Use of surveys to explore Ghana’s HM landscape

Urban Ghana has experienced recent transformative changes in Herbal Medicine (HM) availability, in patterns of HM presentation and in HM use culture within a national socio-cultural climate that is characterized by changing social-demographic categorizations, altered health beliefs and increasing socioeconomic status as represented by high income and high educational attainment. Yet stakeholders have not addressed the contemporary pattern of HM usage in urban Allopathic Medicine (AM) resource-limited settings. Survey data from a nationally representative user population can be used to provide factual context to describe recent transformative changes in HM and offer solid grounds for the promulgation of health policies that consider HM as part of a larger integrative approach to urban healthcare.

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HM encompasses the specific or permissive formulation of extracts of the stem-bark, roots, leaves, flowers, fruits and seeds of a single or multiple plants, shrubs or trees to provide a broad range of therapeutic outcomes. Its therapeutic role in disease treatment (symptom alleviation) and in disease management is comprehensively acknowledged across Africa and, by WHO criteria, maintain approximately 70-80% adherents (WHO, 2003). While this much quoted WHO prevalence estimate has provided a normative/statistical framework for assessing HM prevalence in Africa, it merely represents a static snapshot of an intrinsically dynamic culture that exhibit broad geographical variation in regional presentation. Additionally, no independently verifiable literature on HM prevalent estimates exists in Ghana.

Consequently, HM practice in Ghana suffers major information gap with its sizeable literature lagging behind contemporary practice and scattered within non-peer-reviewed sources. Ghana’s inadequate current literature on herbal medicine is also almost exclusively focused on reports of folkloric use in remote, resource-constrained rural communities where human populations are the poorest and where educational attainment of the populations are equally low and where, additionally, access to basic or conventional medical care is hindered by lack of close proximity to AM care centers and by unaffordability of AM care. Furthermore, reported clinical practice of HM in such rural areas are generally within the exclusive confines of traditional healers that operate within patterns of care practices entrenched in animistic beliefs and executed with hygienically substandard crude plants extract preparations. Socioeconomic disparities among and within user populations in rural and urban communities have been reported to be related, intricately, in contemporary prevalence estimates and in its usage culture, yet the nature of these interrelations is almost entirely undescribed in the existing current literature on HM use in Ghana.

Patterns of HM practice in urban Ghana has unwittingly undergone recent unreported transformations in presentation, in packaging and in marketing that differs in distinct manner from past usage and diverges in significant ways from current literature reports. Support for this notion is derived from key observations including: a) Use of semi-industrial methods for commercial-scale preparation under relatively hygienic conditions; b) Proliferation of HM centers nationwide that run parallel to AM hospitals and that provides comprehensive care services with the sole use of medicinal plants; c) Aggressive promotion of branded HM formulations that address both immediate and long-term medical concerns and needs through routine and unorthodox marketing campaigns that includes: i. advertisements and infomercials on national TV and radio, local FM stations and in the print media; ii. surge in unorthodox HM user-directed marketing including the barrage of information, from automobiles fitted with public address systems, in suburban streets and in local markets; d) Increasing popularity, as determined by increasing rates of TV and radio ads, of aphrodisiacs formulated as medicinal herb-infused alcoholic beverages or ‘bitters’; e) Strengthened government partner relationship with HM practitioners through: i. the permission for over-the-counter sale of herb-based medicinal formulations in Government approved Pharmacy outlets, ii. HM product marketing at specialized HM retail outlets iii. concurrent integration of HM care structures, facilities and treatment modalities into select community AM health centers and iv. the introduction of HM specialty programs in the schools of Pharmacy of local universities.

Convergence of these multi-dimensional emerging trends highlights the increasing recognition that the current literature on the prophylactic and therapeutic uses of HM in Ghana is inadequate to describe the scope and heterogeneity of existing practices. And although these profound transformative changes also provide a 'natural setting' through which one can explore the multiple dimensions of contemporary HM presentation including the availability, affordability, acceptability and accessibility of its care in an urban population as well as examine the impact of its prevailing culture on health behaviors and health outcomes, there has been a dearth of such reports on the assessment of these constructs and on their associations exclusively among urban Ghanaian populations.

Indeed questions as fundamental as why urban population with good accessibility to reasonably resourced AM care facilities still relies on HM to treat their symptoms remains open and subsidiary questions including:  1) what are the user demographics? 2) What are the HM use rituals including usage formulation types, frequency of use, dose regimen for use, and duration of usage? 3) What are HM users’ perceptional information on safety and efficacy?  4) What are the medical context and the symptoms for which HM use is prescribed and; 5) what are the associated risks of adverse health events including hepatotoxicity and nephrotoxicity; remain unanswered.

These outstanding questions emphasize the need for an in-depth multi-dimensional study that will delineate the underlying causes of the observed alterations in urban usage and examine its involvement in contemporary HM culture as well as identify how it can be exploited to optimize health outcomes. Since survey can uncover the full range of distinctive features and variations in HM care and assess perceptional influences and its impact on health within user populations, an essential step towards developing such a solid knowledge base about HM use in urban Ghanaian communities involves the use of survey data from an urban community. Invariably, urban populations are ideally suited to the application of survey methods to decipher HM use culture because of its fairly adequate representation of gender, ethnicities, socioeconomic and cultural background and educational status than rural areas. The relatively greater diversity of users afforded by the urban population can enrich the pool of survey participants with users from diverse backgrounds to provide broader perceptions of user responses and ultimately to generate a broader perspective on the study agenda.

Survey data can be used to constructs a comprehensive picture of HM care in a large, diverse urban population such as  Kumasi in Ghana through the: 1) definition of the socio-demographic details of HM users including user age, educational attainment, marital status and income level; 2) provision of population prevalence estimates for HM use; 3) elucidation of reasons for herbal medicinal use; 4) documentation of HM use patterns including formulation types, dosage, modes/routes of administration, usage frequency, perceived shelf-life, perceived safety and perceived clinical efficacy; 5) enumeration of the medical contexts including symptoms that commonly require HM use; 6) examination of user perceptions about medical doctors’ views on HM and assessment of whether or not users communicate with doctors regarding HM use; 7) assessment of levels of adverse herbal medicinal use awareness including the possibility of herb-herb and herb-drug interactions that may result in hepatotoxicity and nephrotoxicity and even death; and 8) description of  other baseline user characteristics and health-related outcomes associated with its use.

Provision of such a data will expand our understanding of the contours of the urban HM landscapes and lay the foundations for the address of some broader contextual questions that reflect users’ experience: What is the impact of HM use on community health?  1) must use be sustained for HM to have beneficial effects as assessed by increased healthspan and lifespan? 2) To what extent do the beneficial effects of HM among urban population result in overall reductions of health symptoms? 3) What are the AM clinical recommendations for HM use in co-occurring scenarios to reduce inadvertent prescription drug-HM use adversities; what types of HM medical alterations likely enhances longevity among Ghanaians as assessed by increased healthspan and lifespan?; 4) to what degree or extent are HM use mediated by educational level, socioeconomic status of users; 5) what are the correlation between user defining features and observed alteration of HM care; 6) what are the medico-cultural underpinnings of HM renaissance in urban populations? 7) What are the underpinnings and variability of the altered HM package? 8)Why does HM science lag behind contemporary use.

The results of such a study will provide the foundational layer for Ghana’s HM use culture and serve as baseline data that can govern future large-scale hypothesis-driven study on the safe and efficacious use of HM. And such a survey study will not only of interest in itself, but also provides a useful metric that can be used to judge HM use and its outcome research in other urban areas in Ghana.