribution to the acquiring of additional habits for understanding and
coping with subsequent problems as they occur (Dewey, 1936/1963, p.
36). ,

Hams. Means (or tools) for actively coping with the problems posed by the
environment . Habits need not be executed blindly or unthinkingly, but
can be carried out intelligently with awareness of (changing)
circumstances and (probable) consequences. A habit is a learned
tendency or disposition to respond in a certain manner in a given
situation (Dewey, 1936/1963, p. 35).

M. An individual who practices only herbal treatment.

W. A visit, orcluster of visits, for the treatment of a single
illness.

II

WM. Level 1 = no formal education
Level 2 = some primary school

Level 3 = some secondary school
Level 4 = secondary school graduate
Level 5 = some post-secondary education

W (Look grun man). Individual who mixes herbal treatment
with clairvoyance.

W- That which thwarts growth (Dewey, 1936/1963, p. 25).

m. A Muslim diviner.

W. A condition produced by an infestation of filarial worms,
which live in subcutaneous and connective tissue.

W. A parasitic disease resulting from infestation with blood
flukes belonging to the genus Splittefasama People become infected by
bathing or wading in water that contains cercaria which have come from
snails.

Sum (Medicine man). Individual who mixes herbal treatment with
supernatural practices.

WWW. Community women working as midwives among
their own people. They are respectfully described as “grannies.“

Some have had formal training, but more have not had any training.
Virtually all are members of the women's sodalities.

W. Monthly immunization clinics for children up to the age
of five years. The clinics include health education and curative care
components.

MW. Conjunctival dryness following chronic conjunctivitis and in
disease due to a vitamin A deficiency. Softening, desiccation, and
ulceration of the cornea result.

I2

Generalizability

Numerous similarities existed between the Kaseia Hospital outpatient
dispensary and the outpatient dispensaries of the other nongovernment
hospitals visited as part of the study. Therefore, the findings from the study
at Kaseia may well be applicable to the other outpatient dispensary settings.
Further, as discussed earlier, overcrowded outpatient dispensaries are
common throughout Africa, and indeed other parts of the world. Portions of
the study may be of value to staff of those institutions as well.

Importance of the Study

The study answered the major question, “What did patients learn about
the nature and treatment of their illnesses in the outpatient dispensary?“
The answer was that learning was primarily related to information patients
gained regarding instructions about their treatment and knowledge of how to
take medications. They learned little about the nature of their illnesses or
the purpose of their medications. Environmental factors including crowding
and limited time partially shaped the learning environment, but staff role
expectations that did not include expectations or a protocol for patient
education were also important. That is, there was no institutional plan for,
or commitment to, outpatient education.

Other important data focused on the health habits (beliefs, practices) of
those using the outpatient dispensary. In some cases the Western and
traditional systems coexisted but did not seem to affect each other. In other
cases, modifications of one of the systems occurred. The findings supported
the results of other studies in the medical anthropology literature. Important
themes included medical pluralism, the importance of therapy-managing
groups, and the reinterpretation of Western pharmaceuticals.

I3

The study was intended to make four contributions: (a) to provide
insight into what patients learn about their illnesses and treatments in a
busy outpatient dispensary, (b) to contribute to the knowledge of what
effect a dispensary experience has on patient learning about illnesses and
treatments, (0) to assist health care workers in considering what
constitutes an educative outpatient environment, and (d) to bring into focus
the issue of patient learning, in this common setting, before people who
have both a concern for this area and the ability to do something about it.

CHAPTER II
PRECEDENTS IN THE LITERATURE

Four bodies of literature provided precedents for this study: ethnographic
anthropological studies, literature related to health in Sierra Leone, works
in the field of medical anthropology, and health education literature.

Two writers in the field of anthropology provided ethnographic
precedents for this study. They were E. E. Evans-Pritchard and Ruth Finnegan,
both of Oxford. Evans-Pritchard focused on two ethnic groups in the Sudan,
whereas Finnegan wrote on the Limba of Sierra Leone. Literature relating to
health in Sierra Leone provided a context in which to view health care at the
Kaseia Hospital outpatient dispensary. In this area, literature on health
status and services was considered, as well as writings on health beliefs
and practices. Literature related to health beliefs and practices included
writings on concepts of disease, traditional medicine, geophagy, perceptions
of Western pharmaceuticals, and women and health. The medical anthro-
pology literature provided rich substantive precedents for understanding
patient learning in an outpatient situation and dealt with such themes as
therapy-managing groups, causality, logic in selection of treatment, and
medical pluralism. The health education literature reviewed for this study
dealt with the way health education concepts have changed over the years
and specific considerations that arise when one examines health education in
an outpatient dispensary setting.

I4

IS

Ethnographic Precedents
Ethnographies by two British writers provided both methodological and
substantive precedents for this study. E. E. Evans-Pritchard of Oxford wrote
about the Azande and Nuer in Sudan. His student, Ruth Finnegan, wrote
extensively about the Limba of Sierra Leone.

We:

A social anthropologist, Evans-Pritchard wrote classic ethnographic
studies of the Azande and the Nuer in monographs entitled W
WW (1937/ 1963) and the mm:

(1940/ 1962). At the request of British colonial officials, Evans-Pritchard
lived among the Azande, and later the Nuer, in the Sudan. Specific interests,
which relate to concerns of this study on patient learning, were cases in
which people met and dealt with misfortune, allocation of responsibilities
for action, and how people directed their lives.

Methodologically, Evans-Pritchard recommended that ethnographers have
rigorous training in general theory before fieldwork and a clear sense of
who! and how one plans to observe. He suggested it is “useless going into
the field blind“ and that “one must know precisely what one wants to know“
(1963, p. 241). Once in the field, however, a researcher should be guided by
what he finds in the society under study. For example, the Azande constantly
talked of witchcraft and the Nuer of cattle. Consequently, Evans-Pritchard‘s
observations focused on those areas because of their prominence in the lives
of the people he was studying.

With regard to fieldwork methodology, Evans-Pritchard recommended a
thorough knowledge of the language. He achieved this during his 20 months
among the Azande and year among the Nuer by working at it 12 hours every

16

day. He advocated learning about social processes and relationships by
noting material things because every idea is represented in words and
objects. He also suggested sharing in the ideas and belief systems of the
people being studied on the grounds that a remunerative or even intelligent
conversation with people about what they regard as self-evident is not
possible if the researcher appears to regard their belief set as an illusion or
a delusion. That is, he advocated becoming acculturated.

Evans-Pritchard used the data-gathering methodology that the particular
situation required. When he lived outside the community, Evans-Pritchard
gathered data on the Azande primarily from key informants. When he lived
among the Nuer, he relied on participant observation.

As I could not use the easier and shorter method of working through
regular informants I had to fall back on direct observation of, and

. participation in, the everyday life of the people. From the door of my
tent I could see what was happening in camp or village and every
moment was spent in Nuer company. Information was thus gathered in
particles, each Nuer I met being used as a source of knowledge, and

not, as it were, in chunks supplied by selected and trained informants.
(1962, p. 15)

Finally, Evans-Pritchard (1937/ 1963) suggested that the real work of
fieldwork is in developing theoretical conclusions, which should be implicit
in exact and detailed descriptions of empirical observations. Anyone “who
is not a complete idiot can do fieldwork,“ but the intention of fieldwork is
not to produce a new fact but a new idea (p. 243). For example,
Evans-Pritchard described the cosmology of the Nuer. In this cosmology, an
invisible sky spirit named Kwoth both caused and cured sickness. People
communicated with him through prayer, sacrifices, and obedience.
Complaining at misfortune or grieving excessively at death was considered
inappropriate. Evans-Pritchard described the Azande concept of causation,

I7

which he detailed as part of a coherent and consistent epistemology. He
suggested that factors within a social system made it impossible for people
to think conceptually or account for reality beyond the framework of their
social system. In relation to health, for example, the Azande considered only
causation for an episode of a particular sickness, but had no coherent theory
for causation of sickness in general. Particular situations were accepted,
but they were never clarified or discussed. Consequently, there was no
theory in general about causation of sickness that could be proved true or
false. Evans-Pritchard's monographs provided both methodological insights
into ethnographic research and substantive insights related to health and
disease among a particular group of people.

flflflflgflfl

Evans-Pritchard supervised Ruth Finnegan's comprehensive ethnographic
811101). WM (1965). This
monograph covered the history of the Limba people to the end of the
nineteenth century, the political structure in the twentieth century, social
institutions, economy, religion and witchcraft, and migration. Finnegan’s
was the first, and to date only, published indepth study of the Limba people.
A book of readings on the Limba people edited by Joseph Opala (Department of
Linguistics, Fourah Bay College, University of Sierra Leone) and K. P. Moseley
(Department of Sociology, University of Port Harcourt in Nigeria) is soon to
be published. The ten contributors focused on Limba history, arts, culture,
and developmental issues.

Methodologically, Finnegan's work was also a qualitative study. Detailed
demographic sampling was not included because of variability among the
seven Limba chiefdoms and because it was felt that intelligent selection for

IB

quantitative sampling could be done only after a preliminary qualitative
study. The first government census among the Limbas was not taken until
two years after Finnegan's 1961 fieldwork. She collected data for her study
from informants in each of the chiefdoms, as well as from migrant Limbas in
Freetown and Lunsar. Findings of Finnegan’s research on religion and
witchcraft, which relate to the Limbas beliefs regarding health, are briefly
summarized below. ’

The Limba believe in one god, named Kanu, who ultimately causes all
things. People who are well have their health “by the grace of Kanu.“ If
asked about health, an appropriate reply is, “I am well by God's grace“ (1965,
p. 106). Death can be caused in four ways: by witchcraft, by a swear, by the
power of a spirit, or by Kanu. The Limba would consider a natural death in
old age to be caused by Kanu. The way to deal with the first three cases is to
divine the cause of death and then to catch the person responsible or to free
those involved from further effects.

A sore or saraka is a material charm that is used to protect health. It
may be a variety of objects, such as cowries or kola nuts. A saraka also
implies a sacrifice, which might be a hen, millet, guinea corn, or rice flower.
In WWW Rivers (1924) described belief in the power
belonging to material objects prepared in a certain way as fetichism. Dead
ancestors may be reached through sacrifices and prayers and are believed .
still to be concerned with helping their children. *

Spirits, who have never been human, live outside the villages and are
believed to have particular relationships with individuals. People who have
double sight or “four eyes“ are said to have the ability to see the spirit
world. All twins have four eyes, and the child who follows them in the birth
order does also. Spirits help individuals prosper but may later demand

19

payment, including requiring a person to “eat by means.“ When a person is
“eaten by means“ nothing appears to happen immediately, but the victim later
dies an unexplained death. Disease may be ascribed “to absence of the soul or
of the vital principle“ in other areas of West Africa, as well (Rivers, 1924, p.
79).

Witches are men or women who attack their enemies by spiritual means.
They go out at night spiritually, not in a physical body, and “eat“ the heart of
a victim, who later dies. Charms on the door of a house can prevent a witch
from entering and may even cause the witch's death. Deaths are commonly
attributed to witchcraft. Witches may control animals such as snakes and
crocodiles, causing them to bite people. Witches are also thought to use
special guns called “witch guns“ to kill people. These guns are made from a
variety of materials, such as animal horns.

Finnegan (1965) summarized the importance of religion and witchcraft in
relation to health and disease in this way:

Limba life is therefore full of detailed rules and prohibitions which
must be observed,- sacrifices must be made to the dead, offerings to
spirits, charms hung up to fight witches, cowries fixed on knives,
handkerchiefs, instruments, certain places and acts avoided as being
forbidden and so on. But the main theme that unites all these swears

and sacrifices and purifications is that of combating evil influences,
those that cause death and disease. (p. 122)

Knowledge of religion and witchcraft is essential to an understanding of
causality in Limba thinking. In turn, this understanding is essential to an
understanding of health beliefs and practices.

The ethnographic studies of Evans-Pritchard and Finnegan provided both
valuable methodological suggestions regarding fieldwork, as well as
substantive insights on thinking regarding causality, health, and disease.

20

Finnegan's work also provided much information on the Limba people, the
major population of this study.

Health in Sierra Leone
An understanding of the learning that occurred in the Kaseia Hospital
outpatient department can be strengthened by an understanding of health
care services, practices, and beliefs that existed in the country as a whole.
The information relating to health in Sierra Leone is considered in two main
categories: health status and services, and health beliefs and practices.

Wm

In a 1960 World Health Organization (WHO) W
W (Amonoo-Lartson A Olu-Williams) article, the leading causes

of morbidity and mortality were cited as infection, malnutrition and
communicable disease. Solutions to those problems were made more
difficult by acute shortages of “human, material and financial resources at
the disposal of the government“ (Amonoo-Lartson &Olu-Williams, 1960, p. 9).
Vital statistics cited in the study are shown in Table I:

Table 1. Vital Events Statistics-Sierra Leone

 

 

Event Rate

Crude Birth Rate 4.41!

Crude Death Rate 1.63

Rate of Natural Increase 2.68

Maternal Mortality Rate 4.5 per thousand deliveries
Infant Mortality Rate 130.3 per thousand live births
Life Expectancy at Birth 46.9 years for males

50.1 years for females

 

Source: Sierra Leone Country Profiles (Health).

2I

Table 2 shows the number and types of health care facilities in Sierra
Leone and also demonstrates the important role that nongovernment
organizations play in the country's health care delivery system.

Table 2. Distribution of Health Manpower and Structural Facilities in
Sierra Leone

 

Hospitals Dispensaries Treatment Centers Health Centers

 

 

Government 24 24 60 30
Mission 6 2 1 - 7
Private 6 - - 4
Mines 4 - - 4
Total 42 45 60 45

 

Source: From Medical Statistics Unit, Ministry of Health:
Vital and Health Statistics Series A, No. 7, June 1960

A variety of nongovernment organizations (NGOs) exist in Sierra Leone. In
the past, they focused on curative services, but more recently they have
become involved in health education, immunization programs, and the
training of village health workers (VHWs) and traditional birth attendants
(TBAs). A brief listing of the NGOs and their major functions is in order, to
provide an overview of services.

Planned Parenthood Association of Sierra Leone provides services in
family planning clinics. Foster Parent-Plan International has three child
welfare programs in the Northern Province, is engaged in training TBAs and
VHWs, and has a Family Development program that focuses on making the
family and community self-reliant. Care has numerous programs, including a
feeder road construction program, a village water supply and environmental
sanitation program, and Project Learn, which is a child health education

22

program. Catholic Relief Services distributes food supplements through
government and private clinics. The Christian Health Association of Sierra
Leone (CHASL) coordinates the activities of the NGO hospitals and clinics.
The West Africa Leprosy Secretariat works with the Ministry of Health as
part of the National Leprosy Control Programme. Additional major health
programs, which involve both government and NGO cooperation, include the
Expanded Programme on Immunization and primary health care programs in
the Bombali district, and in the Bo and Pujehun districts.

A 1960 evaluation of the initial pilot primary health care programs cited
the Southern Province program in Serabu (56 kilometers from 60) as being
culturally appropriate and concerned with community participation. The
Northern Province (Bombali) program was criticized for focusing primarily
on covering the national population by the year 2000 while looking
community participation, building on the wrong categories of health workers,
selecting inappropriate people for training in new categories, lacking regular
in-service training and supervision, lacking regular evaluation for
replanning, lacking realistic means of long-run financing, and needing a
better organization and management structure (MacCormack, 1964, pp. 207).
In the Southern Province program, community assessment was used to
stimulate community participation and to measure program effect. One
result of the program was that the infant mortality rate was almost halved
in the 12-month period between 1979/60 and 1960/61 (Edwards a Lyons,
1963). '

A March 1967 evaluation of the Expanded Programme on Immunization
stated that the program was ineffective as it had fully immunized less than
10% of the new-born population and did not even contact 508 of that
population for an initial DPT/polio immunization. Primary factors

23

contributing to program problems were economic, including the high cost and
scarcity of fuel for transportation, inadequate kerosene for refrigeration of
vaccines, and a devaluation of staff salaries because of rising living costs
which eroded the motivation and morale of the health workers (Expanded
Program on Immunization, 1966).

A review in W cited “a litany of depressing statistics“ related to
health in Sierra Leone. The review wasfollowed by an analysis of the
problems and some positive points to consider.

Infant mortality (among the worst in Africa according to the
Government and the World Health Organization) is about 200/ 1000 live
births; the maternal mortality rate varies from 4.5-6.5:; 95% of
females are circumcised; up to 30% of children are undernourished,
20-252 chronically undernourished, and 3-53 acutely malnourished;
the childhood mortality rate is about 360/1000; only 2.78 of people
living in rural areas have access to safe drinking water and basic
sanitation; gross national product is estimated at $400 per person;
about half the nation's children go to primary school but the illiteracy
rate remains at 60-65% of the population, 441! of whom are less than
15 years old and 168 less than 5 years old; and such hospitals as there

are, are concentrated in the capital, Freetown, although nearly 75% of
the population live in the countryside. (Parker, 1966, p. 449)

A main source of Sierra Leone's economic problems was described as a
shortage of foreign exchange, owing to a law that permits businessmen to
keep the foreign exchange earned from exports overseas, given permission
from the cabinet. An intermittent oil supply, due to the foreign exchange
problem, has resulted in inadequate electricity, refrigeration, and telephone
service, and has made travel both difficult and expensive. In 1965,
immunizations outside Bo, the country's largest city, had to stop due to
gasoline shortages. A WHO report stated that at government hospitals
“equipment and supplies are chronically inadequate especially in the supply
of essential drugs“ (Parker, 1966, p. 449).

24

Favorable aspects of the situation are that infant mortality rates may be
inflated due to inadequate reporting of live births, the Bo and Pujehun
primary health care project reports good community participation, health
education may improve as the British Council has equipped the primary
schools with 1.25 million textbooks, and problems of long-term funding of
health care programs may be resolved with cost-recovery strategies. In the
Bo and Pujehun project, 65% of the cost of drugs was recovered; that figure
dropped to 403 in the Bombali district program.

The subjects of nutrition and malnutrition in Sierra Leone were dealt
with extensively in a series of Michigan State University studies. Kolasa
(1976) cited the nutritional status of children and parturiant women as being
the most important nutrition problem in Sierra Leone. Data on 4,679 children
indicated 16 to 568 were underweight. A study of food consumption in 576
households in rural Sierra Leone (Smith, Lynch, Whelan, Strauss, & Baker,
1979) demonstrated that mean calorie consumption per day was 1,265
calories and that households with higher incomes had higher consumption
rates. Ethnic factors and market orientation also affected consumption
(Smith, Strauss, Schmidt, A Wheland, 1960).

To provide a larger context in which to view health care at the Kaseia
Hospital outpatient dispensary, the literature review has considered both the
current health status of the people in Sierra Leone and the health services
available to them. Next, literature relating to the health beliefs and
practices of the people of Sierra Leone is considered.

W

In the course of the research, a variety of health beliefs and practices
came into focus. The literature related to those beliefs and practices is

25

considered here. Areas of interest are concepts of disease, traditional
medicines, geophagy, perceptions of Western pharmaceuticals, and women
and health.

museum
An article be a physician in W

discussed concepts of disease in traditional patterns of thought (Maclure,
1962). “Diseases of Allah“ are those of which it is stated merely that “God
has sent the disease.“ in Temne areas, leprosy, measles, smallpox, and yaws
have been considered this way. No further explanation of the disease is
given. Accidents constitute another class. They result from the malevolent
influence of a hostile angel, the inattention of a good angel, or demonic
activity. Some diseases are believed to be directly connected with spirit
activity. These supernatural agencies are represented by a variety of words,
variously translated as spirits, witches, demons, and devils. The various
spirits may range from amiable to malevolent and must be “bribed, placated,
used, opposed or tricked“ (p. 31).

Witch doctors have special influence with the spirits, though it may be a
special knowledge of particular spirits. For example, among the Temne,
fetishes (which may consist of a bundle of sticks, leaves, and mud), may be
tied together and suspended over an entrance to a farm to protect it from
thieves and the “cutting grass“ pigs, which destroy the crops. Diseases
caused by violating such fetishes include asthma, dropsy, tetanus, tertiary
yaws, and some types of rheumatism, among others. Epilepsy is thought to
result from direct contact with a demon. Miscellaneous diseases may be
brought about by jealousy. For example, elephantiasis in a man can be caused
by a curse from a jealous wife. A witch doctor may make people fall sick.

26

Sterility can result from one person “summoning“ another to a witch. Some
diseases result from breaking a supernatural law, such as trespassing on a
path that has been “tied“ so some cannot pass. Other health problems result
secondarily from traditional practices. For example, the scarring from a
clitoridectomy (female circumcision) may lead to obstructed labor. Pressure
from an obstructed labor can result in injury to the urethra, bladder, or
rectum. Pursuing traditional treatment may result in delays in seeking
Western treatment, as in allowing obstructed labor to progress until the
child dies.

W

In MW (1963), Sawyerr discussed the use of a
variety of medicinal plants, as well as some of the problems and difficulties

associated with using herbal medicines. A variety of practitioners use
medicinal plants. Some are simply herbalists and use only medicinal plants.
Others, known as lanky/2217mm, mix herbal treatments with divination,
seeking the cause of diseases. At another level, those known as sorcerers or
medicine men mix herbal treatments with supernatural practices.

Several problems are associated with the use of medicinal plants, which
are commonly boiled and then drunk. The potency of the plants varies with
the season and climatic conditions. Also, the dosage is not regulated, and
such regulation is particularly important in medicines for children. Further,
there is limited communication between practitioners as herbal practice is
usually esoteric. Recipients of herbal knowledge are often the children of
herbalists or others who are specially selected.

27

59.99.6999

Geophagy, the eating of earth, is a phenomenon that occurs in many
cultures and may be variously related to religious beliefs, medicinal
practices, and nutritional need (Hunter, 1964). In Sierra Leone, eating clay,
including vespid and termite clays, is common during pregnancy (Hunter,
1965). A field study done in the Kailahun District of Sierra Leone in the
Eastern Province showed that 501! of pregnant women regularly ate clay
obtained from the inside of termite mounds. Women in this study also
reported eating geophagial clays, as well. Analysis of the geophagial, vespid
and termite clays showed that they are mineraliferous, containing
magnesium, phosphorus, potassium, calcium, manganese, iron, nickel, copper,
zinc, and selenium. The study further demonstrated the amounts of
extractable minerals present under conditions of simulated digestion, using
the acid levels of the stomach lining. An example of a farm wife eating
vespid clay during her fourth pregnancy showed that she was taking 160: of
the recommended pregnancy supplement of zinc, 628 of calcium, 593 of
manganese, 47 to 93% of iron, and 30% of phosphorus. Under circumstances
of near-subsistence living, Inadequate diet, and frequent pregnancy (Hunter,
1964), it was noted that geophagia provides important minerals necessary
for fetal development.

W
A study by Bledsoe and Goubaud (1965) among the Mende demonstrated

that Western pharmaceuticals are being used inappropriately, as people
employ traditional beliefs about diseases and treatments to reinterpret the
function of available pharmaceuticals. The authors concluded that the
efficacy of a medicine is determined by its size, taste, color, and purported

28

success in treating analogous illnesses. The result is that the actual use of
medicines is notconsistent with the use intended by Western manufacturers.

Western pharmaceuticals are available through mission hospitals, private
pharmacies of physicians, pharmacies, nurses, dispensers, shop keepers,
market women, and unlicensed and frequently illiterate drug salesmen who
sell on the streets and in the villages. Such pharmaceuticals are usually not
available at government hospitals or clinics due to theft, a problem that also
occurs at the shipping docks. Further, pills are commonly sold without
containers or directions.

An elicitation device of some 30 medicines was made, which included
such things as antibiotics, digitalis, worm medications, and analgesics. Ten
people were interviewed. Findings demonstrated that the drug choices
people made were logical. One factor influencing the choice of drug was the
alleged success of the drug in treating a similar illness in a friend or
relative. Large pills were regarded as more powerful than smaller ones.
Dosages taken varied among informants; most took only a few antibiotic
capsules.

Drug choices are also related to concepts of disease. Fevers are believed
to be caused by exposure to cold or wind. The remedy, therefore, is to dress
warmly, take bitter herbs internally, which produce heat sensations; and rub
white clay on the skin, which gives a sense of warmth. White tablets,
analogous to the white clay, are believed to help with fever. Worms are
thought to generate spontaneously when a person has eaten too many sweet
things, in the sense of being sugary (candy, oranges, papaya) or being good to
taste (chicken, meat). The remedy is to avoid eating sweet things and to eat
bitter things such as herbs or a bitter Western pharmaceutical. Blood can be
lost through injury, debilitating sickness, or worms that suck it. Red foods

29

(palm oil, deep reddish brown Guiness Stout beer, red soft drinks) and red
medicines (vitamins, diuretics, and others) are believed to replace blood.
Maintaining health is traditionally done by consuming certain foods, such as
greens and palm oil, but certain Western pharmaceuticals are also believed
to be effective. For example, plastic capsules are taken after a hard day of
work so one will awaken refreshed for another day. Multicolored capsules
are thought to contain more than one medicine and are therefore believed to
be more potent. The majority of capsules available are antibiotics; they are
commonly opened and poured on wounds. Consequences of these perceptions
included inadequate and inappropriate use of drugs, both of which are serious
problems.

WI)
Familiarity with the importance of the women’s sodalities and the role of

traditonal birth attendants is fundamental to understanding the beliefs and
practices of women related to health and birth.

At about age 13 to 15, young girls are taken to the bush, following a night
of singing and dancing, and a clitoridectomy is performed by the head of the
Bundu or Sande society. This ritual is practiced among all groups except the
Creole women of Sierra Leone. After a period of time in the bush, which
varies from two weeks to two months, the girls return to the village amid
much celebration. Following this, girls are full society members and are
eligible for marriage (Finnegan, 1965). Sande women explain that
circumcision makes a woman “clean.“ Uninitiated women are not respected
and remain girls socially although women biologically. One explanation is
that the ritual scars bring the woman within a moral sphere (MacCormack,
1962).

30

The sodalities, or “societies,“ exist in virtually every village. Senior
officials and some especially adept younger women traditionally supply
maternal and child care, as well as treatment for certain types of illnesses
including infertility, dysmenorrhea, and other female problems. These
traditional birth attendants (T BAs) do not stand by passively during the birth
process but are “towering figures in a village, communicating confidence and
authority“ (cited in MacCormack, 1962, p. 1 16). The youngest TBA identified
in Sierra Leone was 35, but most are over 50 years. A TBA cares for women
during pregnancy, labour, and following delivery, and Is the local authority on
customs and taboos associated with child bearing and rearing. Only seriously
ill maternity cases are referred to the hospital (Williams, 1979). The role of
the societies in regard to the beliefs and practices of women related to
maternal and child health cannot be underestimated and must be considered
in any health education of women.

Medical Anthropology
The discipline of medical anthropology provided rich substantive
precedents for understanding patient learning in an outpatient dispensary
situation. A number of themes from the literature, including therapy-
managing groups, pluralistic medical care, causality, and logic in selection
of treatment were useful in analyzing the research findings.

Janzen
In MW Janzen (1976) studied the

therapies of the BaKongo in Lower Zaire. The therapies people sought
included both Western and traditional types. A key finding was that although
Western medicine was adopted this did not lead to the demise of traditional

3|

practices. In fact, the different forms of therapy played complementary
rather than competitive roles in the lives of those seeking assistance.
Recognizing that a study of the various practitioners did not provide a key to
understanding the relationship between the forms of therapy, Janzen turned
his attention to the group that surrounded the patient. A patient‘s family
was inevitably present to cook, wash clothes, talk, or simply sit. Janzen
called this group of kinsmen and advocates the “therapy-managing group“ and
demonstrated that this group gleaned information, provided moral support,
and made decisions related to care. The group fulfilled a brokerage function
between the patient and specialist, whether the specialist was a traditional
herbalist or a Western surgeon. Janzen concluded from this that the therapy-
managing group rather than the individual patient should be the focus of
public health instruction.

The BaKongo distinguished between natural illnesses (“an illness of God“)
and illnesses caused by humans (“an illness of man“). The former were mild
conditions that occurred when there were no disturbances in the patient's
social relationships. Such things as the death of the elderly and newborn
were also considered “illnesses of God.“ Western medicine was considered to
be helpful in treating these natural illnesses, but a variety of signs, such as
a slowly healing sore or conflict in thepatient's social group, could indicate
that the disease was caused by man. Assistance sought for the latter
diseases involved conflict resolution, counterspells to retaliate, and
purification rituals to bring about healing. Janzen suggested that deciding
which category an illness falls into is one of the functions of the therapy-
managing group.

Janzen's strategy for studying the complex, multiepisodic therapies was
to do case studies. He documented cultural phenomena (concepts, symbols,

32

categories), social phenomenona (roles, social groups, situations), and the
physical condition of the patient. The quests for therapy turned out to be far
ranging as he followed managing groups to a variety of diviners and
therapeutic specialists.

Medical pluralism was a second key concept With which Janzen dealt.
Although indigenous therapies and Western practices coexisted, the beliefs
and practices that constituted them rested on different premises. The result
was that people manipulated these practices individually without
synthesizing them. The logic of choice in seeking therapy was related to the
perception of the problem, and the way in which the problem was perceived
determined what therapy and specialist were sought. With a minor illness,
individuals might simply go to a dispensary, but in a major illness the cause
of the disease was sought.

Janzen concluded with recommendations for integrating the systems. One
suggestion was to develop a well-infomed referral network between the
systems. Janzen stated that African practitioners of Western medicine
already do this and that only European practitioners of Western medicine
referred exclusively to other practitioners of Western medicine. A second
suggestion was to move Western medical personnel nearer traditional
therapists, and a third was to bring the ritual therapist into the Western
hospital. Finally, Western practitioners were encouraged to enlist the
sanctioning power of the therapy-managing group to reinforce their
therapies.

WWW
The issues of therapy-managing groups, causality, logic in selection of
treatment, and medical pluralism have been dealt with extensively in the

33

medical anthropology literature. Feierman (1979) suggested that therapeutic
pluralism exists in explanations of misfortunes as well as in treatments of
illness. Medicine men in Dar es Salaam, for example, treated not only
sickness but also mental illness, unemployment, unfaithfulness of a spouse,
and problems related to an unprofitable business. Some sicknesses were
attributed to malfunctioning organs, spirits, or sorcery, but those causes
could also result in loss of business, lawbreaking, and arrest. Diverse cures
included penicillin injections, herbal medicines, and exorcism. Feierman
also pointed out that therapies change as the therapy managers“ perceptions
about the efficacy of various therapies change. He cautioned that variations
in practice relate to occupation, sex, age, rural or urban residence, and
religious affiliation; thus those factors need to be considered in analyzing
therapy-seeking behavior. Factors of changing economy and demography also
must be taken into account. Feierman discussed the themes that Janzen
developed, but he did so within a broader context.

In an article about the history of therapeutics in western Zambia, Prins
(1979) argued that the introduction of allopathic therapy did not falsify
beliefs in systems of diagnosis and explanation that already existed, but that
the two therapeutic systems coexisted.

A study in Ghana suggested that although two therapeutic systems do
coexist, the modernization process has eroded the authority pattern of the
traditional structure. The educated and economically powerful, who live in
urban areas, have carried new ideas when visiting their rural homes, which
has caused innovations to be adopted in rural areas. This model suggests the
element of adaptation (T wumasi, 1979).

Davis-Roberts (1961) presented a case study of illness among the Tabwa
of Zaire, in which a family seeking treatment for their small daughter used

34

Western and traditional medicine as well as divination. He described the
three treatment efforts as being subordinate to the Tabwa medical system
as a whole. The system had an essential goal of alleviating suffering, rather
than achieving remission of symptoms. Thus the pragmatic use of different
systems by therapy-managing groups did not invalve engagement with an
epistemological system with underlying principles that contradicted their
own. A key idea in this case study was the way in which the Tabwa system
subordinated the other systems.

Kimani (1961) emphasized the unsystematic nature of the traditional
medical care system among the Kikuyu of Central Kenya. A key point was
that traditional medicine is not static but is affected by patterns of
health-seeking behavior, social structures and institutions, and the
personnel involved In therapy.

In “Knowledge of Illness and Medicine Among Cokwe of Zaire,“ Yoder
(1961) made two Important points with regard to causation of illness. The
first was that isolating the cause of an illness was more important in
choosing treatment than in diagnosing the disease. That is, diseases were
caused by God, by sorcery, or by displeased ancestors. In each case, the
treatment was different. The second point was that causal explanations
changed when illnesses did not respond to treatment. Because causes of
disease overlapped in some measure this was not problematic, but it did
explain how a therapy-managing group could logically pursue a variety of
therapies.

Sussman‘s (1961) study of medical pluralism was conducted on Mauritius,
an island with individuals of Indian, African, French, and Chinese origin. A
wide variety of secular and religious healing resources were available on
Mauritius, and most practitioners were consulted by individuals with diverse

35

religious and ethnic backgrounds. Further, in this heterogeneous population,
individuals tended to have similar categories of illnesses and beliefs about
the causes of illnesses.

The medical anthropology literature touched on a number of themes that
arose in the Kaseia Hospital outpatient department study, including therapy-
managing groups, pluralistic medical care, causality, and logic in selection
of treatment. It therefore provided a number of precedents that were useful
in analyzing the findings of the research study.

Health Education

In a study that examines what patients are looming in an outpatient
dispensary, an obvious issue that arises is “what is being taught?“ That is,
what type of health education is occurring? The field of health education is
vast, but at least two topics merit investigation in relation to the present
study. The first is the way in which concepts of health education have
changed over the years and what the term currently encompasses. The
second topic concerns specific considerations that arise when examining
health education in an outpatient dispensary setting.

Writs
Walt ( 1965) discussed the ways in which concepts of health education

have changed over the years. In the industrial nineteenth century, preventive
health education was in focus and efforts were directed to improving
sanitary conditions. However, people were not involved in direct action.
Information was presented to them on cholera and typhoid, and substantial
health legislation was passed in Europe. There was, however, no community
participation in laying waterpipes or sewerage systems. Generally speaking,

36

the public was passive. During the next era, the emphasis was on curative
medicines and technical interventions. Health education emphasized the
individual and the responsibility people had to alter their behaviors related
to eating, drinking, and smoking in order to be healthier. In the third world
this became victim-blaming, in which people were blamed for conditions
over which they had no control. In the third phase there has been a shift
toward community responsibility and a desire to promote self -reliance.

The attention being given to primary health care has again stimulated an
interest in health education. In the colonial era, Western-model health
services were developed in the colonies. Following independence, many
countries continued to use the some structural system for health care,
concentrating largely on sanitation, health centers, and curative hospitals.
In the 19503 and 19609 in French-speaking Africa, an emphasis was placed
on animation/21min or self-help for rural people (MacCormack, 1963). In
Latin America, Paulo Freire's method of conscientization encouraged
Oppressed people to envision taking control of their lives (Freire, 1970). In
Central America, David Werner sought to make health services more
democratic by simplifying medical services and providing them for village
people (Werner, 1976).

In September 1976, an international conference on primary health care
(PHC), sponsored jointly by WHO and UNICEF, was held at Alma Ata in the
Soviet Union. A number of political assertions related to health care were
subsequently stated in the Declaration of Alma Ata: health care is a right;
people’s participation in planning and implementing their own health care is
a priority; morbidity and mortality rates world-wide must be decreased;
health care must be cost effective and equally available for all ;
intersectoral cooperation is Imperative to improve the health status of a

37

population; and health care services must be culturally acceptable.
Participation does not simply imply mobilizing community resources but
indicates the process by which pe0ple gain increased control over the
economic, political, social, and environmental factors that affect their
health (Morley, Rohde, 6t Williams, 1963). Primary health care, as envisioned
at the conference, includes education, water, and sanitation programs;
maternal-child health efforts; control of communicable and endemic
diseases; and an adequate supply of drugs. “Health for all by the year 2000,“
the conference slogan, has been widely publicized as the goal of the primary
health care movement. Although implementation of primary health care has
in some measure been frustrated by political, management, and community
participation factors, the movement has still served to focus world-wide
attention on health care as a right for disadvantaged people.

Health education is a core element of the primary health care movement.
This type of health education is integrally related to development, and
emphasis is on participation and involvement. Such health education is not
concerned with disseminating information to passive audiences, but rather
focuses on an educational role in which behavioral changes result through
people understanding their own environment and how they can exercise
control over it (Walt, 1965).

W
In the last decade, the trend in providing health services in developing

countries has been toward primary health care programs. All of the
nongovernment hospitals in Sierra Leone, in fact, have implemented
community health programs that incorporate at least some of the elements
of the primary health care philosophy. Nevertheless, all of the hospitals

38

still have outpatient dispensaries and a population attending those
dispensaries who have particular health education needs. A large body of
literature exists, indicating that the type of situation faced in the
outpatient dispensaries of Sierra Leone nongovernment hospitals is not
unique. Overworked staff in overcrowded health centers is almost a norm in
Africa (Kasili, 1963). It is appropriate, then, to consider what the literature
says about health education that is suitable for this patient population.

WM
Willis

Scotney (1976) suggested the obvious and of ten-overlooked fact that
health center or dispensary administration affects health education. The
emphasis is often “How many patients did you see this morning?“ He pointed
out that emphasis on efficiency in numbers of patients seen often influences
effectiveness in health education. Organizational changes may be in order
before improvement in health education occurs. Barnes (1976) suggested
that program resources, in terms of both staff time and funds, need to be
specifically budgeted to support the planning, Implementation, and
evaluation of health education programs.

Scotney (1964) stressed the effect environmental factors have on a
suitable setting for health education. Negative factors include noise and
crowding, whereas positive ones include cleanliness, adequate ventilation,
and the availability of food and water for patients. Discomfort and
distractions similarly inhibit learning (Leedam, 1972).

39

WW

Knowledge of the population being served is essential to effective health
education. Cognizance of population values influences teaching strategies. A
study among the Temne of Sierra Leone, for example, indicated that certain
forms of tribal social organization together with particular child-rearing
practices placed considerable value on group reliance, conformity,
maintenance of authority, and strict discipline. Village children who were
“too intelligent“ and spoke up were said to be “affected by witchcraft.“
individual competitiveness was thereby discouraged, and people were
pressured to conform to group norms (Price-Williams, 1969).

In describing education among the Gikuyu in Kenya, Kenyatta emphasized
the importance of knowing the values of the population being served. He said
that for Europeans “freedom of personality is the highest good, and
co-ordination with other people and especially mutual subordination are on
the contrary something accidental,“ whereas in the Gikuyu system of
education “the primary place is given to personal relations“ (Kenyatta, 1979,
p. 117).

Miller (n.d.) emphasized the importance of understanding the attitudes of
the population being served. He recommended asking “What is their attitude
toward the issue under consideration?“ and “What is their attitude toward
the person conducting the instruction?“ (p. 6)

MW

Knowles (1951) suggested that adult learning requires wanting to learn,
the putting forth of effort, and the experiencing of satisfaction. Dewey
termed these elements need, effort and satisfaction Knowles stated that
Ieaming must be purposive and echoed Butler in saying that the best time for

4o

Ieaming is when an individual feels acutely uncomfortable about not knowing
something. He also emphasized that learning will not take place if the
learner is passive, but only when the learner takes part.

In keeping with Dewey's thesis that experience Is an interaction between
an individual and the environment, Cross (1962) suggested a new framework
for learners that included their past experiences, what they thought about
nonschool Ieaming, and what they thought with regard to their life situation.
In MAW Kidd (1973) suggested that learning is effective when
learners determine their need, design the Ieaming situation, and evaluate the
Ieaming experience.

Whereas the preceding authors addressed various aspects of adult
Ieaming, other texts specifically addressed guidelines for health education
in ambulatory settings. Major guidelines commonly included the following:
planning for health education should be an integral part of overall planning;
health education should be based on the needs, values, and previous
experiences of specific individuals and groups; health education should be
conducted when people are most receptive and ready for Ieaming; patients
should be active participants in health education; health education should use
concepts and language familiar to the learner; health communicators should
be selected who are accepted by the patient group as trusted and credible
sources of health advice; all personnel should be prepared to recognize
educational needs and opportunities and to fulfill their educational functions
effectively; responsibility for the overall planning and direction of health
education should be assigned to one person; and finally, health education
should be evaluated continuously, as well as at the conclusion of the program
(Barnes, 1976).

Long (1962) specifically addressed the issue of health education in

.41

outpatient clinics. He suggested that lack of effective education in clinics
is a result of several things. In the waiting area, where health education is
sometimes done, patients are preoccupied with their illnesses and are
distracted by other 111 people. Also, health education in that setting tends to
be very general. During the consultation period, health education is affected
by the press of work, clinicians who are poorly prepared in health education
skills, and status differences between the patients and clinicians. The
patient has come for treatment and not advice. Health education is on the
agenda of the agency, but not on the agenda of the patient. Long described
three types of clinic health education. The first was prescriptive education,
which essentially adds an extra step to the clinic process. Prerequisites for
prescriptive education are a person assigned to give health education and a
quiet place. The chief liability of this method is that patients are in a
passive role and teaching often lapses into the “service delivery“ mode (p. 6).
Second, Long described health education by referral, in which community
health workers visited patients in their homes following clinic visits. Third
was health education by repetition. Staff “from the cleaner to the doctor“ (p.
7) are trained to give the same health education message on the most
common problems. Long suggested that advice from a variety of people is
more likely to be accepted and acted upon than is advice from a single
person.

[MOBILE

The goal of a health education program is a behavioral change and not
simply a change in knowledge. Traditionally, health education has involved
knowledge imparted through flip charts, pamphlets, posters, and films;
little attention has been paid to effectiveness of the effort in changing

42

behavior. Although a variety of methods or strategies may be used, Miller
(n. d.) suggested that in any behavior modification there must be change at
the cognitive stage (involving the communication of information), the
affective stage (concerned with attitude change), and the action stage
(related to translating attitude change Into behavioral change).

In health centers or dispensaries, dialogue is perhaps the most effective
means of health education. Scotney (1964) suggested that the one-to-one '
relationship is both the most effective and has the most lasting effect.
Byme and Bennett (1973) recommended the individual encounter because it
deals directly with the patient's immediate needs.

A WHO technical report on health education (1954) recommended two-way
or Socratic methods, which can involve discussion, drama, demonstrations,
or interviews, as being effective in promoting action. Using the waiting
time in clinics to provide group health education was also recommended
(Colgate, Carriere, Jato, at Mounlom, 1979).

Patients' educational level is also a consideration in selecting the most
appropriate method of health education. Anderson and Windham (1962)
suggested that literacy is perhaps one of the most critical factors
contributing to development. Rural women consistently have had literacy
rates lower than rural men and urban women (Safilios-Rothschild, 1979).
High literacy rates in industrialized countries contrasted sharply with 268
in least-developed countries, with rates of only 138 among the women of
those countries. Literacy enabled people to understand their health problems
and ways of solving them, as well as facilitating an “active involvement in
community health activities“ (WHO, 1961).

The issue of appropriate instructional materials for nonliterate learners
is also salient in health centers and dispensaries in developing countries. In

43-

'lil-Il' l‘l. 'l- I- 'l-I‘ ' il- ' 3-Il'l: ; 3 '
Wings, Miller (1976) described the characteristics of adult illiterates
and then suggested 16 guidelines for Ieaming. Among the guidelines were
such items as identifying traditional modes of Ieaming and then employing
them in the instructional materials, and designing instructional materials
with appreciation of the learners' adulthood, which draw on their experience,
values, and perceptions in the Ieaming process. Atucha and Crone (1960)
recommended emphasizing verbal communication (group discussion and
memorization of new information) and decoding visual images.

An interesting example of these principles being violated occurred in a
functional adult literacy program conducted in the Sela Limbo chief dom of
Sierra Leone. It essentially failed as a functional literacy program. One of
the factors in this failure was the tutors“ inability to relate the content of
their lessons to the adult learners' experiences. Spelling lessons included
such words as desk, teacher, classroom, and blackboard. These words and
objects were more within the experience range of primary school children
than of the adult learners attending the literacy classes (Bangura, 1966).

Summary

The ethnographic studies of Evans-Pritchard and Finnegan provided
methodological precedents; substantive insights on causality, health, and
disease; and much specific information on the Limba people. The literature
on health in Sierra Leone provided a larger context in which to view health
care at the Kasela Hospital outpatient dispensary. In addition, the insights
into health beliefs and practices provided a basis for understanding the
people who use the dispensary. The medical anthropology literature provided
substantive precedents for understanding patient Ieaming and behavior in an

44

outpatient dispensary. In touching on many themes that arose in the Kaseia
Hospital outpatient department study, including therapy-managing groups,
pluralistic medical care, causality, and logic in selection of treatment, it
provided a number of tools for analyzing the research findings. Finally, the
literature on health education provided insight into the current concepts of
health education and focused on specific considerations that arise in health
education in outpatient dispensary settings. These areas of literature
related to the methodology used in the study and to the findings regarding
patients“ learning in the Kaseia Hospital outpatient dispensary.

CHAPTER III
RESEARCH POPULATION AND PROCEDURES

When the investigator went to Sierra Leone to investigate what patients
were Ieaming in the outpatient dispensary, the specific outcome of the study
was certainly not known. More than four years of previous clinical
experience in this setting, however, provided the soil out of which the
research questions grew and suggested avenues of investigation that might
provide answers to those questions. Further, it was impossible to deal
personally with the hundreds of patients over those years who came each
week and month without being deeply moved by their responses to the health
problems they were experiencing and the efforts they were making to be
restored to health.

In W Janzen (1976) touched on an
Issue that arises for practitioners who are also doing research in a setting
such as the one at Kaseia Hospital. “Canons of medical anthropology require
the systematic reconstruction and analysis of illness. But the urgency of
lives hanging in the balance deserves an artful telling.“ “Art and science,“ he
went on to say “share an uneasy union in these studies“ (p. 63). One reason
for choosing ethnography as the methodology for this study was that it
lent itself to both systematic reconstruction and analysis, as well as artful
telling.

This chapter focuses on the population involved in the research study and
on the research procedures, Including the research questions.

45

46

Population

The primary population of the research study comprised persons using the
services of the outpatient dispensary at Kaseia Hospital, which served
70,953 in 1966. Many of the patients came from within the Sale Limba
chiefdom. The town of Kaseia, with a population estimated at 10,000 by the
paramount chief, was the largest town in the chiefdom. The chiefdom had an
estimated population of 27,032 in 1964 (Zampese, 1964, p. 15). Although it
was a Limba chiefdom, the town of Kaseia had a substantial number of
Temne, Fulla, and Susu inhabitants who also used the outpatient dispensary.
In addition, people from outside the chiefdom used the dispensary.
Historically, the Limba chiefdoms that were in the Northern Province
remained relatively isolated from the Southern and Eastern Provinces due to
poor roads, no railway system, and no significant local mining or industry.
There was no high school in the area until the 1960's.

WW

One of the first research tasks was to describe the outpatient dispensary
population. Even the question of who was using the dispensary required some
detailed investigation. At the end of each day, the number of individuals who
had attended the clinic was routinely recorded by dispensary staff. By
obtaining those figures for the last seven years, It was possible to state how
many had come, as well as to note variations in attendance by both days of
the week and months of the year (see Appendix A, Table A. 1., & Figures
A.1.-A.4.).

Outpatient dispensary attendance ranged from 50,976 in 1960 to 70,953
in 1966. Attendance generally peaked at the onset of the dry season In
October and November of each year. Weekly attendance was highest on the

47

four full clinic days of Monday, Tuesday, Thursday, and Friday. In 1966 the
average Monday attendance was highest at 315, and Thursday attendance was
lowest at 252. Wednesdays and Saturdays were half-day clinics, and on
Sunday the dispensary was open only for emergencies or scheduled revisits.

No data were available on the ethnic group, gender, age, or level of
education of those using the clinic. Nor was there Information on how for
patients had come, how much time they had waited at the dispensary, or how
much an illness episode had cost them. Inf orrnation regarding those factors
was necessary to describe the study population accurately. To obtain those
data, a survey was conducted.

mm

For the survey, all patients attending the clinic on seven different days
were Interviewed briefly at the end of their clinic visit. The patient's ethnic
group, gender, and age were noted from his/her clinic card. The cost of the
illness episode was recorded from the card. An illness episode was defined
as a single dispensary visit, or cluster of visits, related to a specific event
of ill health. Each patient was asked about level of education and where
he/she had come from for that clinic visit. The researcher and one assistant
collected the data as patients left the clinic. A translator or “word turner“
who spoke five local languages also set at the survey desk to assist with
translation as needed. The time at which the patient left the clinic was
recorded. Data were obtained on each day of the calendar week (1.9., Monday,
Tuesday, Wednesday, and so forth) during five separate weeks. By having the
survey periods at least three days apart, revisits for the same illness
episode were minimized. The total number interviewed was 1,452.

48

Information collected on ethnic groups using the outpatient dispensary
demonstrated that the two major groups were the Limba and Temne,
constituting 46.38 and 24.28 of the population respectively. Susu, Fullah,
Loko, and Mandingo groups represented significant but smaller portions of
the outpatient dispensary patients (see Appendix 6, Figure 6.1). The Fullah
constituted a larger percentage of the weekly Appointment Unit (AU) clinic
group. This clinic was available for those who wished to pay a fee to see a
physician on their initial visit. The Fullah are known as those who own and
tend cattle. Many of the area traders are also Fullah (see Appendix 6, Figure
6.2).

Males constituted 538 and women 478 of the sample. Adults constituted
658 and children 358 of the sample (see Appendix 6, Figures 6. 3-4).

Figures on level of education were particularly informative and showed
that 57.168 of the patients had no formal education and 27.691! were not yet
of school age. Only 4.068 were secondary school graduates or had
post-secondary education (see Appendix 6, Figure B. 5).

Data gathered on how much time patients spent in the clinic showed that
558 had completed their visit before the clinic closed for lunch break from
12:00 noon to 2:00 pm. This indicated a considerable waiting time for the
remaining 458, who were seen in the afternoon (see Appendix 6., Figure 6.6).

The hospital fee schedule is contained in Appendix 6, Table 6.1. Both
leone (Sierra Leone currency) and dollar figures are included. Dollar figures
were calculated at the December 1966 exchange rate of to 3600/3100.
Table 6.2. shows, in both leone and dollar figures, the range of patient fees
paid per illness episode. Figure 6.7. displays the percent of patients who
paid a fee within each fee range. Nearly 408 of all clinic patients paid less
than Le 15.00 (80.42) per illness episode. Although the dollar figures are

49

minimal, it is important to note that the leone figures are significant in
terms of local income. Income figures for local farmers were not available.
Hospital salaries at that time, which were above government wage scales,
ranged from to 243.34 for a hospital housekeeping employee to Le 592.27 per
month for a registered nurse (K. Gentry, personal communication, March
1967). Rice cost Le 350.00 per 1 10 pound bag in December 1966, and by
February 1967 the cost had increased to Le 460-550 per bag. One boy would
not be sufficient to feed a family of 6 mm people for one month. By
February 1967 a single gallon of gasoline, when available, was priced as high
as to 240.00 per gallon. Public transportation to the next major city,
Makeni, 55 miles from Kaseia, cost Le 100.00 (C. B. Pierson, personal
communication, February 27, 1967). Further, economic conditions were not
static. By March 1967 the exchange rate was to 5300/8100. Government
wage scales at that time were as shown in Table 3.

Table 3. Ways Payments

 

 

Employee Annual /Le Annual/S Monthly/Le Monthly/8
Registered Nurse 3,674.00 69.32 306.17 5.76
Medical Doctor 1 9,691 .00 37 l .52 1640.92 30.96
Public Servant 4,146.00 76.22 345.50 6.52
Trained Teacher 6,406.00 156.60 700.50 13.22

 

Source: 5. Ullom, personal communication, April 1, 1967.

Data on distances traveled to the dispensary were obtained in three ways.
First, chiefdom and area maps were used to ascertain distances. Second,
patients were often able to state how many miles they had traveled. Third, a
list of towns and distances cited by patients was compiled during the survey
and was reviewed several times by staff members. During the busy press of

50

a warm afternoon in the dispensary when one was hurriedly jotting down
survey information, it was particularly touching to have an individual say
simply that he did not know the distance he had come, but he had slept two
nights on the road while walking to reach the dispensary. A list of distances
traveled is provided in Appendix B, Table 6.3. Some 57: of all patients
traveled fewer than 10 miles to reach the dispensary. In contrast,
approximately 708 of the AU patients traveled 30 or more miles to reach the
dispensary (see Appendix 6, Table 6.4., A Figure 6.6).

W

To ascertain to what extent area villagers were using the dispensary and
to interview them about what they had learned from the outpatient
dispensary experience, the investigator visited three area villages over a
period of five days. She selected a Limbo village within the chiefdom that
was six miles from the dispensary, as well as a Temne village that was
approximately the same distance. The third was a Loko village 12 miles
distant from the dispensary by bush path. Limbo and Temne villages were
selected because the Limba and Temne people constituted the largest number
of outpatients. A Loko village was also chosen as representative of one of
the smaller ethnic groups in attendance. None of the villages had a special
institutional relationship with the hospital. One citizen of the Limba village
had formerly been a Kaseia Hospital employee. The Temne village was the
home of a then-current hospital employee. Hospital staff occasionally had
visited the Loko village over the years to hold clinics for one or two days.

The individuals mentioned in the first two villages and a teacher in the
third assisted the researcher in studying the respective communities. The
assistants drew maps (see Appendix C, Figures 1-3) indicating the location

51

of each house and then listed the names of all household members. If a
villager had a Kaseia Hospital outpatient dispensary card, that number was
recorded as well. The patient records of those having outpatient dispensary
cards were pulled from the outpatient dispensary file.

When the researcher visited the village, with the assistant, basic
descriptive information was obtained that related to housing, sanitation,
water supply, facilities related to education and religion, the economic
status of the community, and local health resources (see Appendix C, Table
C.1). In the afternoon and evening, when villagers had returned from their
farm work, the researcher visited with those who had outpatient dispensary
records to discuss their clinic visits and what types of things they had
learned from their trips to the outpatient dispensary. Because the
researcher had the patient records in hand, she could ask questions related
directly to the individual's experience. Former patients were asked what
they had learned from the outpatient dispensary visit and how they had
subsequently used that knowledge. Later the patient records were reviewed
to see how frequently villagers were using the outpatient dispensary (see
Appendix C, Table C2).

In the following paragraphs, descriptive information about each village Is
provided, together with figures on the extent to which villagers used the
Kaseia outpatient dispensary. Information that villagers recalled from their
outpatient dispensary visits is presented and discussed in Chapter IV.

We
The village of Kaloko (see Appendix C, Figure CD was a 12-mile walk by

bush path or 25 miles by difficult motor road. Only one or two vehicles
reached the town each year by the road. The walk involved crossing 13

52

watersides - that is, rivers, streams, or swamp areas. The villagers got
their drinking and bathing water from a river that passed within a few
hundred yards of the town. All household heads except the school headmaster
were farmers. In addition to farming, five men were traders, three were
tailors, four were teachers and one was the village blacksmith. Villagers
sold Oranges, bananas, and grass mats to each other and on occasion to people
from the area gold mines.

Many of the inhabitants prepared native medicines made from leaves and
roots. There was no trained traditional birth attendant but village women
filled that role. There was no sorcerer. Four men explained that “we don't
mix with evil medicine.“ Patients with serious illnesses came to the Kasela
outpatient dispensary. Those too 111 to walk were carried in a hammock over
the 12-mile footpath.

Almost 448 of villagers had outpatient dispensary tickets, but the
frequency of use was far below that of the other two villages surveyed. The
3.5-hour walk up and down steep hills, tiring even for healthy individuals,
provided a formidable deterrent for the 111. Only two inhabitants had 10 or
more visits to the dispensary recorded on their cards, in contrast to much
higher usage rates in the other two villages. Villagers holding
dispensary cards had an average of 2.71 illness episode visits recorded (see
Appendix C, Table C.2).

Retemnflillage

A village of tobacco farmers, Rotemne was located within six miles of
Kasela Hospital. A motor road into Rotemne was kept in good condition for
the tobacco company trucks. The villagers, however, walked to the
dispensary, and the seriously 111 were brought in by hammock. Drinking

53

water was taken from a shallow hole just below the village that
spontaneously filled with water. The population was 133 people, of whom
61.78 had dispensary tickets. The per capita visit rate was nearly quadruple
that of Kaloko. Rotemne was a Muslim town, although it had no mosque.
Health resources included two herbalists, a sorcerer, and traditional birth
attendants in two of the houses who assisted with deliveries. They were
described as “those that have carried age and delivered above five children.“

M

A second tobacco-growing village within six miles of Kasela Hospital had
both the largest population (366 people) and the highest percentage of people
holding outpatient dispensary cards of the three villages surveyed (76.98).
The frequency of illness episode visits per capita (10.45) was slightly above
that of Rotemne. Forty-five persons had visited the dispensary for 20 or
more Illness episodes.

A shallow well had been put in near the town waterside within the last
year through the assistance of a Peace Corps volunteer. The town chief
stated that the well water had eliminated the town's “belly problems,“
meaning that a clean water supply has decreased symptoms of intestinal
problems. Local health resources included two herbalists, a sorcerer, and a
trained traditional birth attendant, as well as other older women from the
village. A trader selling medicines visited about every two weeks.

The village had the distinction of being the only one in the chiefdom with
electric lights. Each house had one light bulb on the front porch, which was
illuminated on special occasions by a gasoline generator that was a gift from
a former citizen. All households had forms, but five of the men were also
traders and one was a tailor. The tobacco raised in Kalimba was sold to the

54

local company that assisted with production, as well as on the black market
through traders who sent it to the urban areas of Bo, Kono, and Freetown.

As indicated earlier, information on what villagers learned in their
dispensary visits is discussed in Chapter IV.

Research Questions

The main question of the research study was “What are patients Ieaming
about the nature and treatment of their illnesses in the Kasela Hospital
outpatient dispensary?“ The research questions that arose from that were
the following:

1. What is the Ieaming environment of the outpatient dispensary?

2. How are learning opportunities organized and conducted in this setting
in terms of understanding the nature and treatment of illnesses?

3. What specific information about the nature and treatment of their
illnesses do patients recall from their clinic visits?

4. Is the Ieaming environment of the Kasela Hospital outpatient
dispensary similar/dissimilar to that of other mission hospitals in Sierra
Leone?

5. What are the health habits (beliefs, practices) of those using the
outpatient dispensary?

a. What health habits (beliefs, practices) have been generated from
previous experiences?

b. What health habits (beliefs, practices) have been generated from the
outpatient dispensary experience?

55

Research Procedures

The ethnographic method was chosen for several reasons. First, it
provided for an “insider‘s“ viewpoint on the group being studied, which was
particularly important in a cross-cultural setting. The researcher examined
dispensary care from the patient's perspective. Second, with the
ethnographic method it was possible to focus on the total situation rather
than on a few elements within a complex situation. This was important in
the environment of the Kasela Hospital outpatient department. At least five
language groups used the dispensary each day. Staff interacting with
patients rotated positions frequently and varied widely in terms of clinical
experience and degree of acculturation. Severity of illness, length of
waiting time, and the number of prescriptions received were all factors that
affected the patient’s learning experience. Third, by using the ethnographic
method, the data were considered within the context of the environment in
which they had been gathered. Fourth, ethnography provided an opportunity
to use a variety of methodological strategies including observations,
interviews, participant observation, surveys, and case histories. Finally, by
not starting with specific hypotheses, preconceptions that could have biased
what was seen in an observational situation could be minimized (Borg A Gall,
1963, pp. 492-493).

A recurring point of disagreement in the ethnographic literature with
regard to methodology concerns the degree to which a study can be
conceptualized before research Is begun. In mm
mm for example, Bogdan and Biklen (1962) went so far as to suggest
that even a proposal “is more of an exercise to show those who read it that
you are conversant with the qualitative research literature and are
imaginative in your thinking about the issues, than an actual, concrete

56

description of what you will do“ (p. 71). Schatzman and Strauss in Help
81mm (1973) echoed this position, stating that problem statements are
not prerequisite to field research but may emerge even toward the end of the
research process. They described the researcher as a methodological
pragmatist who sees “any method of inquiry as a system of strategies and
operations designed . . .for getting answers to certain questions about events
which interest him“ (p. 6). In contrast, Miles and Huberman (1964) suggested
that looseness in initial design results in less selective data collection
because mill/m looks important before key constructs or regularities
emerge. They further suggested that such looseness is unwise in research
done under time pressure with a limited budget.

This researcher used a structured model for three reasons. First,
previous experience in the field site provided a basis for knowing which
methodologies and strategies might prove most fruitful. Second, time and
financial constraints necessitated using the research period as efficiently
as possible . Third, the writer preferred an articulated conceptual
framework (in this case Dewey's theses on experience and education) that
could be used to guide the research questions.

Erickson (in press) advocated this process of deliberate inquiry in a field
setting and argued against “the romantic conception of fieldwork, in which
the fieldworker arrives in the setting with a W mind, carrying only
a toothbrush and hunting knife“ (p. 96). On entering the field, therefore,
initial methodologies and strategies had already been selected. Adaptations
were made to investigate meaningful data as they arose. A variety of
research methods were used. Each is discussed as it applied to a specific
research question.

57

The main research question, “What are patients learning about the nature
and treatment of their illnesses in the outpatient dispensary7“, was
formulated before entering the field. Initially the writer had intended to
study We! and M»! patients were learning. Studying I’m-i" patients learned
would have involved exploring such elements as mimicry, modeling, and the
influence of significant others. During data collection, however, while the
content question of m: patients were Ieaming remained clearly in focus,
the process question of new they were learning diminished in deference to a
more salient issue - the health habits (beliefs, practices) of those using the
outpatient dispensary. With the ethnographic method, It was possible to
explore this important issue as it arose. The research design and findings,
then, are grouped into two categories. Research Ouestions 1 through 4
pertained to patient Ieaming, and the findings related to these questions are
reported in Chapter IV. Research Question 5 concerned health habits; the
related findings for this question are reported in Chapter V.

Want

The strategies to answer the research questions focused on several key
areas: the learning environment, learning opportunities, and knowledge
patients gained from the outpatient clinic experience. Because the
researchers previous experience with outpatient dispensary work had been
at Kasela Hospital, she decided to spend time looking at other mission
hospital outpatient dispensaries to see if their learning environments varied
significantly from that at Kasela Hospital. The questions that emerged from
focusing on those four areas, and the methods and strategies used to pursue
them, are considered in greater detail in the following paragraphs.

56
WW

1. What is the learning environment of the outpatient dispensary?

The first task was simply to describe the facility itself as the location
of the Ieaming environment. Because no drawings of the dispensary and
hospital complex were available, an initial step was to map the facility. A
particular focus of the mapping was to note where patients waited, were
interviewed or treated, and received their medicines.

Noting the services available to patients was a second step in gaining
insight Into the patients' Ieaming environment. The hospital constitution,
standard operating procedure, and annual report provided information on
specific services, as well as insights into broader areas of hospital policy.

The first week, blocks of one or more hours were spent observing in areas
where patients received services. These areas included the laboratory,
record room, doctor's clinic, appointment unit clinic, drug-dispensing line,
injection table, and dressing room. Observations were also done in
nonservice areas, such as the waiting room and patient market. This style of
initial observation was suggested in Dorr-Bremme's (1964) tactical
W as a way of familiarizing
people with observer behavior and to “remind them that you are, In fact,
present“ (p.126). During brief intermissions from the observation site, the
researcher recorded notes on a TRS 60/100 lap computer. She reviewed and
printed the notes later the same day.

Within the first few days of observation, it was apparent that patients
were involved In two major types of Ieaming. The first type concerned
learning how to get through the outpatient dispensary itself, that is,
“learning to use the system.“ After this was noted through initial
observations, interviews were carried out with people important In that

59

process. Such people included laboratory and record room staff, nursing
staff, family and friends accompanying patients, and even a woman who
played an important role In this area although her main clinic function was
simply to provide water to patients.

The second type of Ieaming was primarily related to information patients
gained regarding instructions about their treatments and knowledge of how
to take medications. Insights into this Ieaming were obtained by observing
at sites where patients Interacted with staff (Including registered nurses,
drug dispensers, and physicians), by Interviewing those staff, and by
interviewing patients both in the dispensary and in their home villages.

WM

2. How are Ieaming opportunties organized and conducted in this

setting In terms of understanding the nature and treatment of Illnesses?

To address this question, observations were made to note at what points
during dispensary visits patients had opportunities to learn about the nature
and treatment of Illnesses. As interactions with the registered nurse, drug
dispenser, and physician emerged as the most significant areas, time was
then spent observing in those situations. Interviews were later conducted
with staff members involved in the interactions. In those interviews the
issue of what staff felt patients learn In the outpatient dispensary setting
was also explored. Health education for patients was discussed, although
Kasela Hospital had no organized health education program for dispensary
outpatients.

60

WW

3. What specific information about the nature and treatment of their
illnesses do patients recall from their clinic visits?

To determine how patients perceived their illnesses before their
dispensary visits and what they learned about their illnesses and treatments
during the interaction, both pro-visit and post-visit interviews were
conducted. Pro-visit interviews did not pose problems because the majority
of cards for patients who had previously used the clinic and new patients
were available by 10:00 am. each morning. Arranging post-visit interviews
with those same patients in the general clinic was more difficult. A patient
interviewed at 9:00 am. might well not be finished with the clinic visit until
4:30 pm, and the area that had been a quiet interview setting in the morning
was a busy doctor's clinic in the afternoon.

To see how the interview process might work best, the first set of
interviews was done in the Thursday morning Appointment Unit clinic. In
this clinic, unlike the general clinic, patients paid a fee to see a physician.
The physician did the interview, physical examination, and prescribing.
Patients then went directly to get their medications. Normally 30 to 40
persons attended this clinic. On one of the Appointment Unit clinic days the
researcher conducted the regular morning registrations, as a participant
observer, and In the process was able to obtain the information contained on
the pro-visit interview form. Registrations began at 6 am, but the
physicians often did not begin work until 9:30 or 10:00 am, so ample time
was available to talk with patients about what had brought them to the
dispensary, what they felt might have given them their sicknesses, and what
they had done for their Illnesses before coming to the clinic (see Appendix E).
On another Appointment Unit clinic day, roughly half of the total patients

6)

were interviewed both before and after their visit. To avoid interfering with
the flow of the clinic, interviewees“ cards were simply selected from the
stack of those waiting to be seen. No effort was made to obtain a true
random sample. Data from each Interview were typed onto a computer
immediately following each interview. On numerous occasions patient
comments were typed on the computer during the course of the interview.
The computer either was accepted as “part of the treatment“ or was the
subject of friendly inquiry. All 21 patients interviewed before seeing the
physician returned for a post-visit interview.

Some of the post-visit interviews were limited to the four questions listed
on the Outpatient Interview Form (Appendix E), but many were more
open-ended. Longer interviews occurred particularly with patients who had
come to the clinic a number of times or over a period of years.

Similar Interviews were conducted in the general clinic; 26 patients
were seen over the course of several days. The greater time lapse between
interviews, the location of the Interview area, and the more general
confusion In this part of the clinic had the anticipated effect: 9 of the 26
patients did not return for a post-vi sit interview. Nevertheless, the
interviews provided many profitable insights.

In the Population section of this chapter, village survey work was
described. One purpose of that survey was to ascertain to
what extent villagers were using the dispensary. Another purpose was to
determine what outpatients had learned during dispensary visits. During the
survey, villagers with outpatient records were interviewed. Having the
patient's outpatient dispensary record in hand enabled the researcher to
know what treatment and instructions patients had been given. If the card
showed, for example, that a green spoon used to measure salt and sugar had

62

been given for oral rehydrati on, the individual was questioned about what
he/she remembered of the instructions and was asked If the green spoon had
indeed been used for that Illness or subsequent episodes of dehydration.
Individuals who had received treatment for schistosomiasis or
onchocerciasis were asked if they knew what caused that sickness. The
village interviews are described In more detail in the section dealing with
the three village surveys under Population. Data collected from those
interviews are discussed in Chapter IV.

W
W

4. Is the learning environment of the Kasela Hospital outpatient
dispensary similar/dissimilar to that of other mission hospitals in Sierra
Leone?

An important factor affecting health care services in rural or “up country“
Sierra Leone was the system of made, which made travel to the various
hospitals and outpatient dispensaries difficult In many places. Under normal
conditions the last 55 miles to Kasela Hospital took three or more hours.
One effect of this was limited communication between hospitals. Short
staffing at the Institutions often meant that staff commonly did not leave
their own Institutions for several months at a time. Consequently, staff
often were not familiar with services available or methods of doing things
at other similar institutions. At a Ministry of Health/Nongovernment
Organization conference held in February 1967, 32 agency representatives
presented papers highlighting their activities. One of the constraints
Identified by the organizations was poor communication among
nongovernment organizations (Staff, 1967).

63

In 1974 the Christian Health Association of Sierra Leone (CHASL) was
formed. The membership comprised eight hospitals and 21 clinics, all
nongovernment organizations. One of the objectives of the organization was
to foster cooperation among members. The eight hospitals all had outpatient
dispensaries. To describe and analyze patient learning in the Kasela Hospital
outpatient dispensary without considering what was occurring in other
similar institutions would have been to neglect an important source of
comparable data. Thus, part of the research Involved traveling to the other
CHASL hospitals over a two-week period with the executive secretary of
CHASL. One of the eight hospitals was not reached because of Impassable
roads. A letter was sent to that hospital requesting information on
attendance figures and health education efforts, but a reply was not
received. The other hospi tale, however, were visited and provided a broad
context In which to view the learning that occurs in outpatient dispensaries.
At each institution the researcher had an opportunity to tour the facility,
Interview administrative officials and staff members, and read the annual
reports. Data collection focused on services offered, health education
programs, and what occurred In an outpatient dispensary visit.

W
5. What are the health habits (beliefs, practices) of those using the

outpatient dispensary?

As already Indicated, John Dewey provided a conceptual framework for
learning experiences in which he described experience as an Interaction
between the individual and his environment. Experience, In Dewey's
framework, is continuous and generates habits that are available In and
temper the character of subsequent experience. In view of the continuous

64

nature of experience, then, It was Important to view patient learning In the
Kasela Hospital outpatient department in the larger context of previous and
subsequent experiences that produce health habits.

W
W

5a. What health habits (beliefs, practices) have been generated from
previous experiences?

The question essentially asks, “What do clinic patients believe about the
causes and treatments of illnesses, and what do they do when 111?“ It Is
important to remember that the individuals sampled in the research were all
dispensary patients. The researcher would not have been looking at health
practices before a dispensary visit when the Individual being Interviewed
was seated in the dispensary. People who had come to the dispensary
seeking care were already different from those who had never come. The
starting point for looking at health beliefs and practices was among those
who had chosen to come to the dispensary. Further, to limit interviews to
those using the dispensary for the first time would not have provided a
useful distinction because many patients had used other dispensaries as
well. That is, they had had an “outpatient dispensary experience“ even if it
was not at Kasela Hospital.

The main source of Information in answering this question on health
practices was the outpatient interviews mentioned in connection with the
first research question. The ninth question in the Outpatient Interview Form
(see Appendix E) addressed one of beliefs about illnesses: what the patients
felt had caused the sickness that had brought them to the dispensary.

65

The tenth question dealt with what patients had done for their Illnesses
before coming to the dispensary. Patients were asked if they had used
traditional medicine, purchased medicines from traders or in the markets, or
gone to other hospitals or dispensaries. After answering that structured
question, they were asked to talk further about the course of action taken.

In the outpatient interviews, several themes relating to beliefs and
practices kept recurring. Patients were seeking treatments from a variety
of sources. Families were influential in selecting the type of treatment.
Nevertheless, the information and insights were limited to those particular
patients. To gain a broader understanding of the recurring themes and their
meaning within the local culture, several local authorities were interviewed,
as well. Goodenough (1970) recommended seeking out local experts to gain a
better understanding of a group's culture.

Ethnographers concerned to describe a group's culture, in the sense In
which I am using the term, make a regular practice of seeking out
recognized local authorities and experts in order to use them as their
principal sources of information. . . .The authorities are, obviously,
more likely to provide information from which an ethnographer can
formulate for the community he studies a set of standards that, taken
as a guide for acting and Interpreting the acts of others, leads to
behavior the community‘s members perceive as in accord with their
expectations of one another--behavior they accept as being properly
Trukese, country Irish, or whatever. (p. 100)

Eight Interviews were particularly rich in this regard. Three informants
were traditional practitioners: an herbalist, a traditional birth attendant,
and a Muslim shopkeeper who sold traditional medicines. One was a health
worker not employed at the hospital, two were townspeople, and two were
hospital staff members. All eight informants had used the outpatient
dispensary services at some time. Six were Limbo, one was Temne, and the

66

shopkeeper was a Hausa who had lived in Kasela a number of years. All had
respected positions in their various communities.

Two publications mentioned In the literature review proved useful as
springboards for discussion in the interviews. The first was McCormack's
“Health, Fertility and Birth in Moyamba District, Sierra Leone“ (1962), and
the second was Sawyerr's (1963) W. For
example, In talking to the midwife it was useful to say, “The Mende believe
that eating plantain in pregnancy can cause a retained placenta. What do the
Temne and Limba think of this?“ Or, “Among the Mende, green paw-paw
leaves are crushed and tied to the stomach for abdominal pain. Is that also
done here in Kasela?“

In addition to the use of traditional medicines that patients discussed, it
was also readily apparent that Western pharrnaceuticais played an Important
role in the health habits of patients coming to the dispensary. Even the
small market stand within 200 feet of the outpatient dispensary sold not
only analgesics and antihelminthics, but also such prescription drugs as
tetracycline, ampicillin, ephedrine, and valium. A useful means of obtaining
Information about the way in which patients regarded and used these
medicines was to make an elicitation device similar to the one described in
Bledsoe and Goubaud's study (1965). The device used was a manila folder
containing 32 different samples of pharmaceuticals and traditional
medicines in small plastic bags. Sixteen were available in the Kasela town
market and 16 were from the Kasela outpatient dispensary. The purpose of
the device was to stimulate discussion on appropriate treatment for various
diseases. Fifty people, both children and adults, comprised the sample.
Following Bledsoe and Goubaud's methodology, the sample was not selected
to be representative of the local population. Patients, those accompanying

67

patients, and several individuals from the town were shown the medicines
and were asked which medicines they had seen before, the Illnesses for
which they were used, and what quantities were taken. In addition,
discussions were held with local drug vendors about their medicines and the
various ways in which they were to be taken.

W
W

5b. What health habits (beliefs, practices) have been generated from the
outpatient dispensary experience?

Before entering the field for research, the researcher had anticipated that
the outpatient dispensary experience would have some effect on the health
habits of those who came to the dispensary. This effect was anticipated in
keeping with Dewey's theses that experience is continuous and that health
habits existing when patients came to the dispensary would interact with
the dispensary experience, resulting In subsequent health habits.

Patient interviews, staff interviews, observations of patients' behavior,
and several case studies related to behavior In specific illness episodes
provided the material for a series of vignettes that illustrated a range of
health habits generated from the outpatient dispensary experience. These
are presented in Chapter V.

Summary
The ethnographic method was chosen for the study because it provided a
framework for a systematic reconstruction and analysis of events, as well
as an opportunity for “artful telling.“ Both outpatients and area villagers
were surveyed to gain a clearer understanding of characteristics of the

66

research population. The major ethnic groups using the clinic were the
Limba (46.38) and the Temne (24.28); the Susu, Fullah, Loko, and Mandingo
groups constituted significant but smaller portions of outpatients. With
regard to education, only 4.068 of patients were secondary school graduates.
The waiting time for clinic patients was considerable; 458 of patients were
still present at 2:00 pm. Although nearly 408 of clinic patients paid less
than Le 15.00 (80.42) per illness episode, even that small amount constituted
58 of a monthly income of Le 300.00. Approximately 578 of all patients
traveled fewer than 10 miles to the dispensary, but 708 of the AU patients
traveled 30 or more miles to attend the clinic. In the three villages
surveyed, from 43.98 to 76.98 of all villagers had been to the dispensary at
least once.

The main research question focused on “What are patients Ieaming about
the nature and treatment of their illnesses In the Kasela Hospital outpatient
dispensary?“ To answer that question, research strategies focused on the
Ieaming environment, learning opportunities, specific Information patients
recalled from their clinic visits, the learning environment of other mission
hospital dispensaries, and the health habits (beliefs, practices) of those
using the outpatient dispensary.

The value of using the ethnographic method was reinforced during the
course of the research as It became evident that numerous complex elements
were related to patient Ieaming in the Kasela outpatient dispensary. With
the ethnographic method it was possible to explore those elements as they
arose. The village surveys, for example, grew out of the need to gain a
clearer understanding of who was using the dispensary, and also to know
what patients recalled and did after some time had elapsed following their
dispensary visits. Similarly, data collection focused on health habits

69

(beliefs, practices) of patients after that emerged as an important theme.

An Important consideration that arose in exploring this complex
environment was how best to focus the study so it did not devolve into a
superficial exploration of many areas. In time, however, It became clear
that two major themes were emerging. The first was the Importance of
patient Ieaming and factors that affected that learning. Related findings are
analyzed In Chapter IV. The second theme that emerged was the patients'
health habits - that is, the way in which patients Incorporated the
dispensary experience into a larger system of health beliefs and practices.
Findings related to that theme are analyzed in Chapter V.

CHAPTER IV

FINDINGS RELATED TO PATIENT LEARNING

The method of analysis in qualitative research has historically been
ambiguous. As Miles and Huberman (1964) stated, “One cannot ordinarily
follow how a researcher got from 3600 pages of field notes to the final
conclusions, sprinkled with vivid quotes though they may be“ (p. 16). To
demonstrate as clearly as possible the way in which the findings of the
research were reached, the data related to each research question in
Chapters IV and V are presented first, followed by a discussion of the
implications. Chapter IV deals with the findings of the first four research
questions, which arose from the main research question: “What are patients
learning about the nature and treatment of their illnesses In the outpatient
dispensary?“ Those four questions are as follows:

1. What is the Ieaming environment of the outpatient dispensary?

2. How are learning opportunities organized and conducted In this setting
in tonne of understanding the nature and treatment of Illnesses?

3. What specific information about the nature and treatment of their
Illnesses do patients recall from their clinic visits?

4. Is the learning environment of the Kasela Hospital outpatient
dispensarysimilar/dissimilar to that of other mission hospitals in Sierra
Leone?

To answer those questions, attention ultimately focused on several areas:
the Ieaming environment, Ieaming opportunities, and knowledge gained from

70

71

the outpatient dispensary experience. The outpatient dispensary learning
environment of other mission hospitals in Sierra Leone was also considered.
On Initial review of the main research question, it might seem that simply
considering knowledge gained from the outpatient dispensary experience
would essentially answer that question. But even a brief period of
observation in the dispensary would alert a researcher to the fact that the
frequently crowded, often hot, and almost Invariably busy environment might
affect both the learning opportunities and the subsequent knowledge gained
from the outpatient dispensary visit.

The Learning Environment
1. What is the Ieaming environment of the outpatient dispensary?
In this section the facility and services of the outpatient dispensary are
described, and observations related to patient Ieaming are discussed.

mm

The outpatient dispensary was part of Kasela Hospital as a whole (see
Appendix D, Figure D.1). The hospital buildings were constructed of
whitewashed cement block and had zinc “pan“-roofs. Outpatients went to the
hospital for minor surgery, dressing changes, and procedures, but otherwise
they were cared for in the outpatient dispensary. The outpatient waiting
area was covered with a “pan“-roof and was open to the air. Numerous
benches were provided, but seating was generally inadequate on busy days as
the 300 or more patients who came were often accompanied by escorts or
kinsmen. Patients commonly sat out under the trees or congregated in the
market area. Services for patients were provided in the Interview area, at

72

the drug-dispensing counter, in the laboratory, In the lI-ray room, and in the
doctor's clinic (see Appendix D, Figure 0. 2).

The outpatient dispensary was open 6:00 am. to 5:15 pm. Mondays,
Tuesdays, Thursdays, and Fridays. On Wednesdays and Saturdays the
dispensary was open until noon, and on Sundays it was open only for
requested revisits and emergencies. On Thursday mornings, patients who did
not wish to attend the general clinic and who wanted to see a physician at a
particular time could attend the Appointment Unit clinic, for which they
payed an additional fee. Wednesday afternoon was free for staff meetings,
classes, and work projects. In addition to the general clinic patients, 25 to
30 more came each morning for the streptomycin Injections, which were part
of the treatment for tuberculosis. The dispensary was closed from noon
until 2:00 pm. each day. During that time patients could be seen stretched
out on benches, resting on a cloth on the concrete floor, chatting under the
trees, or simply sitting and waiting.

The market outside the dispensary provided food and small wares for
patients: oranges, hot groundnuts, bananas, guavas, cola nuts, rice chop,
cherry tomatoes, fried cakes, candy, cigarettes, razor blades, and even
assorted medicines.

WWW

During the observation sessions, numerous incidents similar to the
following one, recorded by the researcher, occurred. The dialogue,
transcribed in Krio, was translated to English with as little alteration as
possible.

Ya Konde, the elderly part-time women's chaplain, sat in the middle
of the dispensary waiting room with a metal bucket filled with water

73

at her feet. Inside was a worn green plastic pitcher and two equally
worn plastic cups with handles. As I approached she stood up and
offered her seat. I went instead to the doctor's clinic and got a chair
to sit on as all the benches were filled. She patted my shoulder and
chatted amiably in Krio. Every few moments a person waiting in the
dispensary area came up, and she would hand them a cup of water.

At 9 am. a sudden, sharp shower poured down. A young woman in an
attractive blue tie-dye outfit who had gotten caught in the shower
hurried up the dispensary steps. Our eyes met and she smiled brightly.
“You have come back. It has been along time. The time I bomed this
child [gesturing to the child on her back) you gave me clothes for
the child.“ Ya Konde greeted her also. A small, clear plastic envelope
was in her hand. Inside the envelope a green clinic ticket, a five leone
note and other money were visible. “1 don't know if I brought the right

ticket,“ she said shyly, taking the green clinic ticket and holding it
out to Ya Konde. Ya Konde took the ticket and handed it to me to read.
“Fatmata Jalloh. That's your name,“ I said. “Yes.“ She smiled again,
seeming relieved that she had brought her own ticket and not one for
someone else in her house. She hesitated with the ticket. Ya Konde
took it from her again and went off to the Record Room. We chatted
until Ya Konde returned, and then I excused myself with “I have to go
do some work now.“

Although Ya Konde's official job was dispensing water, her amiable nature

and central location In the middle of the dispensary made her an information

source for patients, as well. Aware that Fatmata could not read her ticket to

see if she had brought the right one, and perceiving that she did not know

where to take her ticket after arriving, Ya Konde took care of both functions

for her.

The clerk in the Record Room had a similar function beyond his regular

duties. A conversation recorded between the clerk and a patient was as

follows:

Patient: “I've been here since this morning. I came first, but until
now they haven't called me.“
Clerk: “Did you come yesterday? Did you bring a [stool] sample?“

74
Patient: “Yes, they told me to see the doctor today.“
Clerk: “The doctor hasn't come yet. Wait until 2 o'clock.“

During one morning's observation an old lady came repeatedly to the
clerk's window for assistance. She had brought two children's tickets
instead of her own, but being nonliterate she did not know she had brought
the wrong tickets. When asked about the help he had given her, the clerk
replied:

I have to help her because she's old and doesn't understand too much.
You have to help her throughout. So today to clarify the whole show,

I had to take the mum Inside. I have to get them all [the staff) to
assist. You have to go every place with some. You tell her to go inside
[to the screenerl but she goes to the doctor instead and says, “He told

me to come here.“ So It is good for me to take them. It is good for us
to take them hand in hand.

On numerous occasions, the Record Room clerk was observed helping
patients who did not know how to proceed through the dispensary system.
Other staff assisted patients, as well.

A lab technician, when asked about his role In assisting patients,
responded, “When some people come in the morning, they don't understand
[how to do things). They always ask questions.“ In the laboratory, during an
observation period one morning, a local pastor stood by a woman with a
young child; through gestures and by speaking quietly to her, he told her
what to do next.

The assistance patients commonly sought in the clinic was not limited to
information on how to progress through the course of a day in the clinic.
Frequently, patients also needed assistance with food and lodging. On the
day of interviews in the lab, one technician had six patients who had come to
stay with him and the other had ten. The Record Room clerk had four
“strangers“ or guests. Virtually all staff had outpatients staying with them.

75

People in the town had the same experience. One townsperson who was asked
about patients who had come to “sit“ with him said:

Many times It costs more to keep the person than even the amount
of money he pays at the hospital and [for] his transport. Kasela people
are doing a In! to run this hospital. The amount of money they put in
to run this hospital is too much. Because many times somebody will
come here just for a day. Sometimes he feels that he has malaria and
Is coming just for malaria treatment and will go. And when he comes
he has amoebiasis, he has schistosomiasis, he has spiders
[onchocerciasis]. . . . Different things. And then it is far for him to pay
transport to go back and come back. So he stays. You are going to end
up feeding a man, keeping a man, lodging a man for a month or two
months who has just come for a day and has only planned for a day, you
see?

And sometimes the people come here and don't know anybody and
[don't know] the procedure in the hospital. First, you go here. From
there you go there. They’re not used to that. The hospital Is a big city
for them when they come here. A big city. So they are afraid even to
come alone. So they ask the person from Kasela to bring them, just to
go through the procedure for two, three days before they can know how
to go by themselves. So it Is costing again the man In Kasela to stay
out of his work two, three days just taking care of the man.

This, then, is the environment of the Kasela outpatient department. Busy.
Crowded. It is a place of multiple languages, and a spot that is unfamiliar to
many. And for many patients coming through the dispensary line, questions
of importance are not simply “What medicine am I getting?“ or “What
sickness do I have?“ but “Where will I sleep tonight?“ and “Do I have enough
money to get home?“

A Kasela police officer, who had accompanied a patient to the clinic one
morning, said that on that particular day he had six patients staying with
him. He had originally come from a Loko village, and when people from Loko
areas some to Kasela they often stayed with him. He said that most of the
time he had three to five patients at his house. “They bring only a pan of

76

funds [milletl,“ he said, “and a bottle of palm oil. I am responsible for the
rest of It.“

Learning Opportunities

2. How are learning opportunities organized and conducted in this setting
In terms of understanding the nature and treatment of illnesses?

Observations about Ieaming In the dispensary focused on three specific
areas in which patients and dispensary personnel Interacted with regard to
understanding the nature and treatment of illnesses: nurse/patient
interactions, drug dispenser/patient interactions, and physician/patient
interactions. In addition to observing these Interactions, the researcher
interviewed staff who participated in them.

It would perhaps be more accurate to describe these as “interaction
opportunities“ rather than “Ieaming opportunities.“ Although the intention
was to find out about patient Ieaming, the observations actually focused on
teaching and the constraints on teaching.

611W

The registered nurses interviewed, diagnosed, and prescribed for some
608 to 908 of the outpatients each day. The other 108 to 208 who had more
serious illnesses or needed to be evaluated for surgery were seen in the
doctor's clinic each afternoon. A set of standing orders provided guidelines
for treatment of maladies seen frequently in the clinic, such as malaria,
measles, onchocerciasis, schistosomiasis, neonatal tetanus, and amoebiasis.
On full clinic days (Mondays, Tuesdays, Thursdays, and Fridays) an RN would
characteristically see 60 to 120 patients. The average interaction time was
about five minutes, although this was less at particularly busy times. The
following interactions occurred in a IS-minute period.

77

The interview desk was clean, and the only Item on it was an infant
scale. The patients“ cards were already on the desk, and the patients
had been seated outside In order on a long bench. As the name was
called by the RN, each patient came Inside and sat down on a chair next
to the RN.

The first patient was a young man who appeared to be in his
twenties.

RN: (The RN spoke in Krio) “What thing is hurting you?“

Patient 1: “It's my chest“ (encircling both sides of his chest with
his hands).

RN: “Do you cough?“

Patient 1: “Yes.“

RN: Do you smoke?

Patient 1: “No.“

RN: (T he RN wrote silently on the card, then put the card face down at
the side of the desk.)

Patient 1: (He quietly went out the same door he had used to enter.)

The second patient was a woman with a small child. The conversation

was again in Krio.

RN: “What is the sickness?“

Mother of Patient 2: “He Isn't well.“

RN: “Is his body warm at night?“

Mother of Patient 2: “Yes.“

RN: “Does he cough?“

Mother of Patient 2: “Yes.“

RN: (The RN put the child on the scale and weighed him in order to
calculate a medication dosage. The child voided and the RN made a
smiling comment to the researcher, “They always urinate when put
on the scales.“ The RN returned the child to the mother, wrote
silently on the card, then placed the card aside and the woman
stood to go.)

The third patient was again a woman with a small child.

RN: “Do you speak Krio?“

Mother of Patient 3: (She nodded her head from side to side, a
negative response.)

RN: “Go call someone.“

Mother of Patient 3: (She rose and walked to the waiting room to

76

call someone to speak for her. Another young woman entered,
stood beside the first, and addressed the RN in Krio.)

Second Woman: (She nodded toward the child.) “His body Is warm at
night. He coughs.“

RN: (The RN listened to the child's chest with a stethoscope.)

Second Woman: (After talking to the first woman in Fullani) “The

woman herself is not well.“

RN: (Addressing the first woman) “Did ydu get medicine?“

Second Woman: (Answering for the first women) “They didn't call
her yet.“

RN: (The RN finished writing orders on the card and set it face down.)
“Go wait yonder.“

The preceding set of interactions was selected because the environmental
'factors associated with it wereso common and because a similar type of
interaction occurred with virtually all the staff in this role at some time. A
large number of patients awaited their turns. The verbal Interchange
basically focused on symptoms. Languagebarriers further hindered
communication in a situation already constrained by time pressures. The
presence of a number of people also meant that there was no privacy in the
conversation. The treatment written on the patient's clinic card was not
explained, nor was the health problem of the patient discussed. It must be
noted, however, that this set of interactions was characterized by a sense of
courtesy and orderliness. Patients gave no appearance of dissatisfaction. A
sense of “this Is the way things are done here“ seemed clear to those
involved.

WWW

Two staff normally dispensed medications to patients and relayed to
them the instructions written on the clinic card by the registered nurse or
physician. One dispenser was a registered nurse and the second was often a
nursing assistant. There were no pharmacists or pharmacy clerks at the

79

dispensary or hospital. The nursing staff handled pharmacy responsibilities.
When the clinic first opened, patients who were “revisits“ coming for
particular medicines were called first. A translator or “word turner“ who
spoke six languages sat at the counter and explained the medications when
one of the staff dispensing drugs was unable to speak that patient's language.
Instructions generally Involved how much of the medicine to take and how
often it should be taken; for example: “Take two morning, two suntime, and
two at night for three days.“ The name of the medicine was almost never
mentioned, and the function was explained sporadically. During an
observation done part of one afternoon, for example, 72 patients received a
total of 196 medications whose purpose was explained 57 times or 298 of
the time. One nurse accounted for 36 of the 57 explanations or 678.
Patients were occasionally asked if they understood the instructions but
were not requested to repeat them. The medication packages were marked
with circles in pencil or magic marker to indicate the frequency with which
the medicine should be taken. Three sets of two circles, for example, meant
that two tablets were to be taken In the morning, two at noon, and two again
at night. Mothers often tried to listen to the explanation about the medicines
while coping with small children. Some patients would be untying a small
piece of cloth to get their money while listening to the instructions.
Occasionally a patient would return to the line, after having leftthe
dispensary, and ask again how the medication should be taken. Quite often
those In line waiting for medications moved close to the counter, and the
noise level invariably rose as the dispensers tried to explain the medications
amid the press of people. One staff member was responsible for keeping the
line in order.

60

Several elements of the drug-dispensing line were salient with regard to
learning opportunities for patients. First, the dispensers basically
communicated how to take the medications. There was no emphasis on what
the medication was for, or side effects of which patients should be aware.
Second, the interaction was primarily a one-way communication. Thus it
was not possible to know, from observation, how well the patients
understood the instructions. Third, numerous environmental factors such as
crowding, noise, heat, paying for the medicines while simultaneously
listening to instructions, and distractions by other patients or small
children interfered with the learning situation. The fact that one, and
sometimes both, of the staff dispensing medications were nurses
contributed In a measure to some of the confusion that arose on the line.
Patients would periodically ask for “more medicine“ or launch Into another
explanation of their Illnesses, and the nurses would become involved In an
assessing and prescribing role. This was invariably time consuming and
conflicted with the drug-dispensing function of the line.

The Ieaming opportunity presented to patients at this Interaction site
was primarily “how to take your medicines.“

BOW

Beginning at 2:15 pm. each afternoon of full clinic days (Mondays,
Tuesdays, Thursdays, and Fridays) there was a doctor’s clinic. The registered
nurses who screened the patients determined who would be referred to that
clinic. A variety of patients attended the doctor's clinic, including those
needing a surgical evaluation, those with eye injuries, those suspected of
having tuberculosis, the seriously ill, trauma cases requiring a police report,
and those who had not responded to earlier treatment by the RN. Perhaps 108

BI

to 208 of the general clinic patients attended this clinic. One or two
physicians worked each afternoon along with a registered nurse who was
also a physician's assistant (PA). Interruptions requiring the physicians to
leave were common and included such things as emergency surgeries, diesel
generator problems, and treatments needed for hospital patients. A nursing
assistant served as a translator for patients who did not speak Kri o.

An average of eight minutes was spent with the patients seen during one
afternoon's clinic. The time was spent reading the history recorded on the
patient record, listening to the patient talk, writing orders, and talking with
the patients. The practitioners set within eight feet of each other,
separated only by partitions, and considerable interaction took place
between them. Animated conversations on paradoxical effects of digitalis,
appropriate tolinase dosages, and a new bronchodilator punctuated the
afternoon. Seven interactions related to appropriate treatment for patients.
The physician's assistant, who was new to the clinic, received extensive
information and suggestions from the physicians. With the exception of one
town dignitary, the patients were usually silent except when addressed. At
that time they would usually relate symptoms associated with their health
problem, often quite extensively. During this particular afternoon of
observation, only the physician's assistant explained the medication orders
to one patient.

Observations similar to those already noted were made on five separate
occasions in the doctor’s clinic. The camaraderie among the health
professionals was evident. Patients consistently received courteous
attention when talking about their health problems. Virtually no time,
however, was devoted to explaining anything about the illness or the
treatment that was being prescribed.

B2

51mm
Ten staff involved In the Interactions just described were interviewed,

singly or In groups, regarding their perceptions of what patients learned in
the dispensary. Some specific information that had been communicated by
nurses in the screening area was mentioned, such as appropriate oral
rehydration therapy, contaminated water as a cause of diarrhea In children,
and foods recommended for young children. But discussions largely centered
on barriers to patient Ieaming. The barriers mentioned were language,
culture, education, limited time, and the discomfort caused by the afternoon
heat. A drug-dispensing staff member, commenting on interactions in the
drug-dispensing line, said:.

We're awful in the afternoon. We just get so tired. You've said 50

times that day “this Is for your worrns' or whatever and you start

to get slack. And where you might have been patient with somebody

pulling out their money really slowly the first thing in the morning,
by the time it's 5:30 pm. all you want to do is go home.

An RN commenting on a patient screening experience said:

I don't reel/y know what's going on in the patients' heads. One lady
with some education and multiple chronic complaints including chest
pain begged and begged for a chest iI-ray. She believed that would
cure her chest pain. I spent a long time talking with her and trying to
educate her and help her understand )I-rays do not cure anything, but
she went away believing that was her only hope of recovery.

Several staff also said that the role expected of them, by both patients
and other staff, did not include patient education. A physician commenting
on an experience in the doctor's clinic said:

[In the USA] I was used to spending probably 208 to 408 of the
time making the diagnosis, and the other 608 helping the patient

understand his disease and what we were going to do about it. A game
plan. Work out a game plan with the patients about what to do. When I

63

first tried to do that here the word tumors [translators] would listen
and they wouldn't turn it [i.e., translate It]. I'd say “You tell them this.
Tell them what I said.“ And they might try. And finally they got
frustrated with me and said “Just tell them to go for their medicines.“
Well, I found that with the numbers we were seeing, and with the
problems of language and everything. . . .I found it very tempting just
to say “Go for medicines.“ Which Is what I mostly do now. It's the
tradition. What the patients expect, what the word tumors expect,
what everybody else expects. Once in a while I still tackle it. I
usually tackle it in a patient that can speak Krio, that I can talk to
directly.

In analyzing staff responses to the question of what patients learned In
the dispensary, it is important to know that no organized health education
program existed. Neither was there a protocol for teaching patients in the
screening or drug-dispensing areas. Although there was consensus among
those interviewed that there ought to be more systematic health education,
the energies of the staff were actually focused on coping with the large
numbers of patients coming each day. Like many other problem areas
awaiting attention in busy situations, health education might be described in
this situation as “a high-priority item on a low-priority list.“

Patient Recall of Specific Information

3. What specific Information do patients recall about the nature and
treatment of their illnesses?

As indicated in Chapter 111, information on what patients recalled about
the nature and treatment of their Illnesses after an outpatient dispensary
visit was elicited first from patients in the clinic, and later during
interviews in three villages.

B4

W

The Interview questions are listed in Appendix E. Patients were
interviewed both before and after their clinic visits. Questions 1 through 7
were posed to obtain baseline information on this group. Questions 6 through
10 related to Research Oueetion 5a and are discussed in Chapter V. Question
11 simply concerned whether the patient had come alone or had been
accompanied or “escorted“ by another person. The post-interview questions
focused on Information the patient had gained from the clinic visit. The
interview data are presented in Appendix F.

As noted in Appendix F, more than half of the patients in the AU sample
were Fullah, and more than half in the general clinic sample were Limba. No
children were among the AU patients, whereas 13/26 of the general clinic
group were children. Of the AU patients, 16/21 came from more than 30
miles, and only 3/26 of the general clinic patients came from that distance.
Only 2/21 AU patients had any formal education. Eleven of the general clinic
patients were not yet of school age, but of the remainder only 5/17 had any
formal education. These data are similar to those describing the clinic
population, which were presented in Chapter III. A number of patients were
accompanied by someone who either translated for them or simply stayed
with them.

In the post-visit Interviews, patients were asked to recall specific
instructions they had been given regarding their illnesses. Individuals came
to the interview directly from the drug-dispensing line. Instructions
included orders to return at a later date for additional medicines, directions
on bringing sputum samples, and dietary recommendations. All 21 AU
patients and all 6 general clinic patients correctly recounted the
instructions written on their clinic cards (see Appendix F, Post-Visit

65

Interview, Question 1). Patients were then asked to show the medications
they had been given and demonstrate how to take them. The data showed
51/56 correct responses among AU patients, and 41/49 correct responses
among general clinic patients (Question 2). However, when asked what the
medications were for, only 10 AU patient responses and 6 general clinic
patient responses were correct (Question 3).

in analyzing this Information, it seemed clear that patients understood
instructions given on the drug-dispensing line and likewise knew how
medications were to be taken. Since the interview immediately followed
patients' receipt of the medications, the data did not reflect knowledge
decay over time. It is not surprising that patients did not know what the
medications were for, since observations of the drug-dispensing line showed
that this information was not systematically communicated to patients.

When patients were asked to recall what they had learned about their
diseases or treatments from earlier visits, relatively limited information
was forthcoming. For example, a patient described an admission four years
earlier and said that the medicine was “good“ and made her stronger to go and
work on her farm. One portion of the general clinic group, however, was a
marked exception to this. Seven of the mothers had attended one of the area
Under Five immunization clinics with their children, and they had a great
deal to say about what they had learned there. One told about being taught
not to hand feed children (because of the dangers of aspirating food) and said
since then she had been using a spoon to feed her eight month old. The same
woman told how she had used the green spoon (given to measure salt
and sugar for making an oral rehydration solution) to make “salt and sugar
water,“ which she gave In “small sips all day“ to her child when it had
diarrhea. Another told how she had listened to instructions about feeding

66

small children starting at four months. She had started her child on soft
mango and ground rice following that. At the time of the Interview the child
was old enough to eat soft rice with finely cut greens. Another also talked
about the correct diet for children and told how she had started eponging her
children when they had fever, after Ieaming about it in the Under Five clinic.
Others told about Ieaming to feed their children “fine chop“ (good food) and
eponging them with cool water when feverish. Two mothers indicated they
had been instructed about such things at the outpatient dispensary, as well
as at the Under Five clinics.

An analysis of this Information pointed to the effect on both knowledge
and practice of the planned educational programs of the Under Five clinics.
Teaching In those clinics was done through songs, stories, and
demonstrations, in addition to didactic instruction. Mothers were in their
own villages and seated comfortably during the clinics. The Under Five
clinics were staffed and financed through Kasela Hospital. A number of the
staff who went to the clinics also worked at times in the outpatient
dispensary.

W

The three village surveys had two primary functions. First, they provided
an indication of dispensary usage by villagers several miles distant from
Kasela. Second, they provided an opportunity to talk with people at their own
homes about what they had learned from using the outpatient dispensary. By
having the individual's outpatient record in hand, it was possible to ask what
he/she recalled about specific illnesses. A secondary benefit of the village
surveys was that they provided descriptive information about the life
circumstances of the survey population.

67

15919391111999

Kaloko Village, an arduous 12-mile walk from Kasela, had the lowest use
rate of the three villages. Seventy-one people who had used the clinic were
at home during the survey. Two mothers had received green spoons for oral
rehydration therapy for their children, but in each case the spoon had been
lost. The mothers said, “It got missing.“ They remembered the Instructions
for using the spoons but no longer made an oral rehydration drink. No sugar
was available in Kaloko Village, so the mothers could not make the
sugar-containing oral rehydration solution they had been Instructed to make.

One patient who had been treated for amoebiasis knew only that he had
“worms.“ A mother commented that she received “no teaching, just
medicines.“ A man who had come In for 12 weeks of streptomycin a year
earlier for treatment of tuberculosis had followed through on taking all his
oral medicines, as well. He was feeling well and had gone back to doing heavy
work on his farm. Several talked about bringing patients in to the hospital
by hammock over the steep, narrow footpath. One man had carried patients in
more than ten times, including his own son who subsequently died at the
hospital. He said, “Anyone that is sick says “Go call John, let him come,"
Indicating that the people of Kaloko were accustomed to having him help
carry patients in to the dispensary. One woman had been carried in twice for
Caesarean-sections. The second time she had arrived too late and the child
had died. Another woman with both pulmonary edema and a nephrotic
condition took two days to walk to the hospital. Her symptoms abated after
five weeks in the hospital, and it again took her two days to walk home. One
woman had been instructed at the dispensary to join an Under Five clinic, but
the nearest one to Kaloko was 12 miles away. Another patient had asked for,
and received, additional medication for a skin condition after explaining in

the dispensary that he came from “a for place.“ One household head, who had
outpatient tickets for all 14 members of his family, said that he learned at
the dispensary to take care of his body and keep clean by washing. All the
children he had taken to Kasela for treatment were still living, and he
expressed gratitude for that. An older man, with a heavy worm load of
onchocerciasis, had been instructed to come for treatment, but he said he
was not able to walk that far and so would not go.

In analyzing what Kaloko villagers learned through their visits, two
matters were particularly important. First, with regard to oral rehydration,
although the mothers correctly recalled how to use the green spoons, the
knowledge was of no benefit to them once the spoons were lost. Further,
since no sugar was available in Kaloko, an alternate rehydration solution was
necessary. The green spoons had created a dependency. Mothers needed to
learn how to rehydrate their children with resources available to them.
Second, orders could be more appropriate for patients when their home
circumstances were known. A negative example of this was suggesting the
mother have her child join an Under Five clinic when the nearest one was 12
miles away. A positive example was providing a patient with additional
medicines because of the distance he had to travel.

891mm

Information gleaned from Rotemne villagers was similar to that learned
in Kaloko. A patient with amoebiasis said he know only that he had “worms.“
Another was also told only “worms.“ A woman who had been treated for
chronic cervicitis said she had been told “nothing at all“ about the nature of
her sickness. A woman with anthrax said she was told that eating “sick
goat“ had given her the disease. One patient, who had been referred to an eye

B9

hospital several hours south of his village, followed through on the referral
and went. Another older man, however, had not followed through on
treatment for his onchocerciasis at the Kasela Hospital outpatient
dispensary because he “forgot about It“ and had “no chance to come.“ When he
was offered the treatment free of charge, he accepted and came to the
dispensary the next morning. One older woman who had used the dispensary
on a number of occasions smilingly said, “I am the owner of the hospital,“
referring to the money she had invested in her health care. Several mothers
in Rotemne attended an Under Five clinic that was within two miles of the
village.

One issue that these data made apparent was that a financial barrier
prevented some patients from following through on instructions related to
treatment.

Kalimboiiilege

In Kalimba, eight of the interviewed mothers had been given green spoons
for their children. In all cases the mothers recalled the instructions on how
to use the spoons, but three had been lost, one had been broken, and four had
been used only once. On asking one mother where she had put the green spoon
she no longer used, she replied, “there“ and pointed upward, to where the
bright plastic piece had been woven into the thatch roof as a decoration.
Everyone present joined In laughing over the fate of the unfortunate green
spoon.

Of the four villagers who had been treated for onchocerciasis and the ten
who had been treated for schistosomiasis, none knew what caused the
disease. One man described his schistosomiasis as “DC,“ a reference to the
common conception that blood in the urine, which occurs with

90

schistosomiasis, Is caused by gonorrhea. A common belief related to “BC“
was that a person contracted the disease by stepping on ground where
another person with venereal disease had urinated.

One woman explained how she had been taught to sponge a child with
fever. Two had received medications for the treatment of scabies, but both
had used it incorrectly. One stated she had not returned for medicines as
instructed because of lack of money.

In considering the significance of the Kalimba findings, one important
observation is that correct Mair/edge of how to use the green spoons for
oral rehydration had not affected practice In the village.

In considering the data from the three villages, it seems clear that those
who had used the dispensary had not learned a great deal about the nature and
treatment of their illnesses. It is important to note, however, that the
villagers used the dispensary frequently. Comments by villagers regarding
the dispensary commonly concerned the issue of availability of medicines:
“Medicine is there.“ “I believe the medicine.“ “There is medicine to carry.“
The importance of medicines to patients is further discussed in the findings
of the fifth research question.

The Learning Environment of Other Mission Hospitals
To provide a basis for discussing the outpatient dispensary learning
environments of other mission hospitals in Sierra Leone, the following
figures are given to indicate the size and work loads of the facilities in
1965 (see Table 4). The facilities are referred to by pseudonyms (courtesy
of H. L. Maclure).

91

Table 4. Attendance Figures at Nongovernment Hospitals and
Outpatient Dispensaries (1965 figures) (Biseye 1964 figures)

 

Hospital Kasela Bua Gbobe Foreban Robake Biseye Gbeba

 

OPD Visits 63,915 9,164 9,553 9,367 66,530 16,665 5,630

Hospital
Admissions 1,660 1,979 4,037 653 3,321 1,542 643

 

Source: Hospital annual reports

All were general hospitals except Foreban, which was an eye hospital.
Gbeba was a combination leprosy/general hospital. All of the hospitals had
community health outreach programs that had an educational component.
Only Foreban and Robake had daily educational programs for outpatients. In
both places the programs for outpatients occurred at the beginning of the
clinic day. At Robake the presentation was limited to 10 minutes. Topics
were based on various diseases: measles, polio, tetanus, diarrhea, and so
forth. A nurse and primary health care worker coordinated the program. The
program at Foreban had been set up in 1966 by a professional health
educator, who had spent six months assisting staff in developing a health
education program. Attractive visual materials, a well-prepared curriculum,
and staff skilled In encouraging patient dialogue characterized the daily
presentations. At the time of the researcher’s visit, the individual who had a
full-time assignment as head of the health education program was serving in
an administrative capacity, as well, due to a staffing shortage. He stated
that “the health work has gone down a little bit because I have not been
working [on it].“ This example supported Scotney“s (1976) assertion,
discussed in the literature review, that administrative priorities affect
health education.

92

Bua and Gbobe Hospitals had nurse-training programs. Teaching in the
outpatient clinics was part of the nursing program curriculum. Gbeba had
eight staff members who worked with patient education and rehabilitation
programs. Biseye Hospital had just reopened after being temporarily closed
and had no organized educational program for outpatients.

Two main impressions arose after observing patients In these various
environments. The first was that the Kasela outpatient department was the
most crowded of the facilities. Other facilities of similar sizes were seeing
for fewer patients. Robake, which saw a comparable number of patients, was
more spacious and patients had more privacy when seeing the health
professional. Each patient there was seen by a physician. Also, the Robake
clinic did not close over the noon hour; consequently, the clinic was normally
finished by 3:00 pm. or 4:00 pm, which was an earlier closing hour than at
Kasela. Greater privacy was also evident at Bua, where most of the patient
education was done on an individual basis and related specifically to that
patient's health problem.

The second impression was that having an individual with a specific
assignment in the area of health education was the key to a well-prepared
program. All of the general hospitals had health education staff in their
community health programs. These people could be excellent resources for
developing appropriate strategies for outpatient healtheducation.

Annual reports from the mission hospitals indicated that economic
conditions In the country and staffing shortages were their main problems.
Characteristic statements were as follows. “A major problem In
administration. . . .was obtaining foreign currency to pay our drug bills.“
“Rising costs of living, of transport and [a] closed border to Guinea caused. . .
reduction in the patient load of the hospital.“ “The present economic

93

constraints in the country [have] repercussions. . . .at every level of
functioning; the consequence being struggles for survival rather than the
implementation of the ideals of health care delivery.“ “(Our hospital] was
faced with inflation, economic depression, devaluation [of the currency].
shortage of Imported goods, and scarcity of essential equipment and drugs
for healing patients.“ “1’ he medical director has been alone with the medical
responsibility [for six months] and has not been able to leave the compound
for a break. . . .“ Several hospitals reported not having an adequate water
supply and all reported shortages of fuel to run their generators. Three
administrators indicated that the monthly cost of running the hospital
generator for a few hours each day exceeded monthly staff salaries. The
phrase “chronic crisis“ could be used to describe the functioning of the
hospitals in a number of respects. This Is important because staffing and
funding for health education programs are commonly compromised during
times of shortage.

Summary

The data related to the first question asking “What is the learning
environment of the outpatient dispensary?“ indicated that the Ieaming
environment was shaped by environmental factors including crowding and
time pressures. Many patients were unfamiliar with the dispensary system.
Hence, one type of Ieaming that took place was “learning to use the system.“
Patients' concerns in this regard included not only finding their way around
the dispensary, but finding food and lodging as well.

The second research question asked, “How are Ieaming opportunities
organized and conducted in this setting in terms of understanding the nature
and treatment of illnesses?“ Data from interactions between patients and

94

staff demonstrated that communication was primarily related to
Instructions and was essentially a one-way process rather than a dialogue
that included the patient. Instructions regarding health practices, such as
eponging a feverish child or mixing an oral rehydration solution, were given
at the discretion of the physician or nurse and were not associated with a
teaching protocol. Staff roles did not include an expectation of patient
education.

The third research question asked, “What specific information do patients
recall about the nature and treatment of their Illnesses?“ Information the
patients recalled was primarily related to Instructions about treatments and
knowledge of how to take medications. Patients who recalled information
that affected their practice were more likely to have gained that information
from an Under Five clinic Ieaming situation than from an interaction in the
dispensary. Similarly, data from the village interviews indicated that
meaningful Ieaming about the nature of a patient's Illness did not take place
during the dispensary visit. The data regarding the use of green spoons for
oral rehydration suggested that the knowledge acquired had not affected
practice.

The fourth research question asked whether the learning environment of
the Kasela Hospital outpatient dispensary was similar/dissimilar to that of
other mission hospitals in Sierra Leone. Only Kasela and Robake hospitals
were seeing 60,000 to 70,000 outpatients annually, whereas the other
facilities were treating 9,000 to 17,000 patients. One overall Impression
was that the Kasela outpatient department was the most crowded of the
facilities. Each of the seven hospitals had a community health education
program, but only two had educational programs specifically for outpatients.
The community health education staffs could be excellent resources for

95

developing appropriate strategies for outpatient health education. A second
overall impression was that having an individual with a specific assignment
in the area of health education was a key to a well-prepared program. All
hospitals reported economic difficulties and staffing shortages.

The implications of these findings are considered in Chapter VI.

CHAPTER V
FINDINGS RELATED TO HEALTH HABITS

In considering the fifth and final research question, “What are the health
habits (beliefs, practices) of those using the outpatient dispensary?“, it is
again appropriate to turn to Dewey's conceptual framework. Dewey
emphasized the importance of continuity in experience. A person coming to
the dispensary as a patient had already had experiences related to Ieaming
about health, illness, and various types of treatment. Those experiences had
generated various health habits. Because experience is continuous, those
habits interacted with the dispensary experience. To understand what health
habits had been generated from previous experiences, and then to examine
what health habits had been generated from the dispensary experience, a
longitudinal study would be in order. But as indicated in Chapter III, the
starting point for this study was with patients who had already presented
themselves at the dispensary for treatment. It was also mentioned that
limiting interviews to patients using the dispensary for the first time did
not provide a useful distinction, as many individuals had used other
dispensaries as well. They had had an “outpatient dispensary experience“
even If it had not been at Kasela Hospital.

The strategies used to answer the fifth research question were detailed
In Chapter III, and the data obtained are considered in the following sections.

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Health Habits Generated From Previous Experiences

So. What health habits (beliefs, practices) have been generated from
previous experiences?

Data from dispensary outpatient interviews were a main source of
information in answering this question; these findings are considered first.
Second, inf orrnation from local authorities was obtained through interviews.
Finally, the importance of Western pharmaceuticals In health habits was
investigated. In each case the data demonstrated a mixture of beliefs and
practices. For that reason, the categories are simply considered as health
habits.

W
The interview data considered here were obtained as part of the pre-visit

Interviews discussed in Chapter IV. The interview form is contained In
Appendix E, and the data are contained in Appendix F.

Question 6 asked, “What brought you to the dispensary?“ Patients
generally responded to this query by recounting symptoms (20/21 AU
patients and 23/26 general clinic patients). The remainder named a
particular disease such as “dry cough“ (tuberculosis) or “kidney infection.“
Question 9 asked, “Do you know what gave you this sickness?“ The majority
of respondents simply said they did not know. Often that response was
accompanied by a gesture that seemed to indicate the question had not been
considered before. Occasionally the response was, “Na God,“ that is, “It is
God.“

In reflecting on those responses, it would seem that they had been
conditioned by the clinic environment. Question 6 was essentially “Why are
you here?“ or “What is the problem?“ In the screening setting, patients

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invariably responded to that question with a recitation of symptoms.
Responses to Question 9 demonstrated that there was not much consideration
of causation within a Western context. One Informant said, “They don't trace
cause. They know about the sickness. Sometimes they know about some kind
of cure.“ He went on to discuss traditional beliefs in witchcraft, which
concurred with F innegan's description summarized in Chapter 11. That is,
patients had specific ideas of causation in traditional terms, but none in
Western categories.

The responses of the 21 AU and 26 general clinic patients to the question
about what they had done so far in seeking care for their present illnesses
are contained in Appendix F. Seven members of each group had used
traditional medicine. Four AU patients and three general clinic patients had
purchased medicine In the market or from a trader. Only 6/26 of general
clinic patients had gone to other clinics or hospitals, some of which in fact
were area dispensaries, 7 and 12 miles from Kasela. Of the AU patients,
however, 16/21 had already been to another clinic or hospital for this illness
episode, and virtually all of which were major hospitals 100 or more miles
from Kasela. Among the general clinic patients, 25/26 had traveled fewer
than 30 miles to come, whereas 16/21 of AU patients had traveled more than
30 miles. Because the narrative responses of the AU and general clinic
patients were different, their responses are considered separately.

WW3
When asked about traditional medicines, two patients responded that they

“tied their chests.“ One woman with edema of the feet had gone to an old
woman in her village, who gave her water to drink, in which roots and leaves
had been boiled. She had had diarrhea following that and noted some

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decrease in the swelling, but had come to the clinic when no further
improvement occurred. One mother said that she had not “joined upon native
medicine“ from an old woman in the town because she thought the medicine
“humbugged' the children. If her children had fever at night and she could not
bring them to the dispensary, she beat the leaves of the sour yellow plum
tree, heated them in warm water, and then put them on the baby to keep him
warm. She had also regularly attended one of the hospital's Under Five
clinics. Four of her seven children had died. Two had died of measles after
they had been weaned. All four children who had died had attended the Under
Five clinic.

When asked about medicines bought in the market or from traders, one
man said he bought the medicine from traders and then asked how to use it.
If his child, who also attended the Under Five clinic, was not better a day or
two following use of medicines from the trader, he said he would then bring
her to the hospital. He said he did not use “country“ or traditional medicine.
Another man said he bought tetracycline tablets and would use the contents
of one capsule in water for diarrhea in his child, which effectively
stopped diarrhea “one time“ or Immediately. They had an oral rehydration
green spoon at home but he said his wife did not know how to use it. Two
men had used local dispensaries but when the dispensaries no longer had an
adequate supply of medicines the men came to the Kasela dispensary.

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In contrast to the general clinic patients, the AU patients did not talk

much about either traditional or market medicines, but they did talk a great
deal about going to other clinics or hospitals. Numerous unlicensed “private
practices“ flourish, and one man had attended one of them. His laboratory

100

work at Kasela showed hookworm, amoebiasis, and tuberculosis. He
reported seeking care In the following way:
I went to a doctor In my village in Guinea. He told me I had malaria.
He gave me seven days of penicillin chooks (injections). I sat down

[stayed] for three months with him but I didn't feel better. The people
in my family said “You go to Kasela to get a well body.“

One patient who had had generalized abdominal pain for five years had
been to two hospitals In Guinea and another In Senegal. He had come to
Kasela because a relative had been to the hospital and agreed to accompany
him on the trip.

Another man who had urinated blood for three years had been to two
hospitals In Guinea. He had been given tablets for his illness but still did not
feel better. He concluded he had “worms.“ His urine sample at Kasela showed
a heavy infestation of schistosomiasis.

A woman who had first been to a Freetown hospital with generalized
abdominal pain had came to Kasela at the suggestion of her mother. The
mother had sent her other children to the Kasela dispensary with illnesses,
as well. A man with kidney problems had been to two other hospitals and
two dispensaries. Another man, who had used four different hospitals for
sicknesses in the past, had come to Kasela needing a hernia repair. He said
he had come because his family had told him, “If you don't go to Kasela, you
won't get well.“

Disturbing elements in the data were the evidences of inappropriate
therapy and the extent to which patients lacked accurate knowledge about
their health problems and therapies. Warming a favored child is consistent
with the belief that warmth drives away fever, but it Is in fact a harmful
practice. Penicillin injections for tuberculosis are both ineffective and
detrimental. One tetracycline tablet is of no value for diarrhea and

101

contributes to the development of drug-resistant organisms. A green spoon
for oral rehydration is of no value to the child if the mother does not know
how to use It.

In analyzing the data about the health-care-seeking practices of the
general clinic patients, two significant patterns emerged. The first was a
pattern of medical pluralism. Patients were seeking care from many
sources. Among the general clinic population, such sources Included local
traditional medicine, tablets from traders, and area clinics. The more
affluent AU population traveled wider distances and made greater use of
hospital services. The second theme was the importance of the therapy-
managing group. Family members In these groups not only recommended
where the patients should go, but often escorted the patients as well.

Medical pluralism was not limited, however, to those who used
Institutional health services. A man who lived in a village around 25
miles from the hospital, which was also quite a distance from the motor
road, was asked about action taken when sick in that village.

Normally, if they don't have trust In the hospital they go first to the
medicine man. And they try. If no cure, they go to the looking-ground
man. They look. And then the looking-ground man tells them
something and then they go on that. And they try. If no success. . . .if
they’ve done all these things and [have] no success, than they look for
the hospital. The hospital [is] always last. Not the first place. That

Is one reason why so many times before they come to the hospital the
child is hopeless.

The medicine man referred to was an herbalist who also had supernatural
powers. The looking-ground men was one who divined the cause of a disease.
When asked to what extent financial considerations affected the order of
therapy choices, the response was:

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That also makes them go to the juju or to the medicine man, because
they are cheaper. So they go there. They try there first. They find the
cheapest place first to solve the problem. If they don't go through [is
get cured] then sometimes they go and trust [bon'owl the money from
a neighbor and come to the hospital.

In a remote village, the choices of therapy were different from those in
larger towns or for individuals with greater financial resources.
Nevertheless, individuals and families pursued a number of therapies within
constraints that affected them.

WWW

Local providers of health care generously shared their time and the
knowledge related to their particular arts. An herbalist, who lived seven
miles from Kasela, related how his grandmother had instructed him in the art
of herbal medicines. He said his ability to heal was “by God's power and the
leaves“ that he pulled. Some of his patients went on to the Kasela outpatient
4 dispensary for treatment and then returned to him when “the doctor said
there was no [more] medicine there“ to help with that particular sickness.
The wife of a madman, a Muslim diviner, in the town of Kasela went to the
bush to gather a dozen different leaves and then carefully explained how each
was prepared and used. The moriman himself spent several hours talking
about his own medicines and charms: a leather arm band that protected
against enemies; a scissors-shaped neck charm that would ensure safe
delivery of an infant; an egg in a bottle that prevented thieves from entering
a house; a leather cord that went around the waist to prevent pain; and the
lasmami water, containing ink from koranic writings, which had the power to
drive away evil spirits and cure infertility.

A town market woman took time to explain the small pieces of baboon,
goat, and monkey skin she sold as waist charms to protect from witchcraft.

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Tailors working near the market showed the undergarments of red, white,
and black sacrifice cloth they made, which were often seen on severely ill
dispensary patients.

Women who were part of the village sodality graciously demonstrated
obtaining and preparing geophagial clays from area clay pits. Clay was dug
out of wet pits and then rolled into palm-size balls, removing as much
yellow and red clay as possible so that only the white clay remained. The
balls were dried in the sun for several days. When eating the balls, women
separated the clay from whatever sand was present. The sand was discarded,
and only the clay was eaten. The amount of clay consumed during pregnancy
depended on personal preference. Some women ate a large ball each day,
whereas others ate smaller amounts on a less regular basis. Similarly, the

choice between eating mineral-rich termite mound or mineral-rich clay was
I a matter of personal preference (A. Langham, personal communication, March
30, 1967). The white clay was also put on the bodies of girls following their
circumcision ceremonies. The same type of clay was used for finishing the
surface of houses.

Two midwives related numerous folk meanings of fertility, such as
prohibitions in pregnancy: eating pineapple will give the baby a skin rash;
eating plantain will hinder the cord from dropping quickly; eating eggplant
causes the umbilical cord to be big; eating a chi cken's 899 (Le, causing the
“chi cken's child“ to die) will cause the baby's death; sitting in a hammock
will cause the child to stay and swing inside the womb instead of coming out
easily at delivery; and bathing outside at night is dangerous because the
child in the womb will see devils and look like one when born.

All facets of traditional beliefs and practices related to health deserved
further exploration. From these interactions with local authorities, three

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major Insights arose. The first was the complexity and depth of meaning in
the various traditional practices, whether herbal medicines, the role of the
moriman, or folk meanings of fertility. The Importance of these beliefs In
people’s lives was also evident. Traditional practices had legitimate
authority, in the Weberian sense, In the culture in which they were practiced.
A second major Insight was the fact that these traditional systems were
also part of a larger pluralistic system of medical care that included
Western medicine. Traditional practitioners themselves used the Kasela
outpatient dispensary. The Muslim moriman had 10 visits recorded on his
clinic record and had been admitted for the surgical release of a small bowel
obstruction. A prominent local sorcerer had 15 visits recorded on his card in
addition to three admissions, including one for surgery. Western medicine,
even to authority figures in the area of traditional practices, was an option
used in times of illness. The third insight related to a lack of
Interrelationship between these systems and Western medicine. Traditional
and Western systems of health care were both proximate and disparate. Like
a mixture of oil and water, they were contained in the same cup and yet
remained distinct.

One area in which an interrelationship of systems has developed over the
years is women's health and childbearing. Ways to link that system of
beliefs and practices with Western medicine have already been explored. in
the 19403, Mangai (1946) began working through the society system to
increase the skills of the traditional birth attendants. His “Village Maternity
Assistants“ were elderly and respected women of the community who were
also members of the women's sodalities. The training program at that time
emphasized cleanliness, safe deliveries, and recognition of abnormalities in
the ante-partum period (Williams, 1979). More recently, MacCormack (1961)

105

argued, using Weber's analysis of the three forms of social legitimacy, that
the traditional authority of the village midwives must be incorporated into
the current primary health care system to make it effective. A

legal -rational health care system that ignores traditional authority is not
likely to be effective because it is not regarded as a legitimate authority.
The willingness of traditional practitioners to augment their knowledge with
Western medical skills makes them a natural link in developing a
comprehensive health care system.

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The Importance of Western pharmaceuticals to clinic patients cannot be
overemphasized. Patients frequently made the following patient comments.

- “I have come to the hospital because I was told medicines are here.“ “The
medicine here is good.“ “The first time I came I had a heavy sick. You gave
plenty medicine and I felt better. I believe the medicine.“ “When I carried
[brought] my mother [here] I got medicine.“ “I am ready to return to my home
now. I have come for medicines to carry.“ When an eight-year-old boy was
asked what he did when sick, his reply was, “You go to the hospital and make
them give you medicine. If you get sick, you take the medicine to swallow It.
When the medicine is done you go back for other medicine. Take it from the
white man.“ , ’

Both quantity and types of medicines were considered important. An
Appointment Unit patient who had been seen by a physician, and had received
only one medication for his intestinal parasites, was ridiculed by his peers
with the comment, “Ah, you paid to 50 to see the doctor and you only got
Le 6.00 worth of medicinei“ Patients who had been at Kasela for surgery and
came back for a post-operative visit, or those who had come from great

loo

distances, commonly requested “traveling medicines“ to take with them on
their journeys home.

A number of factors have contributed to the importance of Western
pharmaceuticals in the patients' eyes. One major factor was the use of
penicillin to treat yaws. In 1939, yaws was the most common disease seen
in the Kasela outpatient dispensary. Five thousand patients that year
received treatment for yaws. In the initial stage the patients had painless
ulcers. In the second stage they had skin eruptions that looked like “a
hundred raspberries over the skin.“ Eruptions on the hands and feet made
work difficult and walking painful. In the third stage, patients suffered bone
deformities, liver tumors, and ulcers on the palate and nose that ate the
entire nose away (McMillen, i939). Injectable penicillin used in the “yaws
, campaigns“ brought dramatic cures. A resulting, firmly entrenched belief
has been that an Injection is essential for any serious illness and is more
efficacious than tablets.

Second, Western pharmaceuticals were widely available. The Kasela town
market tables contained chloroquin, aspirin, ampicillin, tetracycline, valium,
ephedrine, and a large number of other analgesics, antibiotics, and
antihelminthics. Market tables in the larger cities of Makeni and Freetown
contained an even wider selection of pharmaceuticals, Including such
prescription drugs as butazolidin, tandearil, tagamet, lasix, and vibramycin.
An independent pharmaceutical representative in Freetown said that once
when he needed vibramycin for a customer he happened to pass a trader
outside the City Hotel selling vibramycin. He asked the price and was quoted
the same price as for any other antibiotic - La 1.00 (S .026) per capsule. He
purchased the few capsules the trader had, as he knew the actual cost per
capsule to be Le 12.00. The trader offered to get more, and the following day

107

he brought the pharmaceutical representative more than 1,000 capsules
(Kargbo, personal communication, December 13, 1966).

Medication theft from government and private health facilities was
described as “so widespread that It has rendered many medical facilities
virtually impotent. Medications end up for sale on the street or in private
drug stores and clinics of private practitioners“ (Bledsoe A Goubaud, 1965,
p. 277). Pills and capsules were sold at market tables without containers or
directions. Purchasers usually bought one or two tablets.

Nongovennent hospitals commonly reported that cartons in drug
shipments, in which each carton had been Identified numerically, had been
pilfered or were missing when the shipments were claimed in the capital
city. A typical example Included a carton that was missing a
sphygmomanometer, a stethoscope, acetaminophen, penicillin, riopan,
surgical tape, and surgical gauze. A missing carton contained 5,000
chloroquin, 600 valium, 40,000 iron, 40,000 folIc acid, 5,000 penicillin,
2,000 promethazine HCI, 500 tubes of tetracycline eye ointment, and 5,000
tetracycline tablets (D. Spores, personal communication, March 2, 1967).

An elicitation device was made for this study, similar to the one
described in Bledsoe and Goubaud's investigation. It contained 32
pharmaceuticals and traditional medicines, 16 of which were available in the
Kasela town market and 16 from the dispensary pharmacy. Fifty people,
including patients, children, villagers, and even visitors at the door were
asked which medicines they had seen before, what illnesses they were used
for, and what quantities were used. The purpose of the device was to
stimulate discussion of appropriate treatment for various diseases. The
findings were of interest (see Appendix G).

The traditional remedies sold in the market for toothache, bed bugs, and

106

round worms were included to stimulate initial discussion and were quickly
Identified by most informants. A small container of Mentholatum was
variously rubbed on, licked, or mixed with water and drunk for colds and
coughs. Nearly all informants agreed on how each remedy was to be used.
Virtually all informants identified the red and yellow tetracycline
capsule. Most called it just “capsule“ and agreed that It was to be put on
sores or that one or two should be taken for “belly pain.“ Tetracyline had
been in the markets for some time and was called “the old medicine,“
whereas the more recent ampicillin capsule was “the new medicine.“
Iloeone, being the newest, was described as the “most powerful.“ Antibiotic
capsules such as keflex (green and white), chloramphenicol (white) and
ilosone (orange and cream color) were assigned the same dosage and
. functions as the tetracycline capsules. Various informants commented that
the yellow tablets (ambilhar for schistosomiasis and the tranquilizer
vellum) were for “fever.“ This association probably originated with the use
of yellow mepacrine tablets for malaria treatment. One informant
identified a small orange chlorpromazine tablet, a tranquilizer, as “blood
medicine,“ probably because of its color. Some “small“ tablets, such as
chlorpromazine and digoxin, were considered to be for “small“ children.
Adults and children alike correctly identified the analgesics Colonel and Top
Tabs, sold in the market, as “head hurt“ (headache) or fever medicine. Eleven
respondents pointed to the small white tablet (d1 goxin for cardiac problems)
and called It “dry chook,“ mistakenly identifying it as the ephedrine tablets
(a powerful stimulant) that are sold at many market tables. People take it
when they are “tired from the farm,“ and it is considered effective “If you
don’t sleep all night.“ It may be used before going to an all-night dance. Two
inf orrnants knew individuals who had died after taking several ephedrine

109

tablets. It was also correctly identified for use with asthma. The essential
finding confirmed that of Bledsoe and Goubaud (1965): people interpreted the
medicines consistently. However, the uses and dosages that they described
were at variance with those intended by the manufacturers. Western
pharmaceuticals were being reinterpreted in light of local values related to
size, color and efficacy.

Health Habits Generated From the Outpatient Dispensary Experience
so. What health habits (beliefs, practices) have been generated from the
outpatient dispensary experience?

A variety of sources provided information on the health habits of those
who had used the outpatient dispensary as a source of care: patient
Interviews, interviews of staff, observations of patient behavior, and
observations made while participating in providing care for patients. From
those data, three vignettes were selected that represented classes of
vignettes typical of a range of health habits characteristic of those who had
used the outpatient dispensary. A brief discussion of emerging themes
follows each vignette.

We
Papa, the two-year-old son of a village dispenser, had fever and

convulsions In his home village. His parents immediately took him to Kasela
Hospital. There were no significant laboratory findings. A spinal tap was
negative for meningitis, although the child had a markedly stiff neck. For
two days the fever remained high and the convulsions continued. Treatment
included antimalarials, antipyretics, and antibiotics. A diagnosis was made
of probable cerebral malaria or encephalitis. A flaccid paralysis of the leg

110

developed. The child was discharged two weeks later to recover at home.
The paralysis and stiff neck were still present. No fee was charged for the
hospitalization.

Following no improvement at home, the family consulted a looking ground
man to ascertain the cause of the illness. The looking ground man said that
the illness had occurred because the child had seen a demon. The mother
recalled that shortly before the onset of the illness she had taken Pope to a
waterside. While there, he had said, “Mommy, look at the monkeys there.“
The looking ground man said the child had really seen the devil. The devil
said, “You stop looking at mei“ Sighting the devil had occasioned the child's
stiff neck. The looking ground man said the child had four-sight (is, the
ability to see the spirit world). The family paid the looking ground man
‘ Le 16.00. He referred them to a man who could deal with “devil business.“

The man to whom the family was referred was a Muslim moriman. He
asked for Le 6.00, as well as a black fowl and a kola nut for a sacrifice. He
also prepared lasmami water (water containing ink from Koranic writings),
which he sprinkled in Papa's eyes. More lasmami water was sent home with
the family to rub on Papa. The stiff neck did not Improve, and Papa was
unable to sit up by himself. » .

After several days of no improvement, the parents took the child to
another moriman in Kasela, who also prepared lasmami water. The child
drank this water and it was rubbed on his skin. Additional sacrifices were
also made there.

When the child was still unable to sit up by himself, the parents took him
to a man especially known for driving the devil away from children. This
village “Pa“ (a term of respect for a man) confirmed that Papa had seen a

111

devil. Following another sacrifice, the child was able to walk a little bit by
holding onto others.

After this, Papa's paternal grandmother came and took the child to her
home village. Different sorcerers were consulted in the next three weeks, to
ascertain what type of swear had been put on the family that had resulted In
this problem. The sacrifice of a sheep, costing to 120, was required.

Several days later, the child was taken to a Limbo sorcerer who agreed to
help if the family used only his medicine. He made numerous cuts on Papa's
buttocks and legs and then rubbed in medicine. Two days later, Papa began
crawling. The father returned to the sorcerer and said, “There Is much help
in your medicine now.“ The sorcerer said, “Just continue with my medicine
and don't mix it with any other.“ Papa began walking by himself, although his
left foot was not straight. A charm (a small rope) was tied on Papa's left
foot, two were put on his neck, and one was put on his waist. A charm in a
bottle was hung at the house entrance to keep a devil or enemies from
entering the house.

At the time of the interview, Papa still had on two of the protective
charms. His father's conclusions about the situation were as follows:

Interviewer. “As you look back on that Illness, how do you understand
Papa's recovery?“

Father. “At firstl thought it was the brain problem. That was my
first thinking. But as time went on I changed my mind. I actually
know It was something superstitious.“

Interviewer. “As you look back on It now, do you feel that was the
right course of action to choose?“

Father. “Well actually I am glad about the whole situation. Even the
money I spent. I felt it was just an expenditure. You know, the
money did not go In vain. So I am glad over it, even if I spent
two or three hundred pounds. As long as he has regained his health
and is able to walk now, I am pleased about that.“

112

Interviewer. “What response do you think you would have had if Papa
had died or continued to be crippled?“
Father. “I can‘t actually judge, because I had two different minds
(is. ways of thinking about the situation). One, I was thinking It was
brain damage. But I knew he didn't have a fall, and nothing had hit him.
On the other hand, I felt it was something superstitious. I might have
thought that It was because of Papa's four-sight that he had seen the
devil and the devil killed him.“

The vignette about Papa demonstrated that Western medical care is
Incorporated Into the quest for therapy. The father was the key figure in the
therapy-managing group, and although he had had a Western education,
including health training, Western therapy was not his final choice. Janzen
(1960) described this pattern of behavior in seeking multiple sources of
care. The evidence of this vignette also supported Yoder's (1961) finding
that causal explanations change when illnesses do not respond to treatment.
The cause of Papa's problem was initially perceived as encephalitis, but it
was later perceived as being related to “something superstitious.“ The
evidence likewise supported Prins's (1979) finding that the introduction of
allopathic therapy did not falsify a belief in systems of diagnosis and
explanations that already existed, but that the two therapeutic systems
coexisted.

W
In the village of Kalimba a measles epidemic occurred in 1975, when no
measles vaccines were available. Many children died. The village people
determined that witches had caused an evil breeze to come to the village and
they planned to “eat“ the children. The town decided to find a medicine man
who could take the children out of the hands of the witch people. A medicine
man from the distant Temne Sande area was summoned to come and “pull the

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sickness“ from the children. He came and stayed overnight. Amid drum
beating, he went and dug in certain places around the village. He unearthed
various things which he said were devils, ties (things that place a hold on
other things) from the witch people, and even witch guns. The witch guns (a
special “gun“ used by witches to secretly kill people) looked like pistols.

All of those things were burned.

This second vignette, describing Kalimba villagers“ response to a measles
epidemic, illustrated two things. First, it again illustrated the
pluralistic use of health care systems. Some villagers were already using
the outpatient dispensary for care at that time (see Appendix C, Table C.2).
This was the same Kalimba Village as the one surveyed as part of the
research study. During October and November 1975, dozens of measles cases
were treated at the Kasela outpatient dispensary each day. Measles vaccine,
however, was not available at that time, and the Under Five immunization
program had not yet been started In a village near Kalimba. The villagers
therefore resorted to a form of therapy well known to them.

Second, the vignette illustrated that a concept of causality will
determine a course of action. Measles is generally believed to be caused by
witches blowing on the children of a town. A single case may be attributed
“to God,“ but multiple cases are attributed to witches. A logically
appropriate action would then Involve ridding the town of witches. Finnegan
(1965) suggested that beliefs that form part of a concept of causality will
not quickly die.

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Wow
Pastor Abu, in a remote village 35 miles from Kasela, became seriously

ill with a fever. At that particular time, nurses from Kasela Hospital came
out to the village to hold a clinic. They treated him with chloroquin and
aspirin for malaria. By the following morning his condition had worsened
considerably, and he was delirious. The nurses returned with him to the
hospital, where he was treated for a fulminating case of typhoid fever. When
well, he returned to his village. Some time later, his small child Daniel also
became seriously ill with fever. The following was his account of seeking
therapy for Daniel:

When Daniel became sick there were a lot of things said about his
illness. The village was just newly evangelized and the people didn't
know much about the hospital or even things on the religious side. So
when Daniel become sick, they came to us. Some suggested that it was
a devil. Some suggested that it was a kind of medicine they call km‘r’e
In Limba, which would make a child become unconscious. Normally
[unconsciousness] Is caused by the convulsion because of the fever.
But to them it was not a convulsion. It was either a devil or this
medicine tar/a. You see, one particular woman In the town, an old
lady, controlled that type of medicine. Sometimes they made a sign of
it and put [the sign] in their groundnut or cassava farms. it threatened
people. Whoever took the cassava would get that kind of medicine (Le,
a thief would get tar/o]. Even if you passed by the sign, they had the
belief that you might get the Arr/tie So they said my wife had passed
by the sign and caught the tut/e, and because of that the child got the
mm So that was theirbelief.

But myself, I knew what was wrong. I knew that it was a heavy,
heavy malaria that had attacked the brain. We waited, but there was
no medicine around. So I decided to come with the child at night. We
started out around 12 o'clock at night, and we walked nearly the whole
night with the child to the main road. We reached the main road around
6 o'clock In the morning, and we sat there and waited until i 1 o'clock
In the morning before we got a vehicle. . . .before we got transport to
Kasela. And when we came, they said it was malaria. And they took
care of it very quickly. And we went back.

115

The third vignette was representative of three similar vignettes obtained
from interviews. All were of people who used herbal and Western medicines
but no longer resorted to sorcerers or looking-ground men. A number of
clinic patients who were interviewed also stated that for health care they
used only Kasela Hospital or the dispensary. Several stated that their whole
family used only the clinic for care. In the third vignette, Pastor Abu had had
a positive personal experience of being helped with a serious illness by
providers of Western medicine. Further, In his role as a pastor, he had
developed personal relationships with hospital staff members. In his case,
beliefs about the causes of illnesses had changed, as had his practices in
seeking therapy.

Summary
Findings related to the fifth research question, “What are the health
habits (beliefs, practices) of those using the outpatient dispensary?“, were
analyzed in this chapter.

_ First, the data related to health habits generated from previous
experiences were examined. Both AU and general clinic patients practiced
medical pluralism, although AU patients traveled greater distances, made
greater use of Western health services, and paid more money in seeking care
than did general clinic patients. Disturbing elements Included evidence of
Inappropriate therapies and patients' lack of correct knowlege of their health
problems and therapies. The important role of kinsmen as the patient's
therapy-managing group was noted, as well.

Local authorities, Including an herbalist, a moriman, and midwives,
provided insights into traditional beliefs and practices. MacCormack
suggested linking the traditional authority of these practitioners with

116

Western legal-rational systems to provide a comprehensive health care
system. The importance of Western pharmaceuticals, and the extent to
which they are misued, was also considered.

Second, data related to the health habits of those who used the dispensary
were examined by means of three representative vignettes. The vignettes
illustrated that those who had used the dispensary commonly combined that
use with traditonal systems, particularly in the event of serious Illness.
Some people had come to rely solely on Western medicine. In the vignette
that exemplified such behavior, both a positive personal experience with
Western medicine and personal relationships with hospital staff members
had contributed to that action.

The findings related to health beliefs and practices were congruent with
Dewey’s thesis on the continuity of experience. Health habits rooted in
traditional beliefs about religion, witchcraft, and Western medicine formed
the basis for interpreting the dispensary experience. If the dispensary
experience had been satisfactory for the patient seeking therapy, then it was
often a final source of care. If the experience had been unsatisfactory, the
patient sought additional therapy.

The dispensary experience was incorporated into a larger system of
beliefs and practices. In some cases the dispensary experience was
overshadowed by traditional beliefs and practices, and in other cases the
experience with Western medicine served to modify or alter those beliefs
and practices.

Implications for providers of health care services arose from the data
gathered In this study. First is the importance of knowledge of traditional
beliefs and practices, which is essential in understanding patient behavior.

117

Second is the Importance of developing strategies for working within that
framework of understanding.

CHAPTER VI
CONCLUSIONS AND RECOMMENDATIONS

As indicated In the initial description of the research methodology, it
was not possible to be Involved in the Kasela Hospital outpatient dispensary
without being deeply moved by the responses of hundreds of patients to the
health problems they were experiencing, and by the efforts they were making
to be restored to good health. The purpose of the study, however, was not to
produce a journalistic description of events, but rather to give an analytic
description, concluding in a conceptualization of patient Ieaming in a
complex dispensary environment. Nevertheless, as medical anthroplogists
Janzen and Prins (1961) well stated, when the subject includes suffering,
pain, and bewilderment, its urgency never permits students to ignore the
practical side and the role of practitioners (p. 169). So the researcher
sought not only a conceptualization of Ieaming but also the Implications that
arose from that conceptualization.

In this chapter the findings of the research questions are reviewed first,
followed by Implications and recommendations, and suggestions for further
research. .

Conclusions Related to the Research Questions
I. What is the Ieaming environment of the outpatient dispensary?
In considering the learning environment, both observations and the

literature supported the negative effect that environmental factors such as

116

119

crowding, discomfort, and distractions have on Ieaming (Leedam, 1972;
Scotney, i976). Crespo (1965) stated that “Ieaming environment“ includes
not only the aspect of the Ieaming setting, but the aspect of customs that
provide a context from which people relate to health behaviors--that Is,
what Dewey would describe as previous health habits, an area that was
explored in connection with the fifth research question.

2. How are learning opportunities organized and conducted in this setting
in terms of understanding the nature and treatment of Illnesses?

Patient learning In the interactions with nurses, physicians, and drug
dispensers was affected by at least three considerations. Environmental
factors such as time pressure and lack of privacy influenced the interaction.
Within the clinic setting, language and cultural barriers further hampered
Interaction. Second, there was not necessarily consensus on what
constituted an appropriate role for providers and patients In that situation.
What some interpreted as a passive posture on the part of patients, was
interpreted by an anthropologist In Sierra Leone as a way of showing respect,
submission, and obeisance (J. Opala, personal communication, December I 1,
1966). MacCormack ( 1961) argued that practitioners“ therapies normally
involve talking at length with patients to understand their hopes and fears.
Third, the dynamics of the situation may have been different from what is
traditionally considered in a provider/patient relationship. In an article
entitled “The Importance of Knowing About Not Knowing,“ Last (1961)
suggested that people's disinterest in medicine is an Important medical
phenomenon. Patients are not Interested in knowing about cures or ideas.
They simply expect that, somewhere among all the providers, a cure is
known. Practitioners do not care about other systems, and each is left to

120

flourish in seeming anarchy. Last suggested that in going to various sources
for therapy, patients “do not so much “switch codes“ as simply “switch off'“
(p. 391). In a final analysis of what occurred in the Kasela Hospital
outpatient interactions, it is probably most accurate to say that elements of
all three considerations were present.

3. What specific Information about the nature and treatment of their
illnesses do patients recall from their clinic visits?

The data indicated that patients primarily learned Instructions about
their treatments and the correct way to take their medications. This ability
to accurately recall an “information list“ suggests the type of remembering
described as rote memory, the ability to recapitulate what has occurred by
simply repeating information in the original temporal sequence. Bartlett
(cited in Cole A Scribner, 1974) described rote memory as the preferred
memory technique of nonliterate people. It differs from the type of
remembering that is an active process, in which past experience and
information are reconstructed for the purpose at hand.

The study was delimited to patient Ieaming in outpatient settings and did
not include Ieaming in Under Five clinics. Yet in the course of interviewing
general clinic patients and former patients in their own villages, much of the
Information they did recall about oral rehydration, nutrition, and eponging
feverish children, had come from their Under Five clinic experiences.

The knowledge retained about the use of green spoons for oral rehydration,
however, did not seem to Influence practice. When the spoons were lost or
broken, or sugar was not available, no oral rehydration solution was made.
Mothers had essentially learned “green spoons“ rather than “oral rehydration.“
The Issue of creating dependencies, and knowledge that is inappropriate for a

121

particular cultural setting, arises from this and deserves further
consideration.

4. Is the learning environment of the Kasela Hospital outpatient
dispensary similar/dissimilar to that of other mission hospitals In Sierra
Leone?

Two main impressions arose following observations at other mission
hospitals In Sierra Leone. The first was that the Kasela outpatient
department was the most crowded of the facilities, and crowding negatively
affected the Ieaming environment. The second was that having an individual
with a specific assignment In the area of health education was the key to a
well-prepared program. All the hospitals had health education staff in their
community health programs. These staff members could be excellent
resource people In developing appropriate strategies for outpatient health
education.

5. What are the health habits (beliefs, practices) of those using the
outpatient dispensary?

Outpatient interview data, interviews with local authorities,
investigation of the use of Western pharmaceuticals, and vignettes
describing health-seeking behaviors all provided data with which to address
this question. The findings related to health habits could not be stated as
firm conclusions, but rather suggested a number of themes.

The outpatient Interview data indicated that the dispensary experience
was not a single, definitive event that affected patient Ieaming. Rather, use
of the dispensary was usually incorporated Into a larger system of
health-seeking behavior. This behavior was widely described in the medical

122

anthropology literature as medical pluralism. More than half of the general
clinic population came from within 10 miles. Nearly 408 paid less than Le
15.00 ($0.42). They used local traditional medicine, tablets from traders,
and area clinics as alternatives to dispensary care. Appointment Unit
patients came from greater distances, paid more money, and generally used
other hospitals and hospital dispensaries as sources of care. A second theme
that emerged from the outpatient Interviews was that in many cases the
health-seeking behavior was guided by a therapy-managing group of kinsmen
and associates.

Data from local providers of health care pointed to the complexity of and
depth of meaning in traditional beliefs and practices. An implication arising
from this finding was the awareness that an understanding of traditional
beliefs and practices is essential In understanding patient behavior.
Evans-Pritchard (Horton A Finnegan, 1973) pointed out that an adequate
phenomenology of alien concepts, beliefs, and cosmologies is a precondition
for an adequate sociology of them.

The finding that Western pharmaceuticals were reinterpreted supported
the findings of Bledsoe and Goubaud(1965). Pharmaceuticals were an issue
of major concern in the Kasela dispensary. Indeed, providing them was one of
itsmajor functions. This reinterpretation was not an isolated phenomenon,
however. Characteristically, people structure the reality around them.
These “social constructions of reality“ are defined In terms of meaning to
the people concerned, rather than in terms of an “objective truth“ (Berger A
Luckmann, cited in Horton A Finnegan, 1973, p. 26).

The vignettes on health seeking behavior demonstrated that a variety of
health habits were generated by the outpatient dispensary experience. They
were representative of a larger number of patients who were interviewed.

123

Some patients, in a serious Illness, used both traditonal and Western care.
Others relied soley on the dispensary as a source of care. More research is
needed to explore factors that are important in those varied responses.

Implications and Recommendations

Implications of the findings and recommendations based on the findings
are as follows:

1. Provision for patient learning begins at the administrative level, with
an institutional plan for and commitment to appropriate patient education.
Both environmental factors that affect learning and role expectations with
regard to educational functions need to be considered.

2. If patient learning is to become more than rote memory Ieaming, then
staff Involved in educational roles, who are not already acculturated, need to
gain skills in sharing the cognitive orientation of the patients.

3. The type of participative education decribed by Werner (1976) and
Freire (1970) is more suitable to community-based primary health care
education programs then it is to dispensary situations. Nevertheless, health
education efforts that fit within dispensary constraints can be Implemented.
Teaching protocols can be as simple as ensuring that each patient knows
what has caused his/her disease, and the purpose of the prescribed
medications.

4. Observations at other hospitals and recommendations from the
literature suggested that responsibility for the planning and direction of
health education should be assigned to one person (Barnes, 1976). Health
education does not occur spontaneously just because a group of health
personnel are involved In giving health care.

124

Suggestions for Further Research

An ethnographic approach was used because it offered methods that
allowed a wide perspective on Ieaming in a complex situation. Several areas
emerged that require further investigation:

1. What constitutes appropriate health education in this setting?

2. What strategies for health education are best, given the constraints of
the outpatient dispensary situation?

3. How are patients using the medicines they receive, and to what extent
are they complying with treatment instructions?

4. What factors affect changes in health behavior?

5. How can traditional practitioners that have legitimate authority be
incorporated into a health education program?

6. What elements are necessary for an educative, rather than a
miseducative learning environment In the outpatient dispensary?

Summary

Dewey's conceptual framework provided a useful tool for exploring the
learning environment of the Kasela Hospital outpatient dispensary. Further,
the research findings supported Dewey's theses: both the dispensary
experiences studied by the researcher and previous health-related
experiences were incorporated into patients' health habits. Patients were
indeed using those habits to cope with the health problems In their
environments. Dewey, however, cautioned that only habits which enable an
individual to clarify and cope with the problems of his/her environment and
lead to additional habits for understanding and coping with new problems as
they occur are habits which manifest growth. An educative environment is
one which fosters growth. Growth is not evident when habits thwart

125

problem solving or create new problems. In terms of health education, this
means encouraging the growth of habits that will give patients the ability to
understand and cope with their health problems. The data from this study
demonstrated that many patients’ habits did not lead to solutions of their
health problems. The challenge facing health care providers working in
dispensary situations is to provide a looming environment that is educative
rather than miseducative in nature.

APPENDICES

APPENDIX A

OUT PATIENT DISPENSARY USAGE

126

Table A. I. Outpatient Dispensary Attendance Figures, 1 980 through 1986

 

 

Years 1980 1981 1982 1983 1984 I985 1986
Yearly

Totals 50,978 59,074 58,064 66,876 59,850 63,915 70,953
Monthly

Totals

January 4, 158 4,796 4,787 5,478 5,286 5,901 5,351
February 3,893 4,539 4,662 5, 148 4,923 5,783 5,273
March 4,218 4,977 5,729 5,636 5,096 6,467 6,310
April 4,098 4,570 4,093 5, I 15 4,753 5,895 6,037
May 4,096 4,916 3,686 5,105 4,615 4,676 5,483
June 4,514 5,999 4,520 5,068 4,419 3,604 6,192
July 3,968 4,923 5,524 5,671 4,426 4,720 6,529
August 3,742 4,504 4,709 5,405 4,502 4, l 40 5,661
September 4,673 4,573 4,482 5,563 4,631 4,589 6,545
October 4,949 5,490 5,615 6,104 6,282 6,145 6,781
November 4,045 4,896 5,545 5,932 6,268 6,848 5,438
December 4,624 4,891 4,7 I 2 6,651 4,649 5,147 5,353
Dally

Averages

Sunday 16 23 23 20 l 3 1 1 1 6
Monday 239 276 279 309 287 297 315
Tuesday I 89 2 I 9 209 247 223 250 274
Wednesday 87 97 91 l 05 l 00 1 I6 135
Thursday I 87 231 235 269 222 225 252
Friday I 83 205 201 242 220 234 260
Saturday 79 85 79 95 86 96 I I3

 

127

99,999 -
79,999
66,666 -
Number 59,999
Attending “91999“
39,999 »
29,999
19,999

 

 

 

1986 1981 1982 1983 1984 1985 1986

Years

Figure Al Outpatient Dispensary Attendance for 1960 through 1966.

-rrocr3r:2

LDDd‘QDQr-‘r-O}

126

I 1965
1966

7 ,666

6 ,666

5 ,666

4 ,666

3,999

2,999

1 ,666

 

 

 

 

 

 

 

 

 

 

 

 

 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1965 6nd 1966

Figure A. 2. Average Monthly Outpatient Dispensary
Attendance for 1965 and 1966.

356 ‘

 

 

__ I 1965

m 1966

256 -
266 -
156 ‘
166 '

1003::2

56'

 

(DD-*CLDCDr‘F‘}

 

 

 

Sun Mon Tue Wed Thu Fri Sat
Days

Figure A. 3. Average Daily Outpatient Dispensary
Attendance for 1985 and 1966.

 

 

 

 

25«

294

Percent 15,

of
Total 10"
Attendance

51-

a.

MON TUE WED THU FRI SAT SUN
Day of Week

Figure A.4.0utpatient Dispensary Attendance
by Day of Week

APPENDIX B

OUTPATIENT SURVEY DATA

Table 8.1. Kasela Hospital Fee Schedule - (December, 1986)

 

 

SERVICE PRICE IN PRICE IN
LEONES DOLLARS
Admission (per month or portion thereof) Adult 80.00 2.22
Child 0-2 Years 20.00 0.56
3-6 Years 30.00 0.83
7-15 Years 40.00 1.1 1
AU Adult" 120.00 3.33
Child 80.00 2.22
Overnight Adult 6.00 0.17
Child 2.00 0.06
Private Room (per day, to be paid in advance weekly) 10.00 0.28
Intravenous fluids (per bag) 40.00 1.1 1
Whole blood (administration cost) 80.00 2.22
The cost of certain therapeutic courses (1.9., DEC ,*
Ambilhar*, special antibiotics) will be totalled
separately, and added to above fees
SURGICAL PROCEDURE FEES (+ Le 20.00 for AU Patients)
Hernia Repair-Double 280.00 7.78
Single 200.00 5.56
Reduction with Anesthesia 24.00 0.67
Reduction without Anesthesia 10.00 0.28
Hydrocele Repair-Double 280.00 7.78
Single 200.00 5.56
Hydrocele with Scrotal Resection Additional 80.00 2.22
D A C Emergency 140.00 3.89
Elective 120.00 3.33
W/Rubins,EUA* 200.00 5.56
Circumcision Neonatal 1 2.00 0.33
Other 40.00 1.1 1
Ceasarean Section Elective 160.00 4.44
Emergency 240.00 6.67
Laparotomy PP BTL" 200.00 5.56
Interval BTL 240.00 6.67
Ectopic / Hysterectomy 320.00 8.89
01 Resection 400.00 I 1.1 l
Prostatectomy 320.00 8.89
WF Repair 320.00 8.89
MD Delivery 400.00 1 1.1 1
Spontaneous Delivery No Assistance 40.00 1.1 1
MD Assistance 120.00 3.33
Symphysiotomy 1 60.00 4.44

131

 

 

SERVICE PRICE IN PRICE IN
LEONES DOLLARS
Urethral Dilatation Without Spinal 50.00 1.39
With Spinal 100.00 2.78
Lacerations Emergency 20.00 0.56
Lipomectomy 32.00 0.89
Nodulectomy 10.00 0.28
I.U.D. Insertion 40.00 1.1 1
Foreign Body Removal Without Anest 6.00 0.17
Ketamine/cc 12.00 0.33
Dental Extraction (Tooth) 12.00 0.33
F renulectomy 6.00 0.17
OUTPATIENT FEES
Registration/New Ticket Regular 4.00 0.1 1
AU 12.00 0.33
Wed,Sat,Sun,
Late Fee
Adult 10.00 0.28
Child 1.00 0.03
Consultation with M0. Regular-Adult 2.00 0.06
Child 1.00 0.03
AU - Adult 50.00 1.39
Child 30.00 0.83
Physical Examination Adult 24.00 0.67

MISCELLANEOUS
Laboratory tests

X- Ray
Ace Wrap

Dressing Changes
Casts

Crutches

Police Report (requires evaluation by an MD.)
*AU- -Appointment Unit / *Ambilhar--e drug used in the treatment of schistosomiasis
*DEC--Diethylcarbamazine, a drug used in the treatment of onchocerciasis

*W/Rubins,EVA--done in fertility evaluations / *PP BTL--Post-partum bilateral tubal ligation

Child 20.00 0.56
School 6.00 0.17

Adult 2.00 0.06
Child 1.00 0.03
Large film 80.00 2.22
Small film 40.00 1.1 1
120m 30.00 0.83
80111 20.00 0.56
Per Week 2.00 0.06
Per Roll of
Plaster of Paris 10.00 0.28
Adult 20.00 0.56
Child 10.00 0.28
20.00 0.56

 

132

Table 6.2. Fees Paid by Outpatients per Illness Episode

 

 

AMOUNT IN AMOUNT IN AU ALL
LEONES DOLLARS PATIENTS PATIENTS

Data not
obtained 2 6
Fee not yet
assessed 1 9
0.00-4.99 0.00-0.13 0 85
500-1499 0.13-0.41 3 478
15.00-24.99 0.41-0.69 5 245
2500-4999 0.69-1.38 12 243
50.00-74.99 1.38-2.08 10 1 14
75.00-99.99 2.08-2.77 15 71
100.00-149.99 2.77-4.16 34 99
150.00- 1 99.99 4.16-5.55 16 43
200.00-249.99 5.55-6.94 5 l6
250.00-29999 6.94-8.33 4 9
300.00-34999 8.33-9.72 4 19
350.00-399.99 9.72-1 1.1 1 2 7
400.00-449.99 I 1.1 l - 12.49 I I
45000-49999 12.49-13.88 0 I
500.00-54999 13.88-15.27 I I
550.00-59999 15.27-16.66 0 0
60000-64999 1 6.66- 18.05 2 4
650.00-69999 18.05-19.44 0 0
70000-74999 1 944-2083 0 I
75000-79999 20.83-22.22 O 0
>80000 >22.22 0 0

TOTAL OUTPATIENTS - l 17 1452

 

133

Table 6.3. Distance to Kasela Hospital Outpatient Dispensary

 

 

Town or Village Distance Town or Village Distance
Babakunaya in Kono <165 Jamanimekoro in Kono <165
Babakunaya near Makeni 55 --------------
Bafodia 152 Kabaia 130
Game Konta near Kenema 135 Kabba Ferry 7
Bamoi 5 Kabayia near Yebia
Bebeyan near Kambia 60 near Madina 40
Binkolo 60 Kabodogo 6
60 via Makeni 137 Kabombo 7
Bomali-Bana near Makeni 59 Kabonka 2O
Bompe l 1 5 Kadabi I O
Bonkobana near Makumray 27 Kadafafda near Mateboi 3
Bumpe near Kono <165 Kadari Unknown
Burimaya Unknown Kadeli 2
Buyaromeday Unknown Kademba near Kabombo 4
-------------- Kademba near Mateboi 5
Daresalam Guinea 45 Kadembella 8
Daresalam Sela near Kenendl 8 Kadigidigi 4
Dumbuya 3O Kadlngbili 2
-------------- Kafukumba near Kamulay
Fadugu 50/120 near Kabba Ferry 8
F adugu Loko 25 Kagbalibali 4
Fintonla 14 Kagberi 6
Freetown 180 Kagberi near Madina
-------------- Sanda 3O
Gbendembu 33 Kagberi near Makanka 2
Gbendembu near Kamalu 7 Kagboray 6
Gbinti l 35 Kagbungbo 3
Gbintimaria 135 Kakagbiti 20
-------------- Kakamba 7
Heremakono 6 1 Kakanthia 4
-------------- Kakasegi 2
Jaimasewaf e near Mamadu Kakissi 3
in Kono 150 Kakonso 48

134

 

 

Town or Village Distance Town or Village Distance
Kakontiki 3 Kamathotho via

Kakuru 3 Kamaporotho 1 5
Kalangba 40 Kamawanka 3
Kamabai 76 Kamawoni 8
Kamabain 10 Kamayebin 5
Kamabaio 8 Kambia 55/66
Kamabala 26/30 Kambia near Kamaha 7
Kamabanda via Kathantha 15 Kambia Kapotho near

Kamabombo 5/ 7 Kathantha 6
Kamabonko I Kamethe near Ferry 6
Kamademay 46 Kamoya 8
Kamaforay 3.5 Kamulay 3.5
Kamaf of en 5 Kamunday Unknown
Kamagbenkaray 1 O Kanathara 6
Kamagbewue Sella 8 Kanawala 35
Kamagbewue Tonko 35 Kandema 25
Kamaha 7 Kankuya 20/ 30
Kamakanka near Kenendl 5 Kanthia 52
Kamakankoi 8 Kapotho 7
Kamakili 8 Kaquena in Kono >165
Kamakili near Kagberi 2 Kasama 3
Kamakoni 8 Kasama 41
Kamakuya Unknown Kasasi 3
Kamakwie Loko 3O Kasekia 4
Kamalenka 4 Kasekia 7
Kamalo 8 Kasellen near Kambia 57
Kamangi near Kakuru 3 Kasigeri 2
Kamaporotho 13 Kasoria near Kate near

Kamaranka l 8 Kamakoni l 3
Kamasama 1.5 Kasoria near Kathantoro 3
Kamasasa 21 Kasumulay 25
Kamasebe near Kasegiya 6 Kate Sella 1
Kamasoko Tonko 43 Kate Tonko l 1.5
Kamasundo 1 2 Katene 9
Kamataka 1 Kathambi via Thompari l4
Kamatakata near Madina 4O Kathantha 7

I35

 

 

 

Town or Village Distance Town or Village Distance
Kathekia 5 Magburaka 67
Kathiri near Ferry 4 Maharibo I3
Kathiri Yimbo 8 Makai near Gbendembu 34.5
Kathumpe 1 Makaiba 23
Kathumpe near Kadada 4 Makanka I
Kaunde near Kadubaya I7 Makanka near Maforay 5
Kawereh near Kenendl 5 Makanko near Gbendembu 31
Kawono 7 Makankoi I 0
Kayathana 6 Makarankay 29
Kayasi 5 Makasa near Kamalu 13
Kayawuye 2/8 Makeni 55
Kayemba l3 Makoba near Kamalu l 1
Kenema 1 79 Makulon 25
Kenendl 5 Malontho near Masaktaba 22
Kindia Guinea 94 Maluka near Kenendl 4.5
Kindi‘a Loko via Lala 15 Mambolo near Kambia 76
Koidu >150 Mambolo Rokupr >87
Komoya via Kabba Ferry >7 Mamu 150
Kono 165 Manahun near Makwie

Kortho 17 Loko 8
Kukuna 48/57 Maron 5
Kundaya near Madina 4O Masaktaba 22
-------------- Masoti 4
Laia Limba 8 Matakay Loko 28
L919 Loko 25 Matakay near Gbendembu 39
Laminaya via Kamalo 33 Matakay near Maron 6
-- -- Matandoko 15
Mabanta I I Mateboi 3
Mabunyele 7 Mateboi near Gbendembu 44
Madina Fulla 14 Mathoi 7
Madina Limba 60 Matiti via Kamalo 16
Madina Loko 32 Mayolla 10
Madina Sanda 25 Monrovia, Liberia >200
Madina Tonko 40 Moriya 45
Madina Wulla 35 ---------------

I36

 

 

Town or Village Distance Town or Village Distance

Nafaye 50 Sakuma near Kamaranka 19

---------- Samaya near Thompari 15

Panlap 53 Sanya 30

Papanko near Kabaia 70 Sarifula 148

Pereyema F ulla Unknown Sefadu 150

Pereyema near Kabaia 130 Senthal near Kamuli 12

Pereyema near Kono 165 -------------

Petiu 20.5 Thanene Tonko 40

Port Loko 129 Thompari 12

----------- Tongofeld near Sefadu 155

Rochain near Maluka 56/77 --------------

Rogbanan near Kamulu l2 Waliya Unknown

Rogbaneh 55 Wangi‘ near Gbendembu 30

Rogbin 27 Wonkifo near Madina 40

Rogbom near Mankala 13 Wothanka Unknown

Rogbom near Masaktaba 23 --------------

Rokenaya l6 Yamadu near Kono 1 13

Rokulan 24 Yana 20

Rokunthai near Rotembu 12 Yebia 35

Rokulankori near Kamasasa Yemereh Unknown
Junction 20

Rokunthai Gbanti 28

Rokupr near Kambia 74 Note: If two distances are listed

Rosenth 26 the first is the footpath and

Rosenth near Gbendembu 38 the second is the motor road

Rosino (Temne) on Kambia Rd 75 distance.

Rotembu 4.5/9

Rothatha 8

Royema 25.5

Royenka 5

Royenkesa 8/ 15

 

137

Table 6.4. Distance Traveled to Kasela Hospital Outpatient Dispensary

 

 

Distance All Percent AU Percent
in Miles Patients of Total Patients of Total
Unknown 27 1.86 3 2.56
Town of Kasela 281 19.35 8 6.84
05-39 Miles 176 12.12 1 0.85
4.0-6.9 I70 1 1.71 - -
7.0-9.9 202 13.91 4 3.42
10-14.9 1 10 7.58 I I 9.40
15- 19.9 49 3.37 4 3.42
20-29.9 84 5.79 4 3.42
30-39.9 78 5.37 10 8.55
40-49.9 37 2.55 4 3.42
50-599 43 2.96 5 4.27
60-79.9 30 2.07 9 7.69
80-999 17 1.17 10 8.55
100- 149.9 49 3.37 19 16.24
>150 Miles 99 6.82 25 21.37

Total 1452 100.00 1 17 100.00

 

HDQOWCD'U

O'UO “‘0

cD—EUBCOU)

59 -
45 1-
49 -r
35 1-
36 -I-

 

13B

* Others Include

     
  
  
   
 

Creole Kuranko
Expatriate Lebanese
Hausa Mende
Kisi Mulato
Kono Yoruba

 

 

 

 

Limbs Temne Fullah Susu Loko Mandingo Others *

Ethnic Groups

N: 1,452

Figure 6.1. Ethnic Groups Represented in the Outpatient Survey .

I39

 

 

P

e

r

c 63? * Others Include

e 59? Creole Lebanese
n Expatriate Loko

t 49- 1 Hausa Mende

0 Klsi Mulato

f ‘ Kuranko Yoruba
A

U

S

a

m

D Fullah Susu Temne Mandingo Limbs Kono Others“
I

e Ethnic Groups

Figure B. 2. Ethnic Groups Represented by Appointment Unit
Patients in the Outpatient Survey.

140

 

 

 

    
 

16681-

999-

Total 899'
Number 799‘

of 666 i»

Outpatients599“

Surveyed 4‘39 "
399 +

266 I-
1 66 (-

 

 

 

-I

Males Females Hciults Children 6U's*

Categories

*AU: Appointment Unit Patients
N: 1,452

Figure 6.3. Categories of Outpatients Surveyed
(Numerical Representation).

141

Percent
of
Outpatients
Surveyed

 

 

 

Males Females Fidults Children 6U'5*

Categories

* AU : Appointment Unit Patients

Figure 6.4 Categories ofljutpatients Surveyed
(Percent Representation),

142

LEUEL 0F EDUCRT I OH

5=Post Secondary
Education
4=Secondaru School
Graduate

3=Some Secondaru School
2=Some Primarg School

l=No Formal Education

C=Child, Not Vet of
School flge

X=No Information

 

 

A
f 1 V Y Y 1

0 10 28 30 40 59 60

PERCENT OF TOTRL OUTPRTIENTS

Figure 8.5. Level of Education of Outpatients Surveged.

I43

30'

25+
Percent
of
Patient
Visns

 

 

Before Before Before Before Before Before
9:00A 10:00/A 12.00N 3:30P 5:15P 6:30P

Time of Dog

Figure B. 6. Time of Dog at Which Patients Completed Their
Outpatient Dispensarg Visits.

I44

I AU Patients"
All Patients

 

  
 
  

 

 

 

 

 

 

 

 

so?-
so?-
Percent

404' 3

0f ‘ ' '3???
30 2* :?
29 q» :2:-

Outpatients .
'0 i" 35% 231-323:
:;:14 ‘

 

80 .80 15.00 25 .00 50.80 1 00.00 300 .80 >500 .00
to to to to to to
14 .99 24.99 49 .99 99 .99 299.99 499.99

Range of Fees

* AU : Appointment Unit Patients

Figure 8.7. Fees Paid by Outpatients
Per Illness Episode.

‘WO F‘DQOWO‘U

dmfio—l

68 -'

50 l

494

38 1~

28-

10*

 

a-l

 

145

 

 

 

 

 

 

 

0 .8-9 .9 18-1 9 .9 28-29 .9 30-399 40-1499 >158
Miles Miles Miles Miles Miles Miles

Mileage

* AU : Appointment Unit

Figure 8.8. Distance Traveled to Kasela Hospital.

APPENDIX C

VILLAGE SURVEY DATA

I46

Table C. I. Basic Descriptive Information on Villages Surveyed

 

 

VILLAGE KALOKO ROTEMNE KALII’IBA
POPULATION

Total Population 260 I33 368
HOUSING

Number of Houses 27 I0 34
No. of Pan Roofs 27 9 26
No. of Grass Roofs O I 8
SANITATION .

Number of Latrines 2I 4 21
% with Latrines 78 4O 62
WATER SUPPLY

Number of Wells 0 O I
EDUCATION

Elementary School I O I
RELIGION

Church I O 0
Mosque O O I
ECONOMIC INDICATORS

Number of Radios 2 2 I2
Number of Bikes I O 5
Number of Hondas 0 O 3
LOCAL HEALTH RESOURCES

Herbalist many 2 3
Sorcerer 0 I I
Trained TBA 0 0 I

Untrained TBA yes yes yes

 

147

Table C.2. Outpatient Dispensary Usage In Villages Surveyed

 

 

VILLAGE KALOKO ROTEMNE KALIMBA
Total Population 260 I33 368
Number with OPD tickets I I4 82 283
Percent with OPD tickets 43.85 GI .65 76.90
Year of Ticket Registration
I960-64 5 I I2
I965-69 7 6 I4
I970-74 12 I2 3I
I975-79 I2 I4 49
I980-84 45 22 98
I985-86 30 2I 59
OPD Card not Available 3 6 20
Number of Illness Episode
Visits per OPD Card
I-4 94 33 I07
5-9 I4 I8 56
I0- I 4 2 5 38
IS- I 9 0 5 I6
20-24 0 5 I9
25-29 0 3 I I
30-34 0 4 4
35-49 0 I 6
>50 Visits 0 2 5
OPD Card not Available 4 6 21
Total Illness Episode Visits
Recorded on OPD Cards 298 789 2739
No. Visits/No. OPD Cards 298/I I0 789/76 2739/262
Per capita visits 2.7I I038 I045
No. of Hospital Admissions I6 I3 27
No. of Villagers Interviewed 71 33 I55

 

I48

  

HakokoFootpath

  
 
  

 

‘IP

 
   

\ll/

H
Hasowa
Footpath

  
 
 
  
  
  
  
  

Haterside
it»

ill!

Drinking
AV Bathing

 

Orange
Tree

 

‘*f Broken

  
    
 

Main Line
From
Kortuhun

  

 
 

Broken House = House damaged in a serious windstorm.
Residents lived elsewhere at the time of survey.

Figure CI. Map of Kaloko Village.

    

 

Latrine House a 3

\I/

149

 

I i'"
..IIIIIIIIIIIIIIIILIIIIIIIIIIIIIIIIIIIIIG

House 9 I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House 9 10

ill

I II"
“I ..III|I||_|III||||IIIIIIIIIIIIIIIIIIp

Hous * 9
Vii ‘3”,

 
   

0.3) IDSSI‘DrO-OSD

 

 

Hurling,

 

 

 

 

Village of Rotemne

 

 

 

Buying fifi“

“fl Shell $1
Tobacco

i Barn

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tobacco
Storage Barn

 

 

 

 

 

 

 

 

 

   

 

 

 

 

V II;
V " “ it IIIIIIIIIIIIIIIIIIIIII"
a‘_¥ AI ‘,
t " Robat Footpath ‘1 u
e __
r o— Drinking Wager/J House ‘3 8
"‘ .— Sumbuuafiotpath ‘1
i
a to .IIIIIIIIIII III? [II ii

e

ii:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

      

 

Elf!

House ' S Q)
‘1 Latrine

*. “afigflq .jyfi ‘1 To Hamoloko {U}
- - - - afinde Rd River' .
~~ ‘33 l waterside
I FOOt‘\‘\ Drinking
\\‘:§::th Bathing
\\\ 4'

Figure C2. Map of Rotemne Village.

House * 7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

—~

Tobacco Storage Barn

 

   
   
 

Kamakoni
Road

Rothatha é; Latrine

 
 

 

 

 

Roadl To waterside \fly’

and Shallow Hell
¢

   
 

Figure C3. Map of Kalimba Village.

APPENDIX D

FACILITY MAPS

 

 

Doctor's Clinic

 

 

dmvmj'n

Storage

 

 

moJOO'DZJ

Dental

 

 

 

 

 

 

 

 

Clinic

Drug
I Storage ‘3

l I ..
i~ Offices -: E

Latrines V IIIIIIIII 'E :'

 

 

 

 

 

 

 

 

 

 

 

 

Latrines

 

 

Llll

Obstetric: ’ 2 .

 

Operating

 

 

 

 

Room

Concrete Walks _——.

 

Pediatrics Women's Ward

 

 

 

 

 

........ ........................ - . . iii TBAnnex
Office, ”

SerVice and
Storage Area—

Latrines

 

 

 

 

 

 

 

 

Men's Ward Men's Ward

 

 

 

 

 

 

. . . _ , . ............... TBAnnex

 

Figure 0.1. Diagram of Kasela Hospital
and Outpatient Dispensarg.

lS2

 

   

 

 

 

 

 

 

 

 

 

   
    

 

 

Area
To
Town

............................................................................................................................
l 7 7:

i_.J-:-:-:-:-:-:-:-:-:-:-:-:T_J.
Lab ------ Storage 1|2|3l4 I MD I

Chapel V2 -: Patient Waiting - - E‘3'~

‘ - LD'octor 5 Clinic
at m]:'- , Area 3‘-

 

Record

    

Storage
Clinic

 

 

.............
uuuuuuuuuuuuuuuuuuu

ooooooooooooooooo
-------------------

 

 

 

' ; ' :l - . . Interview
Drug Dispensing i E 23 I f 3 1; Area
-———.— _ y : . 3

 

 

Counter

‘ Drug

r

v—vv—vvrvvvrvvv
n:-.--eo-..

Storage

 

Pharmacu : -v

 

 

 

I
,Rest
Room

v v—vv—fi frV—v
. . e . . u u - e
. . . u I n . -

 

Vaccine
Storage

 

 

Librarg

vv Vv—V’V‘fiv
a.- -e . - . . .
. .....-

Doctor's 3 ’33 I ' 23 __:___ Public Health

Office '2 :f:' Iii § Office
E23 31 5

 

......

 

 

nnnnnnnnnnnnn

-.;.;.;.;--;3;5-_--;-:-:-:-: LEGEND
-- Scale21mm=ifoot

Concrete Walk
........ Roof Line

 

 

 

 

To
Hospital

Figure D. 2. Diagram of Outpatient Dispensarg .

APPENDIX E

OUTPATIENT INTERVIEW F DRI‘1

153

OUTPATIENT INTERVIEW FORM

PRE-VISIT INTERVIEW
I. Code number

2. Ethnic group
a. Limbo
b. Fullah
c. Temne
d. Susu
e. Other

3. Sex
a. Male
b. Female

4. Age
a. Child
b. Adult

5. Distance traveled
a. Less than 30 miles
b. 30 or more miles

6. Level of education
a. Not yet school age
b. No formal education
c. Some formal education

7. Religion
a. Muslim
o. Christian
c. Traditional
(1. Not asked

8. What brought you to the dispensary?
a. Named a particular illness
b. Described sgmptoms

9.

IO.

II.

154

Do you know what gave you this sickness?
a. Known cause

b. Unknown cause

c. Not asked

What have you done so far for this sickness?
a. Traditional medicine

b. Medicines from market or trader

c. Treatment at other dispensary or hospital

Escort present with patient?
a. Yes
D. No

POST-VISIT INTERVIEW

I.
2.

3.

Patient could repeat Instructions recorded on clinic card.
Patient could repeat Instructions on how medications were to
be taken.

Patient could state what medicines were for: e.g., 'worms,"
“fever,“ "cough.“

Patient was asked to recall what he/she had learned about
his/her disease and treatment.

APPENDIX F

DUT PATIENT INTERVIEW DATA

OUTPATIENT INTERVIEW DATA

Pre-visit Interviews
Post-visit Interviews

PRE-VISIT INTERVIEW
i. Code number

2. Ethnic Group
a. Limbo
b. Fullah
c. Temne
d. Susu
e. Other

3. Sex
a. Male
b. Female

4. Age
a. Child
b. Adult

5. Distance Traveled
a. 0-29.9 miles
b. 30 or more miles

6. Level of Education
a. Not yet school age
b. No formal education
c. Some fennel education

7. Religion
a. Muslim
b. Christian
c. Traditional
d. Not determined

155

AILEQLIEIZILE

21
21

28
19

AGO-e01

I2

13
15

ll

12

16
IO

F‘: =_-‘_:. ‘ “L

156

We. Went:
8. What brought you to the
dispensary?
a. Named a particular illness I 5
b. Described symptoms 20 23

9.00 you know what gave you
this sickness?

a. Known cause 3 5
b. Unknown cause I I 23
c. Not asked 7 0
I0. Treatment sought for this
illness:
a. None 0 0
b. Self -treatment at home 0 0
c. Traditional medicine 7 7
d. Medicines from market
or trader 4 3
e. Other dispensary or
hospital 18 6
I I. Escort present with
patient 8 18
POST-VISIT INTERVIEW
I. Treatment instructions
on clinic card 2i 8
Correct recall of
Instructions 2 I 8
Percent of correct recall 100% I00:
2. Medications dispensed 56 49
Correct recall of how to
take medications SI 4i

Percent of correct recall 912 848

157

3131134115. W
3. Knowledge of what medicine
was for I0 6
Percent of correct knowledge
about medication 188 I28

4. Knowledge of disease and
treatment Narrative Narrative
Data Data

APPENDIX I3

DATA FROM ST UDY DF PERCEPTIONS 0F PHARMACEUTICALS

158

Data From Study of Perceptions of Pharmaceuticals

1. Name: Codeine tablet

Intended Use: Analgesic

Sold: Kasela market

Cost: Le .60 (3 .017)

Appearance: Large, white, scored tablet, I12“ in diameter

Interpreted Use: Dysentary, 'head hurt," two at night for chest pain,
I/2 tablet for a child. Seven Identified It as the mild analgesic
Panadol. None knew it was codeine.

2. Name: Tetracycline

Intended Use: Antibiotic

Sold: Kasela market, Kasela Hospital outpatient dispensary

Cost: Le i.00 (3.028) market price, Le .60 (3 .0I7) hospital price

Appearance: Red and yellow capsule

Interpreted Use: Called ”capsule“ by virtually all informants. Opened and
used on sores. Seven identified It for “belly hurt.“ Dosage: one (children)
or two (adults). Also used for diarrhea. Described as “the same“ as
the antibiotic llosone (item 27).

3. Name: Mentholatum

Intended Use: Advertised to ”rub an affected parts" for 'colds, catarrh,
Influenza, etc.” Topical analgesic.

Sold: Kasela market

Cost: Le 3.00 (S .083)

Appearance: Commercially packaged in container, 1" diameter

Interpreted Use: Rub an nose, throat, or affected body part. Rub on body
when you feel 'cold.’ Lick, or mix in water and drink.

 

4. Name: Unknown
Intended Use: Unknown
Sold: Kasela market
Cost: Le I00 (3 .028)
Appearance: Large (i/2" diameter), white, scored; manufacturer AFRAB

Interpreted Use: Vendor stated “two for dysentery.“ No one else
identified this tablet.

159

5. Name: Tops (Top tab)
Intended Use: Analgesic containing aspirin, phenacetin, and caffeine
Sold: Vendor In town of Kasela
Cost: Le .60 (S .0I7)
Appearance: Medium (6/16'), white, coated
Interpreted Use: Pain (”head hurt,“ 'waist bone,” 'back"). Recognized by
most Informants.

6. Name: Cafenol
Intended Use: Analgesic containing aspirin
Sold: Vendor In town of Kasela
Cost: Le .60 (3 .017)
Appearance: Commercially packaged, including instructions on use.
Interpreted Use: Pain, Identified for "head hurt" by I I Informants.
Recognized by most Informants. Manufactured in Sierra Leone.

7. Name: Padrax (piprazlne citrate)

Intended Use: Powdered concentrate for roundworms. 2-6 years I
packet; 6-I2 years 2 packets; >I2 years 3 packets.

Sold: Kasela market

Cost: Le I.00 (3 .028)

Appearance: Commercially packaged, Including instructions on use.

Interpreted Use: Inf ormants Identified this as for worms. Dosages were
less than recommended (eg. one for children, two for adults). Three
small boys said to put it In “warm water with no sugar.” One girl
said It was to "soak any swollen limbs."

8. Name: PenicIlIIne pommade

Intended Use: Antibiotic ointment

Sold: Vendor in town of Kasela

Cost: Le I400 (S .369)

Appearance: Commercially packed tube of ointment, Including
Instructions In English and French.

Interpreted Use: For sores, for wounds, for scabies ('kraw kraw,’
penicillin not effective for this), for tinea skin infections ('faclng
cloth,‘ penicillin not effective for this), for conjunctivitis ('Apollo,‘
skin oIntment, not Intended for use In the eye). 2

160

9. Name: Paw-paw seed

Intended Use: Vendor said to grind two with groundnut paste and eat
for “dry belly' (I.e., constipation). Actual efficacy unknown.

Sold: Kasela market

Cost: Le .20 (3 .006) per cluster

Appearance: Small, brown seeds

Interpreted Use: Some suggested grinding and drinking, or grinding and
rubbing on the body for “bone hurt,“ or 'head hurt,‘ or burns.

I0. Name: Alum

Intended Use: For “teeth hurt.” Alum Is a mild astringent for mucous
membranes. Put next to sore gum, or break In small pieces and put In
carious teeth.

Sold: Kasela market

Cost: Le I00 (3 .028)

Appearance: White stone

Interpreted Use: Virtually all informants agreed that It is used for
“teeth hurt.“ Two older primary school students said It Is put in
water to kill worms. Another student said It is "chlorine, to purify
water." Some suggested grinding and drinking in water. 'It will help
any kind of sick.“

I I. Name: Ampicillin

Intended Use: Antibiotic

Sold: ltinerant vendor, Kasela Hospital outpatient dispensary

Cost: Le I00 (3 .028)

Appearance: Black and red capsule

Interpreted Use: It was recognized by most Informants. There was
consensus that It could be used for sores, abdominal problems, and good
health. For diarrhea “a big man swallowed one“ and “a small pikin" took
the powder. For “worms In the belly' one or two were taken. For "belly
hurt” one could be taken each day. One could be taken after 'you come
out from hard work on the farm, for well body" tie, to have a well body).

It was described as more powerful than, or "powerful past“
tetracycline.

I2. Name: Sheku (unidentified botanically) or plum tree nut
Intended Use: Worms (efficacy unknown)
Sold: Kasela market
Cost: Le .20 (3 .006) per cluster

“.5. I. J . .
L

161

Appearance: Medium-size brown nut

Interpreted Use: Informants consistently said that the prickly
Inner substance should be put Inside a banana (to avoid scratching the
throat) and eaten for ”worms.“

i3. Name: An one (the spice 33100.1! main)

14.

Intended Use: For cough, as a purgative, and for Infertility (efficacy
unknown).
Sold: Kasela market
Cost: Le .20 (S .006) per cluster
Appearance: 1-2" brown fruit pods .
Interpreted Use: Informants Indicated they used It for cough (including
whooping cough), and also for fever.

Name: Chen 1 powder

Intended Use: Powder used for lice and bed bugs (efficacy unknown)
Sold: Kasela market

Cost: Le 2.00 (3 .056) per packet

Appearance: Gray powder

Interpreted Use: Used as intended for lice,‘bed bugs, and roaches.

IS. Name: Calcium lactate

Intended Use: Calcium supplement

Sold: Kasela Hospital outpatient dispensary

Cost: Le .20 (S .006)

Appearance: Slender, white, 3/4“ long

Interpreted Use: Only one Informant identified it and called It ”strong
aspirin.” In appearance It resembled an extra-strength aspirin formerly
carried by the outpatient dispensary.

 

16. Name: ChIDI‘OQUII'l

Intended Use: Malaria

Sold: Vendor In town of Kasela , Kasela Hospital outpatient dispensary

Cost: Le .60 (3 .0I7) vendor, Le .I0 (3 .003) hospital

Appearance: Plain white tablet, 6/ I6“

Interpreted Use: One Informant identified It as chloroquin. Others said it
was for headache, “cold,” or “body hurt,” or that It was aspirin.

162

I7. Name: Chlorpromazine

Intended Use: A phenothlazine derivative used as a tranquilizer

Sold: Kasela Hospital outpatient dispensary

Cost: Le .25 (3 00?)

Appearance: Small orange tablet, I/4" diameter

Interpreted Use: A young mother described it as 'blood medicine,"
probably because of Its orange color. One school boy said, 'Drink It when
your body is not well.“ Another said It was for ”any kind of sickness
that catches you.“ One Informant said his sister bought some from a
trader who came up from Freetown and gave it to her small child. A
young boy said it was medicine for “a small pikin (child) to swallow
when he isn't well.’

IB. Name: Niridazole (ambilhar)

Intended Use: A potentially toxic drug used In the treatment of
schistosomiasis

Sold: Kasela Hospital outpatient dispensary

Cost: Le 3.40 (3 .094)

Appearance: 'fellow tablet, I/2' diameter

Interpreted Use: Three informants described It as 'ouinlne,‘ confusing it
with yellow mepacrine tablets. Another two said it was for the same
'belly hurt“ as item 30, a round yellow tetracycline tablet. Another
confused It with the similar flat yomesan tablets and said four should
be taken for tapeworm. A seller of market medicines said the correct
dosage was ”one for adults, and I/2 for children" when the medicine
actually has to be taken consecutively for seven days. Another
Identified it as medicine he had taken, whereas clinic records showed
that his brother had been given niridazole and he had been given yomesan
for tapeworm.

I9. Name: Chloramphenicol

Intended Use: An antibiotic used primarily In typhoid fever, which
should not be used indiscriminately or for minor infections.

Sold: Kasela Hospital outpatient dipsensary

Cost: to .64 (S .018)

Appearance: White capsule, 3/4"

Interpreted Use: Only one Informant commented on this medication. He
sold traditional medicines in the Kasela market and said It was to be
used 'the same as all capsules,’ pointing to the tetracycline, ampicillin,
rifampicine, and keflex. He said capsules "all do the same work.“

163

20. Name: Rifampicine

Intended Use: An antibiotic used in the treatment of tuberculosis.

Sold: Kasela Hospital outpatient dispensary

Cost: La 2.50 (S .069)

Appearance: Red capsule, 3/4”

Interpreted Use: Seven commented on this medication. One said It was
”blood medicine,” probably due to Its color. Six identified it as a
”capsule,” saying variously that It was for sores or for ”belly hurt.‘

None identified it as a drug for 'dry cough” or tuberculosis.

21. Name: Keflex (cephalexin)

Intended Use: Antibiotic

Sold: Local vendors, Kasela Hospital outpatient dispensary

Cost: Le 2.25 (S .063) hospital price

Appearance: Green and white capsule, 3/4”

Interpreted Use: Ten Informants commented on the keflex capsule. It
was to ”put on sores” or for "belly hurt.” One commented that this was
”the new medicine” and that the red and yellow tetracycline was ”the
old medicine,” as It has become available in the markets more recently
than tetracycline. Three said It was for a ”big person” or ”young people”
but not babies. One individual said he had bought some one evening from
a hospital staff member on duty, although the drug was not recorded on
his clinic card. A woman incorrectly identified It as ”Anacin,” and said
it should be taken for pain, confusing it with the green and white Anacin
capsules that were available through the dispensary at one time.

22. Name: Iberet

Intended Use: A multivitamin with iron

Sold: Kasela Hospital outpatient dispensary

Cost: Le .10 (8 .003)

Appearance: Coated red tablet, 3/4”, with manufacturer's stamp

Interpreted Use: Only one group of three boys commented on the
medication and said that it was for ”malaria.” One boy said his brother
had taken it.

23. Name: BufferIn
Intended Use: An analgesic containing aspirin
Sold: Kasela Hospital outpatient dispensary
Cost: Le .10 (3 .003)
Appearance: White tablet, 1/2” diameter, marked with a ”8.”

164

Interpreted Use: Two individuals who had extensive clinic records
correctly identified the medicine. One was a secondary school graduate
who knew that two tablets should be taken three times each day for
fever.

24. Name: Mebendazole

Intended Use: An antihelminthic used for pinworrn, whlpworrn,
roundworrn, and hookworrn

Sold: Kasela Hospital outpatient dispensary

Cost: to .60 (S .017)

Appearance: Small white, scored tablet, 5/16"

Interpreted Use: Seven commented on this medication, one correctly
Identifying It as an antihelminthic. It was variously identified for
”head hurt” and for ”small children.” It was said to be ”the same” as
digoxin (item 25), which Is a cardiotonic glycoside.

25. Name: Digoxin

Intended Use: A heart stimulant or cari otonic glycoside

Sold: Kasela Hospital outpatient dispensary

Cost: Le .20 (3 .006)

Appearance: A small white tablet, 3/16”

Interpreted Use: Nine inf orrnants commented on this tablet, describing it
primarily as ”dry chook” (dry Injection) or ”penicillin.” They were
referring to the small ephedrine tablets commonly for sale in the
market. Ephedrine is a sympathomimetic drug which acts similarly to
adrenalin. It Is used in asthma to dilate the bonchial muscles and
contract the nasal mucosa. Two said the drug could be used for asthma.
Primarily the drug is used to produce a ”high” and is, for example, taken
after a day of farm work when an Individual wants to stay awake for an
all-night dance. The drug is considered successful If the Individual
does not sleep. It is called ”dry chook” (dry injection or ”pencillin”)
because the effect is powerful in the same way that Injections are
perceived as powerful. Only one informant Identified the medication as
digoxin, a tablet that Individual had been taking for a number of years
for a heart condition. Two said it was for ”small pikin” or children,
probably because of Its size, and that It was for ”head hurt” or ”belly
hurt.”

165

26. Name: llosone (erythromycin)

Intended Use: Antibiotic

Sold: Kasela Hospital outpatient dispensary

Cost: Le .70 (S .019)

Appearance: Red and cream colored capsule

Interpreted Use: Six informants commented on this antibiotic, saying It
should be put on sores, taken ”once a day,” or ”swallowed for belly hurt.”
One individual pointed to the tetracycline and ampicillin capsules and
Indicated It was ”powerful past” or more powerful than those. Only one
woman correctly Indicated that it should be taken ”four times a
day' for ”a heavy sick” or serious illness.

27. Name: Erythromycin

Intended Use: Antibiotic

Sold: Kasela Hospital outpatient dispensary

Cost: Le .70 (3 .019)

Appearance: Peach-colored, coated tablet, 1/2” diameter

Interpreted Use: No informant identified this medication. One Individual
said he had taken It. None recognized it as an antibiotic as it was not In
a capsule form.

28. Name: Vitamin A
Intended Use: Vitamin supplement and treatment of xerophthalmia
Sold: Kasela Hospital outpatient dispensary
Cost: Le .40 (3 .01)
Appearance: Bold, fluid-filled capsule, 1/2” long
Interpreted Use: No Informants Identified this medication.

29. Name: Mepacrine

Intended Use: Malaria

Sold: Kasela Hospital outpatient dispensary

Cost: Le .80 (S .022)

Appearance: Gold, coated tablet, 5/16” diameter

Interpreted Use: Interestingly enough, no informants commented on this
tablet. Although some Identified niridazole (item 18) and valium (item
32) as mepacrine, no one identified the actual mepacrine tablet. The
niridazole and valium looked like the flat yellow mepacrine tablets that
were formerly available, but the new gold, coated mepacrine tablet no
longer ”looked like” mepacrine.

166

30. Name: Tetracycline

Intended Use: Antibiotic

Sold: Kasela Hospital outpatient dispensary

Cost: Le .60 (3 .017)

Appearance: Deep yellow, coated tablet, 7/16” diameter

Interpreted Use: Only four people commented on this medication. Two
said It was ”bitter medicine for belly hurt,” one said It was for cough,
and another said it was for ”chest pain.” While virtually all respondents
recognized the identical medication in capsule form (Item 2), in this
form it was basically unrecognized.

31. Name: Engarde
Intended Use: A multivitamin supplement
Sold: Kasela Hospital outpatient dispensary
Cost: Le .10 (S .003)
Appearance: Maroon tablet, 1/2" long
Interpreted Use: A staff member recognized It as a vitamin. Another
individual said to ”soak it in water and drink it for belly hurt.”

32. Name: Valium (diazepam)
Intended Use: Tranquilizer
Sold: Kasela market, Kasela Hospital outpatient dispensary
Cost: Unknown market price, Le .15 (S .004) hospital price
Appearance: Flat yellow tablet, 5/16” diameter
Interpreted Use: Three Informants said it was for malaria. One said it
was for ”belly hurt” and another for ”worms.”

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