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Treatment of Malaria and Febrile Convulsions: An Educational Diagnosis of

Yoruba Beliefs

Article in International Quarterly of Community Health Education · January 1988

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 Policy, Theory and Social Issues

TREATMENT OF MALARlA AND

FEBRILE CONVULSIONS; AN
EDUCATIONAL DIAGNOSIS OF
YORUBA BELIEFS*

JAYASHREE RAMAKRISHNA, M.P.H., PH-D.

WILLIAM R. BRIEGER, M.P.H.
JOSHUA D. ADENIYI. DR.PH.

African Regional Health Education Centre

Department o f Preventive and Social Medicine
University of Ibadan, Nipria

ABSTRACT
An understanding of community perceptions of illness, especially disease definitions
that are unique to a part~cularculture, is essential for developing culturally
appropriate primary health care programs. Malaria is endemic in the Ibarapa District
of Oyo State, Nigeria, and one of its major complications, febrile convulsions, affects
nearly one-third of preschool children a t least once in their lifetime. Perceptions
among the local Yoruba people categorize malaria and oonvulsions as part of two
different disease processes. Ideas of causation, severity, seasonality, and treatment
are in many ways opposites. This means that parents do not perceive the dangers of
convulsions when their children surfer malaria. Unfortunately the small children
themselves cannot be part of the decision-making process which involves potentially
toxic treatment practicer Based on an understanding of Yoruba beliefs, primary
health care and health education interventions have been designed that encourage
parents to take prompt action when they recognize that their child has malaria.

This work was sponsored by the Social and Economic Scientific Working Group of the
UNDPlWorld Bank/WHO Special Programme of Research and Training in Tropical Diseases.

Int'l. Quarterly of Community Health Education, Vol. 9(4) 30531 9,1988-89

0 1989. Baywood hbllshing Co.. Inc.
3M 1 J. RAMAKRISHNA, W. R . BRtEGER AND J. D. ADENlYl
Malaria is a major c a u g of morbidity and mortality in much of the developing
world. Thls disease is particularly dangerous to young children where high
temperatures lead to febrile convuIsions with possible brain damage and death.
Although a variety of extra-cranial infections produce hlgh temperatures whlch
provoke seizures, malaria is the most common 11, 21 . The peak incidence of
febrile convulsions occurs between the ages of one and three years, a stage of Me
when the sufferer is least able to take personal protection for prevention 131.
Much of the adverse consequences of malaria are preventable by early
recognition and prompt treatment. However, quick action may not be taken for
various cultural and social reasons. When parents do react after the disease has
reached a crisis (i.e., convuIsions), their efforts are often more life-threatening
than life-saving [4] . Health services aimed at solving such problems are often
ineffective because definitions and categories of illness perceived by patients
and disease entities diagnosed by physicians do not mesh [5] . A communication
gap exists because both parties do not speak the same "illness language" [6].
Not surprisingly, community members frequzntly distinguish between illnesses
that are amenable to cure by western medicine and those which respond best to
traditional treatment 17, 81 .
What is needed in this situation is an anthropological approach that
emphasizes the importance of distinguishing between people's subjective feeling
of illness and the biomedically defined phenomenon of disease 191. This
approach was taken in the town of Idere in western Nigeria in order to learn
local perceptions on cause, severity, treatment, and prevention of malaria. The
results are presented here and form the basis of an educational diagnosis for
designing culturally relevant primary health care and health education
interventions in the community.
NATURE AND TREATMENT OF MALARIA
Malaria is a protozoal infection caused prlrnarily by Plasmodium falciparum
and P. vivax. These are transmitted to humans by female mosquitos of the
Anopheles species. P. falcip~rum,which causes life-threatening cerebral malaria,
abounds in tropical Africa and accounts for 160-170 million infections and
about one mdlion infant and child deaths annually [lo] . In West Africa, malaria
transmission is stable throughout the year so that adults develop potent
resistance, leaving infants and small children as the most common victims of the
disease [ l l ] .
h disease control efforts, primary or early prevention may be ideal, but in
reality intervention is not always feasible dw to technological, social, and
economic reasons. In the case of malaria, major world-wide attempts at
eradication met with disappointment due to lack of continual organizational and
financial support, growing resistance of mosquitos to insecticides and the
increasing environmental threat of these chemicals I1 2- 1 51 .
MALARIA AND FEBRILE CONVULSIONS 1 307
On the positive side, progress is being made on vaccine development [ I 61 .
Also, pilot work on community organization and mobilization at the village level
t o reduce vector breeding and vector-host contact has been encouraging [17].
For the meantime, prompt treatment remains one of the major tools for malaria
control a t the community level.
Early recognition and prompt treatment with chloroquine-based anti-malarial
drugs (despite parasite resistance in some areas) is the choice of action [18].
This not only limits morbidity, but also controls the resevoir of infection [14] .
The mehcation and the supportive therapy of cooling the feverish child by
sponging with tepid water [19] , can easily be administered by trained volunteer
primary health workers (PHWs)based in the village [lo].
Even though prompt treatment is efficacious and feasible on technical
grounds, there remain social and cultural factors whch must be understood and
accounted for before successful interventions can be designed. In particular,
these include local perceptions of the disease and its consequences.
DISEASE PATTERN IN THE STUDY COMMUNITY
Idere is one of seven major towns in the Ibarapa Local Government of Oyo
State Nigeria. Its 10,000 citizens are divided between a main town (8,000) and
approximately forty small farming hamlets (2,000). Idere has been the site for
research on primary health care and tropical disease control since 1978 [20].
Activities have included both regular epidemiological surveys by medical
students and operations research by faculty and graduate students from the
University of Ibadan, which maintains a practical field training site in the
Ibarapa District. Over the years a wealth of various types of data has been
gathered on the medical and social aspects of tropical diseases including malaria.
Surveys have shown a point prevalence of 19 percent for malaria parasites in
bIood samples from Idere chldren aged two t o sixteen years. Idere dispensary
records show that t w o - h r d s of all patients presenting complain of malaria or
fever. Household survey (described below) indicated that over half (57%) of
residents recall experiencing malaria a t least once annually. In the nearby
Igbo-Ora Rural Health Centre's death register, malaria and febrile illness top the
list of causes of mortality in preschool children. With this as background, the
researchers needed next to explore how the community responded to the disease.
METHODS AND MATERIALS
A variety of data collection methods were employed over the period 1981-85,
and included household surveys, case studies with clinic patients, and in-depth
field interviews with both trahtional healers and their potential patients.
Participant observation provided an o v e r - r i h g framework for study since the
authors were actively involved in the local primary health care program. This
308 1 J. AAMAKRISHNA, W. 8 . BRIEGER AND J. D, A O E N l Y l MALARIA AND FEBRl LE CONVULSIONS 1 309

multi-method approach was found necessary to yield both breadth and depth of Table 1. Believed Causes of Malaria in ldere
information.
Caue Number Percent
Ln 1981, a head of household survey was conducted in all Idere homes, both
town and farm (1935 respondents). This gathered baseline data on existing Mosquito 553 28.6
beliefs, practices, and reported prevalence of four tropical diseases (Malaria, Dust 410 21.2
onchocerciasis, schstosomiasis, and guineaworm) and jaundice. f i s provided
raw material on common beliefs about cause, prevention, and treatment of
malaria.
While the survey data provided a broad baseline, they lacked the fine Overwork 35 1.8
distinctions, interrelationships, and rationahations needed to understand local
perceptions fully and consequently to design interventions in disease control. Disease Naturally in Body 35 1.8
Subsequently, fieldwork methods were added, These included intensive Excess Palm Oil 19 1.O
interviewing of key informants (tradtional healers, town elders, experienced Bad WeatherlCold 17 1.8
health staff). Case studies of patients visiting local health facilities were
developed with the help of medtcal students. In-depth interviews were Badllnadequate Blood 12 0.6
conducted by the authors in the homes of local mothers. Fieldwork helped t o
focus malaria in the context of local disease categories and perceptions. A more Don't Know 648 33.5
detailed traditional pharmacopaeia was also obtainable through interactive data ----.--___-----.-.--------------------------
gathering. N~ 1935
A particularly important realization gained through fieldwork was that local
beliefs do not associate malaria with convulsions. An additional survey of 352 a Local word for onchmerciasis.
Excess worry, heredity, termites, eating bad food. guineaworm,
Idere parents was therefore conducted to throw more light on the issue of bad waather, work of God, not enough blood, impure blood, kokoro
convulsions. The information gathered through the above processes was used as (insects) in the body.
the basis for designing training for volunteer PHWs and primary school teachers Multiple responses recorded.
in Idere.
Results on each of the two conditions, malaria and convulsions, will be
considered by focusing on recogrution, susceptibility, severity, and seasonality. Local beliefs peg peak prevalence for malaria in the hot, dry season. This is
Also, notions of cause, prevention, and treatment will be presented. Survey data not unconnected with local notions of causation. Table 1 shows that many Idere
will appear in tables with minimal description. Supportive information obtained residents can recite the "correct" cause of malaria as mosquitos (28.6%),but
through fieldwork methods will be interwoven to give greater clarity to survey data. traditional ideas like suntheat (6.4%) and dust (2 1.2%), all common during the
dry season, persist. It is noteworthy that supernatural notions of cause were
extremely rare. The belief that malaria is caused by eating excessive red palm oil
PEHCEPTIONS OF MALARIA (1 .Wo) may connect malaria with iba ponju.
Malaria in the Yoruba language is known as iba and is recognized by high The relative large proportion of respondents who say they do not know a
temperature, chllls, and aches. In addition, people ascribe jaundice-like cause of malaria (33.5%) probably reflects a reluctance to reveal traditional
symptoms of yellow eyes and dark urine to malaria. Not surprisingly, the local beliefs during a large scale and impersonal survey. This reinforces the need to
name for jaundice is iba ponju or fever with yellow eyes. rely on a variety of investigative methods.
Through informal interviews it was gathered that people feel that all age There is little concensus on preventive measures for malaria (Table 2), with n o
groups are susceptible to malaria, though children may be more prone to it. Iba idea being the most common response (60.2%). Although a number of people
is not regarded as a serious problem, but a simple common indisposition which blamed mosquitos for causing malaria (28.6%), only 17.1 percent could mention
most people suffer from time to time. This lack of perceived seriousness is borne a mosquito-related preventive measure (nets, insecticide, coil, clearing bushes).
out by cluuc experience. Patients of all ages not uncommonly report with A few suggestions related to traditional notions of causation-avoid dust, heat,
hstories of fever lasting two, three, or more days. sun, excessive palm oil, and overwork.
310 1 J. RAMAKRtSHNA. W. R. BRIEGER AND J. 0. ADENIYI M A L A R I A AND FEBRILE CONVULSIONS 1 31 1

Table 2. Reported Malaria Prevention Activities in ldere purchased from local drug sellers. In-depth interview found that self-treatment
is the norm. Preferred modern drugs are antipyretizs/analgesics (e.g., aspirin)
Preventive Method Number Percent rather than anti-malarials whch cause itchng in some people. Even when an
anti-malarial drug is taken, a lower dosage or shorter regimen than recommended
Mosquito Coil, Net, Spray 204 10.5
is often used. The lower cost of self-treatment, particularly the traditional herbal
concoctions, is a major deciding factor in its choice.
Modern Drug Interviews with traditional healers and community members confirm that agbo
is the most common local medication for malaria. Agbo is made from family
Clear Surrounding Bushes 1 28 6.6
recipes that are handed down through generations and shared among close
Avoid Dust 33 1.7 friends. Almost everyone knows a formula, so knowledge is not exclusive to
Avoid HeatlSun traditional healers. The most common ingredients include mango, neem, orange,
lemon or pawpaw leaves, lime juice, lime peel, and lemon grass. The
Others
ingrebents are boiled in a clay pot for at least one hour. Dosage is flexible but
No Idea 11 65 60.2 consists of at least one cup per day. The concoction is drunk for three days by
_.__f_f____________--------.---+------------.-.--.------------------------------+---
which time the patient is usually said to have recovered. Smaller quantities are
lllC 1935 given to chddren. As supportive therapy, the steam from hot agbo can be
local herbal drink. inhaled, while the cooled mixture can be used for bathng.
Rest, decrease palm oil intake, prayer. blood tonic, boil wafer. Agbo is said to remove all the bad things in the body through sweat and urine.
Multiple responses recorded. Some claim that agbo is longer acting than chloroquine because it stays in the
body and continues to work.
Table 3. Reported Malaria Treatment Practice in lbarapa
--

Method Number Percent

IDEAS ABOUT CONVULSIONS
Go to Health Center 741 38.3
Traditional Medicine 474 24.5 Patient case studies gave some of the earliest clues that people in Ibarapa do
not believe that convulsions are caused by malaria. As one mother said,
Mo&m Drugs "Yesterday my child had fever, so we treated with agbo, but then today the
Don't Know 558 28.8 convulsions started, so I knew he had another disease." This other disease was
___________________-.-.+
*.--..----------------------------------.----------------.--
found to be ile tutu or cold earth. Gin', the Yoruba name for convuIsions, and
N 1935 5 tutu are seen as the same thing by some people, while others say giri is only
the symptom of ile tutu. One traditional healer explained, "In the old days it
was called ile tutu, but now we usually call it giri, and you (health workers) call
Both modern and traditional drug; for prophylaxis account for 17.5 percent it convulsions."
of responses. Mothers who have attended antenatal and preschool clinics, and In the foliowup survey of Idere parents, reports were received that 30.7
are famhar with modern drugs, can specifically name Daraprim (pyramethmine) percent of their 539 preschool age children had suffered as least one episode of
and chloroquine. Trabtional prophyhxis often consists of agbo, an herbal tea convulsion. Gin was usually recognized by spasms (67.3%), clenched teeth
made of roots, bark, and leaves. Some people take agbo every day; others only ( 1 S.O%), and crying (1 5.6%), as seen in Table 4. In-depth interview showed that
when they remember. A few claim that they know when they "want to get iba," these were actually the fmal developments in the disease process of ile tutu.
or that they are most susceptible at a certain time of year, and take preventive Perceived early warning signals include coldness, shivering, gasping, and crying
agbo at these times. out in sleep.
Responses about treatment were recorded in an overly generahzed fashion on Idere parents believe ile tutu is largely limited t o preschool children, although
the questionnaire (Table 3). These included going to health center (38.3%), under unusual circumstances adults may have giri. It is thought to be a serious
taking traditional mehcine (24.5%), and using modern drugs (8.4%) probably condition, associated wth the cold, rainy season.
312 / J. RAMAKRISHNA, W. R. BRIEGER AND J. 0.ADENlY l MALARIA AND FEBRILE CONVULSIONS I 313

Table 4. Recognition of Convulsion by Idere Parents Table 5. Believed Causes of Convulsion in ldere
-.
Symptom Number Percent Cause Number Percenr
Spasms Coldness 79 22.4
Crying
Heredity 72 20.4
Clenched Teeth
High Temperature
High Temperature 42 11.9
Lethargy
Fixed Gaze Dirty Environment 10 2.8

Fainting Exposed to coldb 26 7.4

Others 19 5.4 Don't Know 98 27.8
-----.-+-------------------------------.--------------------------------------------
- ------------- - .___----------------.--.-------------...-.
N (Multiple responses included) 352 NC 352

a A disease called cold earth.

Shivering is a common symptom for bothiba and ile tutu, For the latter it is Cold mether, f d . bth.
Multiple responses recorded.
an initial cause for concern, while in malaria it is a minor symptom. hkewise
hgh temperature is mentioned as a symptom for both diseases. While it tops the
list for malaria, it received only 10.5 percent of responses for convulsions.
Traditional healers interviewed feel thls crossover of symptoms reflects the Table 6. Reported Preventive Measures for Convulsions in ldere
impact of Western education and is not a true indication of Yoruba beliefs.
Ibarapa people do distinguish among different types of convulsive disorders. Measure Number Percent
As noted, g i n are the sudden spasms associated with ile tutu. Epilepsy, known
as warupa, and tetanus, called ipa, are distinct diseases, but all three conditions Agbo for Small Children 159 45.2
are said to be related, or in local terms, "from the same mother." Protect Children from Cold 59 16.8
Commonly mentioned causes of ile tutu cum gin from the survey were
coldness (22.4%) and heredity (20.4%) as seen in Table 5. Exposure to cold or Agbo for Pregnant Women 49 14.0
cold things was the theme of other responses-not c l o h n g d child warmly and Other Traditional Medications 34 9.7
feeding cold left over food. Again, some Western notions have crept in as 11.9
percent said high temperature causes convulsions. Don't Know 91 25.9
---*-_-f._..-_-_.__-----------------.----------------*-------
The concept of prevention for ile tutu is quite strong and unified. Nearly
half of respondents in Table 6 suggested agbo for susceptible children and N (Multiple responses included) 352
pregnant women. Unlike malaria, ile tutu has a different agbo for prophylaxis
and for treatment. The preventive agbo is relatively mild and made from
steeping herbs and roots in a pot of water for at least three days. Children are
supposed to drink small amounts first thmg in the morning every day. About
quantity of prophylactic agbo that will make them vomit so that they can
once a month the old mixture is thrown away and a new brew i s prepared.
Elders are supposed to be able t o detect children who are particularly become lighter .
susceptible t o ile tutu. They lift the child and if he is felt to be "too heavy," he Another course of preventive action includes protecting children from cold
is diagnosed as being prone to the disease. Heaviness in t h s context concerns (16.8%), an action arising from notions of causation. During cold rainy weather
not weight but a perceived density and lethargy. These chldren are given a a mother should not leave her chdd alone. She must clothe it warmly, cover its
head and ears with a cap and carry the child on her back.
314 1 J. RAMAKRISHNA, W. R. BRI EGER AND J. D. ADENIY I MALARIA AND FEBRILE CONVULSIONS / 315

Table 7. Reported Treatment Measures for Convulsions in ldere During further interview, mothers advise that a convulsing child must be kept
warm by placing him, especially hls feet, close to the fire. A child who suffers
Measure Number Percent chronic convulsions is "fumigated" over a fire containing dried peppers.
~ g b inu
o ;gos 121 34.4
DANGERS AND DIVERGENCES
ile tutub
~gbo 90 25.6
70 19.9 A major motivating concern for this study was the greater risk of febrile
Other Agbo
convulsions experienced by Nigerian chldren compared to their counterparts in
Salt and Water 60 17.0 industrialized nations. According to Jolly, only 5 percent of preschool children
Go t o Clinic 27 7.7 in developed countries experience febrile convulsions, but reports from Idere are
approximately six times greater [l ] .
Spoon in Mouth
Idere parents recognize the true seriousness of convulsions, but ironically the
Native Cream traditional treatments put the child at greater risk. Concoctions containing cow's
Herbal Soap 4 1.1 urine produce hypoglycaemia with its scquelae: electrolyte derrangement,
vascular constriction, car diotoxic effects, and carhorespiratory distress [2, 3, 2 1,
Others 22 6.2
__*___._..._f.f*
_._+------------.-+---------------------.-------------.-.---..-.---- 221 . Children may suffer burns and pepper induced conjunctivitis during
attempts at resuscitation from coma after convulsion 14, 231 .
Other ingredients are also harmful. Napthalene is a poison and tobacco is
Drink made of onion, robacco, cow's urine, dcohol. toxic to the cardiovascular system [4] . The goal of traditional treatment is to
b Drink made of leaves, room steeped in water.
Multiple responm recorded. cause the chlld to vomit, but when the patient is semi- or unconscious, he could
inhale the regurgitated concoction whch leads to fatal bronchopneumonia [2 1] .
Ironically the goal of keeping the chld warm may actually sustain the high
temperature and speed the onset of convulsions.
Treatment in the initial stages of ile tutu consists mainly of efforts to keep Simple communication t o avoid these practices is inadequate in the face of
the suspected c M d warm-wearing extra clotlung, covering the child, sitting near disease perceptions that differ so markedly from medical views. Foremost among
the fire. After convulsion strikes the more potent form of agbo, oo gun inu igo these perceptions is the lack of acknowledged relationship between iba and ile
(medicine in a bottle) is used. This mixture is made from a variety of substances: tutu or giri. Consequently, malaria is not seen as serious and prompts little quick
shredded onion and tobacco leaves, camphor, napthalene, and animal bile are and appropriate action that could prevent convulsions. This view is not such an
soakedin either water, local gin, schnapps, or cow's urine. This is kept in a anathema when one considers that the adults who hold the view are t o a large extent
corked bottle and found hanging from the kitchen rafters in most houses, ready immune to malaria, and naturally would see an attack as a relatively inconsequential
for emergency use. If the preparation has not been used in about one year, a experience. A slrmlar perspective was found in the upper hhssissippe Valley of the
new mixture is prepared. Although most people can name some of the United States in the nine teenth century where "in the beginning the 'chills' were
ingredients for oo gun inu igo, only experienced mothers and elderly men know regarded as anecessary element of the inevitable 'acclimatization' and after having
the exact proportions. the 'shakes' for years, people got so used to it that they hardly paid attention t o a
One spoonful is the recommended dosage. The action of the drug is believed little 'ague.' This is a clear example of how an objectively dangerous and burden-
t o be related to the strong smell and foul taste. Ideally it should cause the c h l d some bodily condition can subjectively, by social convention, even lose the
to vomit andlor defecate thereby purging the bad substances associated with the
character of disease" [24]. Closer to home, the Uhrobo people of Bendel State,
disease.
Nigeria, also view malaria as an ordinaq inconvenience requiring little worry [2S].
Another treatment consists of half a teaspoon of an imported patent medicine
Table 8 synthesizes traditional perceptions of the two diseases and gives
containing 90 percent alcohol, called Alcool de Menthe. Salt in the mouth is also
further reason why Idere people would see little connection between iba and ile
recommended for keeping the child's mouth open and causing hrn to vomit. A
rum. The two are seen incorrectly as being more common at different times of
spoon or other long object is usually placed between the convulsing child's teeth
the year. Although endemic year round, malaria is more frequent when the rains
to keep him from biting his tongue. Additional treatments include herbal soaps,
increase the available mosquito breeding sites, but, of course, Idere people do not
cream, and ointments, whch may also be used prophylactically. These measures blame mosquitos for malaria.
are summarized in Table 7.
 Table 8. Comparison of Traditional Yoruba Perceptions of Malaria and Febrile Convulsions

Recognized
Disease Symptoms Susceptibility Seriousness Season Causes Prevention Treatment

Iba High Temperature All Persons Not Serious Hotlory Sun Agbo Agbo to Drink,
(Malaria) Headache though more Heat (Herbal Drink) Inhale, Bathe
Weakness in Children Dust Avoid Sun, Heat,
Joint Pains Overwork Dust, Overwork,
Shivering/Chills Eating or Palm Oil
Yellow Eyes Excess Agunmu
Yellow Urine Palm Oil (Herb Powder)
2
0, Ile Tutu Early: Small Children Very Serious ColdWet Exposure Agbo Agbo with
(Cold Earth) Coldness especially t o Cold or Keep Child COW'SUrine
Shivering Heavy Ones Cold Things Warm Alcohol
Gasping Heredity Salt in Mouth
Crying out in Spoon in
Sleep Mouth
Later : Keep Chi Id
Convulsions/ near Fire
Spasms
Clenched Teeth
Crying
Fainting
318 1 J. RAMAKRISHNA, W. R. BRIEGER AND J. D. ADENlY l
In closing, it is necessary to give further emphasis to the value of multi-
method data gathering strategies. The formal household survey alone would not
have been adequate to design culturally relevant PHW training. Because the
researchers did not perceive a distinction between malaria and febrile
convulsions,it did not occur to them to phrase survey questions in a way that
would hifight local beliefs about convulsions. Follow-upwith qualitative
methods provided an in-depth understanding of local perceptions. This was used
in designing the second survey of parents whlchyielded more relevant and accurate
response. Ideally, fieldwork methods should have even preceded the o r i p a l
baseline survey, and this is a major lesson whch was learned from the Idere project
and is being passed on to other health educators who are reading this article.
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b r e c t reprint requests to:
Y.WWmR.m
WiIliarn R. Brieger, M.P.H. l a w . ~ r wn R d .
Whir. W) P101+59a9
African Regional Health Education Centre
Department of Preventive and Social Medicine
University of Ibadan
Ibadan, Nigeria