|Year : 2014 | Volume
| Issue : 1 | Page : 22-25
Cultural beliefs and attitudes: The psychosocial and economic problems associated with goiter and thyroidectomy in an African population
Abdus-Samiu Adewale Musa1, Monsurat Titilayo Musa2, Issa Baba3
1 Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Educational Foundation and Management, Olabisi Onabannjo University, Ago Iwoye, Nigeria
3 Department of Behavioural Science, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||2-Jan-2014|
Abdus-Samiu Adewale Musa
Endocrine and Biliary Surgical Unit, University of Ilorin/University of Ilorin Teaching Hospital, PMB 1459, Ilorin
Source of Support: None, Conflict of Interest: None
Objective: To evaluate the effects of cultural beliefs and attitudes on goiter and thyroidectomy and assess their psychosocial and economic implications on patients. Patients and Methods : In a 3-year period, between January 2008 and December 2011, a total of 65 patients were randomly selected and interviewed by using an interviewer administered questionnaire in our surgical outpatient department. Standard expressions and explanations in English and local dialects were used. Results: The patients consisted of 60 females and 5 males with a male to female ratio 1:12. Age range was 20-69 years. Major ethnic groups were Yoruba 60%, Ibo 20%, and Hausa 8%. Most of the patients, 72% believed goiter was caused by poison from witchcraft/devil and only 10% have the true knowledge of causes of goiter. In 60%, the most common psychosocial problem was exploitation by the traditional healers (THs), 15% were withdrawn and 12% were apprehensive. About 88% could not afford surgical bill until 2-7 months after initial hospital attendance. Failure of trado-medical treatment and cosmetics were the reasons for advancement in 44 patients for seeking orthodox medical services. In 16 patients, thyroidectomy was successful because neighbors encouraged them to come to hospital, while in 9 patients, it was a result of health education (HE) from electronic media, and in 3 patients, it was because of toxicity and malignant transformation. Formal education had some influence on the attitudes of patients toward goiter and modified their behavior and cultural beliefs. Conclusion: Goiter is believed by some patients to be one of psychic and psychosomatic disorders as a result of cultural beliefs and attitudes. Hence, trado-medical treatments are sought to cure it to no avail. This eventually inflicts a lot of psychosocial and economic problems on patients. HE and medical services need to be improved upon.
Keywords: Attitude, behavior, culture, goiter
|How to cite this article:|
Musa ASA, Musa MT, Baba I. Cultural beliefs and attitudes: The psychosocial and economic problems associated with goiter and thyroidectomy in an African population. Thyroid Res Pract 2014;11:22-5
|How to cite this URL:|
Musa ASA, Musa MT, Baba I. Cultural beliefs and attitudes: The psychosocial and economic problems associated with goiter and thyroidectomy in an African population. Thyroid Res Pract [serial online] 2014 [cited 2017 Mar 25];11:22-5. Available from: http://www.thetrp.net/text.asp?2014/11/1/22/124191
| Introduction|| |
Attitude and cultural beliefs continue to influence patients on their perception on the causes of diseases as well as the type of treatment sought.  Goiter and thyroidectomy (which most of the time is the mainstay of treatment) are not free from these attitudinal and cultural behaviors. , The belief is that the traditional healer (TH) is the expert in psychic and psychosocial disorders. , It is believed that he has an excellent knowledge of social and ethnic background of patients among other reasons. Erroneously, goiter is seen as one of psychic and psychosomatic disorders. ,, The perception of patients about surgery for goiter, occasioned by the strategic anatomical location of the goiter in the neck, coupled with ignorance, poverty, and inaccessibility to orthodox medicine has a lot of adverse effects and psychosocial disturbances on patients. ,, Complications of toxic goiter and hypothyroidism as well as postthyroidectomy are well known but literature is sparse on psychological and economic trauma/problems patients go through before eventually seeking orthodox treatment. The aim of this paper is to publish our experiences on the psychosocial and economic importance of cultural beliefs and attitudes on goiter and thyroidectomy.
| Patients and Methods|| |
Sixty-five patients were selected for this study and interviewed during history taking in the surgical out-patient department of the endocrine unit of Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria and University of Ilorin Teaching Hospital outreach Kishi, Nigeria (Muslim Hospital Kishi). The interviewers were surgeons, hospital social workers, counseling psychologists, and psychiatrists. Standard expressions in local (dialects) languages were used and medical students from various ethnic groups in Nigeria were used as interpreters when necessary. Formal education in this study is defined as education above secondary school level while informal as education below or primary school level. Eligibility criteria are patients that present with goiter as well as patients with recurrence, thyrotoxicosis, and patients with malignant transformation. The exclusion criteria are patients with goiter but have other medical illnesses such as diabetes mellitus, hypertension, renal failure, etc., The Ethics Committee of the two institutions where the research was carried out gave approval for the study. However, details of the research were explained to the patients. Consents were sought and freely given. Statistical analysis of results was by Chi-square test. P value of less than 0.05 was taken as significant.
| Results|| |
The 65 patients recruited for this study included 60 females and 5 males. The male to female ratio is 1:12. The overall mean age is 49.18 ± 5.7 SD. The age range is 20-69 years. The major ethnic groups were Yoruba 60%, Ibo 20%, and Hausa 8% while the remaining were other tribes from across the country.
The causes of goiter as responded to by the patients are depicted in [Table 1]. A majority of the patients believed it was caused by devil's/witchcraft's poisoning while asleep, while only a few believed it was multi-factorial and approximately 10% (n = 7) mentioned disorders of body physiology, heredity or relation to food, source of water, or drug induced [Table 1]. The most outstanding among the psychosocial problems was exploitative tendencies of the THs, worsening the poverty status of the patients in addition to alienation and reduced social interaction with colleagues and associates. According to relatives, some were withdrawn and there was fear with associated anxiety. A sizeable number of the patients approached THs and herbalists for treatment before seeking orthodox medical services and more than a third went in addition to spiritual homes. The most common form of treatment was scarification marks laced with some black powder prepared from roots and leaves [Figure 1] and [Figure 2]. Failure of trado-medical treatment was the major reason for seeking orthodox medical services. Cosmetics and successful surgical treatment in neighbors around encouraged others. However, health education (HE) by Community Health Extension Workers (CHEW) and health campaign on media networks gingered only 14% (n = 9) while in some 2% of the patients (n = 2), symptoms of toxicity especially protruding eyes, palpitations, heat intolerance and malignant transformation in 1 patient (hoarseness of voice, bone pains, severe weight loss) were the main reasons for seeking orthodox medical service [Table 2]. Though, they accepted, they had approached THs for treatment earlier. Some of the patients were afraid of surgical treatment, because of the fear of death from anesthesia and surgery (due to strategic location of the goiter in the neck). Thirty-five percent (n = 23) do not have access to orthodox medical practice and/or repeated postponement/cancellation of surgery discouraged 10% (n = 6) from hospital attendance [Table 3]. About 88% (n = 57) could not afford the hospital bill until 2-7 months after the initial hospital attendance [Table 4]. This eventually delayed their surgical operations and other medical treatment. Formal and informal educations have a lot of influence on attitudes of patients with goiter. The 28 patients with formal education interviewed as compared with 37 of those without formal education was significant (t = 0.48, P ≤ 0.05 = 5.991). There were no differences in the responses of patients from the tribes, although the number was small and statistically difficult to evaluate.
|Figure 1: Scarification marks on the enlarged thyroid gland; a cultural belief of curative measures|
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|Figure 2: Another patient with scarification marks on an enlarged thyroid gland|
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| Discussion|| |
Complications from local herbalists abound in clinical practice. , The type or prevalence of the complications depends on how delicate or intricate the part of the body is perceived to be to human survival. Hence, a complication from local herbalist abounds in the limbs, breasts, eyes, the genitals but rarely occurs in the neck. , This is probably so, because trauma to the neck region could result in torrential bleeding that can lead to loss of life. ,, Most of the complications from herbalists and THs in relation to goiters and diseases in the neck are mainly psychosocial or economic exploitation. To corroborate this, Mselle, in Dar-as-salaam, Tanzania, in a similar study on visual impact of using traditional medicine on the injured eye in Africa, observed complications of keratitis, endophthalmitis, and pan-ophthalmitis with poor visual outcome.  His research work further revealed that the THs were using plant juices; milk mixed with black powder and pounded roots without any scientific bases for the treatment.  Similarly, in this study, most of the treatments offered were in form of scarification marks, laced with black powder from pounded roots as against active intervention, this might be due to perceived intricacy of the neck region [Figure 1] and [Figure 2]. This was in contrast to our earlier works on other regions/parts of the body where active intervention on the diseased parts was observed. 
The effects of cultural beliefs and perceptions of people about diseases can be seen in this study. Over 72% hold the belief that witchcraft/devil cause diseases while only 10%, have true knowledge that the causes of goiter could be explained on scientific basis. Thanni in a related study showed that THs are patronized on account of their services being cheaper, readily accessible and most of his patients found the use of concoction and incantations satisfactory.  The belief is that they achieve faster healing results than in orthodox medical practice. It is this wrong perception coupled with ignorance that dictates patronage of herbalists, THs, and spiritualists.  These in turn exploit the situation to enrich themselves at the expense of the patients. Van Der Geest at the University of Amsterdam, the Netherlands, showed in his study by comparing traditional with orthodox medicine that traditional medical theories have a social and religious character and emphasizes prevention and holistic features.  The practice is further characterized by healer's personal involvement, by secrecy and a reward system.  This is in sharp contrast to biomedical theory and practice, that is asocial, irreligious, curative and organ directed, professional detachment, public knowledge and until recently "free of charge." 
One of the major indications for thyroidectomy is cosmetics. This is due to ugliness of the swelling in the anterior part of the neck and the associated social embarrassment. Patients encounter some psychological trauma like alienation; reduced social interaction/engagement and some are totally withdrawn. The fear of surgical treatment has led to anxiety and fear in a number of patients as shown in this study. 
Readiness for surgical operation is predicated on availability of funds to do necessary investigations and pay hospital bills. The cost of thyroidectomy varies between US$500 and US$1000 depending on whether the hospital is in the rural or urban area. This might be difficult to come by, by an average Nigerian whose per capital income is $2,300. 
Even then, most patients agreed to having been to TH and herbalists who had in one way or the other exploited them financially. It might be difficult to establish directly that the exploitation was responsible for their impoverishment and inability to source for fund for surgery, when they eventually sought orthodox medical services, but this had some bearing and influence on it. ,
Formal and informal educations have a lot of influence on perception about goiter as well as type of treatment sought. Those with formal education and those without formal education gave different responses to the questionnaire. This was statistically significant (P < 0.05 = 5.991; t = 0.48). Patients with formal education were fairly well educated about goiter and the appropriate treatment for it, although they still had fear for surgical operation and its complications. Even then, patients with little or no education had no clue about surgical treatment but exercised undue fear and apprehension.
Notable among the reasons for seeking orthodox medical services was failure of treatment from THs and herbalists and cosmetics ranks next. As much as 24% were motivated by the success of surgery in neighbors around them. However, some of the patients were educated on electronic media and only 2% came to hospital because of unbearable symptoms and signs of toxicity [Table 2]. This underscores the problem with goiter, being a painless swelling. Most patients in Africa do not seek medical attention unless for cosmetics, social embarrassment, and unbearable toxic symptoms and signs as shown in this study. Most often than not, goiters are neglected.  Hence, HE has to be embarked upon in order to educate the populace. Orthodox medical services have to be taken to the grassroots and doorsteps of patients and must be very cheap. Accessibility must be ensured, prompt attention to patients while in hospital must be improved upon in addition to personnel.  Health educators have to be in abundance with comprehensive health program and planning must be available to educate the populace.  These will no doubt reduce the psychosocial problems and cultural beliefs associated with goiter.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]