Health Education Research Advance Access originally published online on November 25, 2005
Health Education Research 2006 21(4):477-487; doi:10.1093/her/cyh073
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Using qualitative methodology to elucidate themes for a traditional tooth gauging education tool for use in a remote Ugandan community
Australian Research Centre for Population Oral Health, The University of Adelaide, South Australia 5005, Australia
Correspondence to: L. M. Jamieson. E-mail: lisa.jamieson{at}adelaide.edu.au
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Abstract |
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The gauging of unerupted deciduous canine teeth occurs in approximately one in three children in some areas of Uganda. It is believed that such teeth are ‘maggots’ that cause fever, diarrohea and vomiting. Traditional healers use knitting needles, bicycle spokes, scissors or broken glass to extract the teeth. Post-ebino extraction complications include septicaemia, anaemia, difficulties in feeding and pain. Some children require hospitalization. Health is further compromised when multiple ebino extractions occur at one time, increasing the risk of human immunodeficiency virus/acquired immunodeficiency syndrome transmission. An ebino education initiative was developed in the southwest Ugandan province of Rukungiri, based on the findings of five community-based focus group discussions. The initiative involved role-plays, didactic presentations and discussion/debate workshops to 23 women's groups in 15 communities (total number of women exposed = 1874). After 1.5 years of the programme's inception, community awareness of the scientific causes and alternatives to ebino extractions had increased (as gauged by follow-up focus group discussion findings) and the number of hospital admissions for traditional tooth extraction complications had reduced. The appropriateness of the model in exploring and addressing ebino extraction beliefs and attitudes is discussed, as are implications of the strategy in its implementation in other communities where ebino extractions are prevalent.
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Introduction |
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Uganda is a landlocked country >240 000 km2 in area in central East Africa (Figure 1; Map 1). The nation shares borders with Sudan to the north, Kenya to the east, Tanzania and Rwanda to the south and the Democratic Republic of Congo to the west. In 2001, the population was estimated to be >22 780 000, with a density of 94.5 people km2 [1]. Agriculture dominates the economy, contributing 44% of the gross domestic product and employing an estimated 80% of the working population. The literacy rate in rural Uganda is 55% for men and 20% for women [2]. Current life expectancy is 45.0 years for males and 50.5 years for females [2].
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Traditional healers in Uganda are ubiquitous. Because they share the same culture, beliefs and values as their patients, they are often the first point of contact for those seeking health care provision [3]. Traditional healers thus play an important role in the delivery of primary health care, particularly in remote communities [4]. A common dental practice undertaken by traditional healers in Uganda is that of ebino (‘false teeth’ or ‘maggots’) extractions [3]. The custom arose from the belief that unerupted deciduous canine teeth (maggots) cause fever, diarrhoea, vomiting and other infant illnesses, necessitating their removal. Ebino extractions are usually undertaken with unsterile instruments including bicycle spokes, knitting needles, razor blades, scissors, broken glass or fingernails. The operator uses a tool to make an incision along the top edge of the gum and extracts the suspected cause of child ill-health [5]. The removed tooth buds exhibit a milky appearance and have varying degrees of flexibility. They do not look dissimilar to a living maggot [3]. In some areas of Uganda, the frequency of ebino extractions is one in every three children [3, 6].
Complications often arise from ebino extractions, including septicaemia, anaemia, osteomyletis of the maxilla and mandible, tetanus and haemorrhage [3]. Damage to the developing permanent canines may also occur and cause such teeth to be malpositioned, hypoplastic or missing in adulthood [7]. Repetition of ebino extractions in multiple infants at the same sitting using the same unsterile instruments may additionally promote transmission of infectious diseases such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) [8]. In some rural areas of Uganda, the frequency of HIV/AIDS is one in three people [9].
Ebino extractions have been acknowledged in the literature since the 1960s [6], and appear to occur throughout Uganda [10–12]. The practice has spread to neighbouring countries including Sudan [13], Kenya [14], Tanzania [15] and Ethiopia [16]. Removal of primary canine teeth as a tradition has also been reported among immigrant Ethiopian Jews in Israel [7] and among Ugandan immigrants in the United Kingdom [17].
Accorsi et al. [3] found that complications from ebino extractions were the eighth most frequent cause of hospital admissions. The median age of children with ebino extractions was 5 months, with a range of 1–17 months. Almost one-quarter of children died during their hospital stay, the third highest disease-specific case fatality rate after meningitis and malnutrition. Accorsi et al. [3] reported that most children who died as a result of ebino extractions had complex medical histories: sepsis and haemorrhage from the ebino extractions, the original illness (malaria, pneumonia, enteritis) for which the practices were undertaken to treat and malnutrition that resulted in anaemia. Similar findings were reported by Iriso et al. [18] and Chindia [19].
Previous initiatives designed to reduce the prevalence of ebino extractions have included health promotion [11], cooperation with traditional healers and encouragement to use other traditional customs for ebino symptoms, for example, rubbing honey or herbs into the gums [3]. This project aimed to explore traditional concepts of ebino through focus group discussion methodology and to develop a community-based ebino education tool that sought to increase knowledge and awareness of ebino extraction alternatives so that the prevalence of such practices, and consequent burden on child ill-health, might lessen.
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Methods |
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The project was based at Kisiizi Hospital—a Church of Uganda private-not-for-profit health care provider in the Rukungiri district, southwest Uganda (Figure 1; Map 2). The hospital services an area of
200 km2 (10 000 people). Permission was granted by the hospital and community councils to design, implement and trial an ebino education programme in 15 communities involved in the hospital outreach programme. The study comprised two components: (i) focus group discussions to identify local perceptions of ebino and (ii) development of a culturally sensitive ebino education tool based on findings from (i) delivered primarily to women's groups in the community (although men were also welcome to attend). It was the view of the hospital and community councils that a specific intervention that targeted women was required in order for women to take part, and that men in the community would join in as a matter of course.
Recruitment for focus group discussion participants was achieved through advertising in hospital and community newsletters, and word of mouth (mainly by ministers in church services). Where possible, a random selection of participants occurred. Participants were provided with an information sheet that outlined the project's aims/objectives (and assured participant anonymity) and signed an informed consent sheet. Both the information sheet and the consent form were written in local language (Rukiga). The discussions were based on techniques described by Rice and Ezzy [20], and Pope and Mays [21] and were facilitated by the author. All discussions were held in the local language and lasted 1 hour. The conversations covered five separate themes (what is ebino, what are the causes of ebino, what happens after ebino extractions, what are the alternatives to ebino and what does the group suggest as ways to remove the ebino problem) and were tape-recorded, translated and transcribed.
Upon analysis of the focus group discussion findings, and with further dialogue with the hospital and community councils, it was decided to use three strategies in the ebino education workshops: a role-play, a didactic lecture and a debate/discussion forum. The workshops were conducted by an ebino education team, which consisted of the author, a local dental assistant and two members of the hospital community outreach team. Newsletters in local language outlining the objectives of the ebino education programme were distributed throughout the community, and ebino education team visits were announced at church services 1 week prior to the group's arrival in a given area.
All workshop participants were exposed to the three components of the ebino education intervention. The role-play component was aimed at less literate participants and was designed to be fun, entertaining, informal and visual. Lasting for 5 min, it generally followed the lines of the author (in the first instance) dressing as a local woman with a baby on her back, and consulting with another local woman (dental assistant) about ebino. The dialogue followed several themes: concern that the child was ill and the mother's desire for the child to have ebino extractions; explanation that it was not because of ebino that the child was sick, but other factors; distrust of Western medicine and conviction that other children's health had improved following extractions; challenge that some children do not recover after ebino extractions and if they do the children do not develop deciduous canine teeth; suggestion that what was removed was not a maggot but a young tooth or that ebino extractions were conducted with unclean instruments that increased the infant's chances of contracting HIV/AIDS; questions as to ways the child's health could be returned without the ebino extractions; information on hygiene, diet and hospital attention and scientific reasons behind fever, malaise, vomiting and diarrohea.
The second part of the initiative embraced a didactic approach whereby diagrams, models and posters were used by members of the ebino education team to explain the position of unerupted deciduous canine teeth in the gum, the consequences of their removal with unsterile instruments, the risk of HIV/AIDS transmission when multiple children were treated in one sitting, the importance of deciduous canine teeth in the eruption pattern of permanent canine teeth and scientific explanations for infant symptoms traditionally associated with ebino.
The third component involved a discussion/debate among workshop participants with ebino education team members acting as facilitators (that is, they did not take part in the conversations per se). In the debate, those who maintained that ebino extractions were a necessary remedy for infant ailment relief were asked to challenge those who supported the scientific model of ebino symptom aetiology. At the cessation of the workshops, attendees were awarded with ebino education certificates and encouraged to discourse with other community members about the programme's content.
Three months after implementation of the ebino education symposia, permission was granted by the hospital and community councils to include an ebino education component into the weekly child health workshops held at the hospital and to incorporate an ebino education message into the information package provided to each hospital in- and out-patient as part of their course of care. Two ebino education workshops with a predominantly scientific focus were also held for village health committees and community health workers.
The programme's effectiveness was assessed by follow-up focus group discussions being held with the original focus group participants (who had all attended an ebino education workshop) 1.5 years after the programme's inception, and by monitoring the prevalence of hospital admissions for ebino extraction complications and other infant illnesses in this time period.
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Results |
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Initial focus group discussions
Some 46 people responded to the focus group discussion recruitment strategies: 21 males and 25 females. The average participant age was 36 years, with an age-range of 23–54 years. All participants lived within half an hour's walking distance of Kisiizi Hospital (itself remotely located, being an hour's drive from a sealed road and then a further hour's drive to the nearest main centre; Kabale; population
35 000) [1]. The level of education ranged from no schooling (three women) to secondary schooling to the age of 15 years (four males). All participants had always lived within an hour's walk of their current abode. Participants were divided into five groups: four groups of 9 and one group of 10. The age and sex of participants in each group were equally distributed. Discussions were held in school classrooms, community halls or outdoors. The initial focus group discussion findings were grouped into themes that generally related to the key questions asked by the facilitator. There were a variety of opinions and beliefs expressed, and although the men were generally more educated, there appeared to be no delineation between traditional beliefs and ebino knowledge between men and women. The ‘what is ebino’ theme included a range of theories and beliefs that generally involved maggots and poor health:
Vomiting, big fever, bad stomach ... caused by the maggots.with one 50-year-old woman suggesting that the ebino problem was a precursor to the AIDS epidemic:Worms in the mouth, causing the sickness, come from Sudan.
Maggots, always in the baby, need to take out or baby becomes more sick.
The maggots is making the sickness then this is making the slim.(‘slim’ being a colloquial term to denote those with AIDS—generally because those with the virus become very thin in the end stages of the disease).
The second theme ‘what are the causes of ebino’ contained a number of responses that illustrated a general lack of awareness of ebino aetiology from a scientific perspective, with some answers revealing a superstitious element:
We don't know, it doesn't always be here, just some 20–30 years.Three respondents aged <30 years were unaware that the ebino problem had not always existed:Don't know why, just always come.
If you say bad thing about someone, then your child have ebino.
Very old ebino is, like a tradition.(‘Baganda’ = people of the Bantu tribe) but were quickly corrected by older members of the groups:This ebino been here long time no, always with Baganda.
Ebino new problem, just like the AIDS.[Museveni has been the President of Uganda since 1986 (after overthrowing Obote); his is commonly referred to as ‘the new government’].Oiwee no, just a new one, just since new government.
For the ‘what happens after ebino extractions’ theme, responses varied depending on the extent that participants had witnessed children recovering from, or having been traumatized by, ebino extractions:
Baby becomes well, no more fever, no more sick.with one 46-year-old woman having two grandchildren who had suffered from the extractions:Sometimes more sick, but because maggots there too long.
Need take to hospital, face gets big, baby can't feed.
First the boy has the crying, he was small one aye, always sad but after the ebino was not better ... then another girl, little bit bigger but need go hospital after ebino, bleeding, bleeding and crying ... she still sickAn apparent belief that there were no options to ebino extractions was evident when the question ‘what are the alternatives to ebino’ was presented to the groups: an inherent conviction that if the ‘maggots’ were left in situ, the infant would inevitably become unwell again:
Nothing that can do, only to take out the maggots.The younger participants (those aged <30 years) in three groups appeared to have a stronger conviction of a lack of ebino alternatives than older participants:Baby might be better, but then later the sickness again—need to take out false teeth.
If maggots stay there, baby die.
These are the days of the AIDS—babies always becoming sick, this like when mother is sick too. Need to help baby by taking out the maggots.with one 54-year-old male adding:So many things harming the children, the ebino extraction is making them strong.
Babies not always having the maggots. New ones (parents) are doing good.For the final theme ‘what does the group suggest as ways to remove the problem of ebino’ a range of solutions were provided, none of which had a scientific basis:
Don't say the bad things about other people—be good like Godwith two 35- to 40-year old women suggesting that:Keep baby away from other ebino children—they can catch too
Don't be traveling in the bus—bad things in the bus makes ebino
Ebino making more problems like the AIDS—all the mother's should be taking out the maggots.Traditional healers too busy, nurses in the hospital should do ebino extractions.
Ebino education tool
All participants of the pre-intervention focus group discussions, including the men, took part in an ebino education workshop. Twenty-three workshops were held: one in each of the communities serviced by the hospital outreach programme and eight to mothers' groups attending the hospital for post-natal care. While the intervention was targeted primarily at women's groups, men were also encouraged to attend. The number of attendees at each presentation varied from 42 to 112, with a total of 1874 women being exposed to the programme (mean of 58 women per gathering). There were between 15 and 20 men who stood around the periphery of each education session (most education sessions were conducted outside) but their numbers were not counted as many men were not present for the duration of the intervention. Each session took 3 hours.
Follow-up focus group discussions
Four focus group discussions were held 1.5 years after the ebino education programme's inception. Of the original 46 participants, 41 took part (20 male and 21 female; age range 25–55 years, mean age 38 years). The methodology was the same as that used for the initial focus group discussions, with the same questions being asked by the facilitator.
In comparison to the initial answers provided for the ‘what is ebino’ question, the findings of the follow-up discussions differed markedly, for example, a greater acknowledgement of the scientific reasons behind ebino symptoms was disclosed:
Ebino not maggots—just the small teeth in the mouth.Two participants aged 30–35 years were surprisingly forthright in their new views towards ebino and took the opportunity to promote much of what they had learned in the intervention:Sometimes being sick because mosquito or bad insect.
Used to be the maggots, but now they are the teeth.
Taking out the teeth means the baby ones don't grow and this makes the big ones have trouble.Similarly, responses elucidated from the ‘what are the causes of ebino’ question varied considerably from the initial focus group discussion findings, with more scientific causes being understood and discussed:The maggots look milky because the teeth aren't hard yet, still too small.
The baby being sick because too tired, too hungry, not clean.One 48-year-old male, who said little in the first focus group discussion, suggested that:Baby is too, too small—can't fight the bad bugs.
Need to be feeding and keeping quiet, or else the ebino.
The malaria is what people thinking are ebino, but malaria is making the sickness. Need to fix the malaria and leave the maggots.For the ‘what happens after ebino extractions’ item, participants provided a range of responses that differed markedly from those provided in the first instance; again conveying a greater understanding of Western health concepts:
Could be having the AIDS—lots of bleeding and pain for baby.Two 40+-year-old males in one group expressed that:The teeth are taken out so no more teeth. Then later big teeth have problems.
Sometimes the baby can die, can't be taking the food and too much pain.
Children that are sick first get even more sick after maggots taken out.while younger women respondents in the same group identified that removing the tooth buds affected the growth of secondary canine teeth:Ebino always have the bleeding—this is bad with AIDS.
Need the first teeth so the second teeth can come. Otherwise not straight.In the initial focus group discussions there appeared to be limited knowledge of alternatives to ebino extractions. However, when this question was repeated in the follow-up discussions, a range of health-promoting options were provided:Big teeth needed for tearing food—if take out in ebino, not can chew the goat meat.
Need go to hospital with good medicine and watching baby.There appeared to be little difference in responses according to age or gender with one 25-year-old woman commenting:Keep baby resting and clean and giving good food.
Not to take teeth out, this is the dangerous one.
Keeping the baby healthy is the good one; clean and not hungry.and a 52-year-old male suggesting:
Taking out the maggots hurts the baby. Should take to hospital first.A number of health-promoting suggestions were similarly offered when the ‘what does the group suggest as ways to remove the ebino problem’ item was asked, which was in direct contrast to responses provided in the initial discussions:
Tell the other women not go to traditional healer but to hospital.A 35-year-old male in one group suggested:Keep baby clean and look after proper—not leave alone.
Make sure the baby takes the good food, don't be making hungry.
Traditional healers are good lots things, but ebino is better for hospital.which was supported by two 40- to 45-year old women in another group:
Traditional healer not always the good one, not good for ebino.One and a half years following the ebino education programme's inception, post-ebino extraction complications fell from being the 5th most common reason for infant admissions in the hospital to being the 11th, with the number of admissions for ebino extraction complications falling from 22 to 9 (a decrease of 59.1%). Of the nine who were admitted with post-ebino extraction symptoms, seven received the extractions in the previous 4 hours and presented before gingival swelling commencement, meaning the child's survival prognosis was relatively high (late presentation was a common feature previously). The number of hospital deaths resulting from ebino extraction complications in the same time period fell from eight to zero, while the number of in- and out-patient services for infant complaints (predominantly gastro-intestinal) rose from 279 to 498.Good food and clean good for baby with ebino; then hospital if still sick.
Four community members were trained as ebino education health workers and employed by the hospital to continue the ebino education series.
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Discussion |
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This paper describes an ebino education initiative that used focus group methodology and interactive community techniques to increase awareness of reasons behind, and alternatives to, traditional tooth gauging in a remote area of southwest Uganda. After 1.5 years of the programme's implementation, there appeared to be increased community awareness of the scientific reasons behind infant fever, malaise, diarrhoea and vomiting, and greater acceptance of hospital services for child illnesses historically treated by traditional healers. The programme appeared to create a ripple effect whereby the ebino education theme was picked up and incorporated into other areas of hospital services, for example, in AIDS education clinics, antenatal classes, the rehabilitation clinic, theatre and prayer groups. General hospital staff began discussing the scientific basis of ebino symptoms to patients in many areas of the hospital and it was the topic of discussion in several church services (the ebino education team presented the role-play component of the education tool to four church congregations). There was increased dialogue about the ebino tradition and rising acceptance of alternatives to ebino extractions among communities where the ebino education programme had occurred. Many people (male and female) presented at the hospital dental clinic to further discuss the ebino tradition.
A strong aim of the study was for the project to be sustainable and for the community to feel that they had contributed to the design and conception of the project and to feel responsible for its continuation. To this end, the hospital and community councils made the final decision as to the make-up of the focus group discussions and the type of intervention to be implemented. It was felt that both men and women should take part in the focus group discussions because although women were the primary caregivers, men—as the traditional head of the household—played an important role in major decisions such as ebino extractions. Once the pre-intervention focus group findings had been analysed, the councils considered that directing the intervention at women's groups was the most cost-effective and logical way of promoting the message. It is reasonably difficult to plan for a group of women to meet in rural Uganda because of their farming, household and childcare duties while men are often idle and free to take part in community events without prior organization.
There are several reasons why attitudes and behaviour concerning the ebino extractions may have occurred following attendance at the ebino education sessions: (i) an underlying belief or intuition that the ebino extractions were harmful—with most participants having witnessed infants who had suffered, sometimes fatally, from the practice; (ii) the compelling scientific evidence in the didactic lecture (posters showing position of developing tooth buds in the jaw, explanation of why there was no eruption of deciduous canine teeth following the extractions, description of what could happen when the same instruments were used for consecutive extractions with HIV/AIDS transmission); (iii) increasing trust in Western medicine versus traditional practices, for example, anti-malaria medication, tuberculosis immunizations, the development of water plants to produce clean water and HIV/AIDS education; (iv) an unfavourable reputation being developed among some traditional healers, who were known to have been harmful to infants, having increased their prices and having been involved in corruption scandals and (v) increasing exposure to Western ideas of health, livelihood and appearance through tourism, television and volunteer organizations.
The initiative's approach differed from other ebino-focussed health education strategies in that focus group methodology was used to reveal community perceptions and beliefs about ebino that were then incorporated into the design and implementation of the education tool. Donovan et al. [22] contend that the only ‘experts’ in health education are those for whom health education messages are intended, and that qualitative techniques are necessary in the construct of health education tools so that themes represent what the community considers important. This is supported by Blinkhorn et al. [23], who ascertain that initiatives addressing issues deemed worthy by the developer, but not the community, are a common shortcoming in health education research. The use of qualitative methodology is particularly pertinent when, as was the case in this project, health education initiatives are designed by a Western person in a non-Western setting. In such situations, the importance of respecting the deeply entrenched diversity in local/non-local values, customs and knowledge systems often make the difference between an initiative being successful or not, which in turn influences the project's sustainability [24].
It is difficult to ascertain which of the three components in the intervention was the most effective. The role-play was well received in the community as it had a large element of humour as its focus. It acted as a good ice-breaker and stimulated people's interest in the ebino topic, with the sounds of laughter often attracting additional onlookers (mostly male). Once the group's attention had been obtained, the didactic lecture challenged traditional attitudes and beliefs about the ebino custom and provided convincing evidence of the scientific reasons behind ebino symptoms. Ebino was something all participants could relate to and the posters and props used very clearly showed the scientific basis for what the extractions actually involved and resulted in long term. But it was perhaps the discussion/debate sessions that truly empowered participants by allowing them to share their views with others and to have ownership of their new-found knowledge. The discussion/debate sessions became quite heated at times and on some occasions lingered long after the ebino education team had departed. Often it was the men who were pivotal in this; being slightly more educated at the outset, they were perhaps more readily able to understand the scientific reasoning behind ebino symptoms and possibly had more time to discuss the ideas put forward in the workshops in their day-to-day lives. It may have been that the ebino education programme in its entirety was greater than the sum of its individual parts, with no one particular component standing out on its own.
Three strategies were used in the current initiative so that participants of differing education levels and conceptual ability might benefit equally from the programme's message. One of the Ottawa Charter of Health Promotion [25] tenets is to encourage community empowerment through ownership of a health promotion idea or concept, but this may not be possible if the message being promoted is pitched at such a level that not all individuals constituting a given community understand, or identify with, it. By implementing the discussion/debate component of the education tool, it was hoped that a further Ottawa Charter of Health Promotion [25] principle might be realized: that workshop participants might increase their personal skills by learning to argue and defend a child health promotion point, and by continuing such discourse after the workshop's cessation. This was suggested by Bhuyan [26] as a technique of ensuring that a particular health promotion message reaches its intended recipients, and of supporting personal growth by encouraging individuals to express a health promotion theme in their own words, within their own peer group.
One shortcoming of the initiative was that traditional healers were not included in the qualitative component of the study or were participants in the intervention. There were eight traditional healers who operated in the Rukungiri district, who were all approached by the author and members of the hospital and community councils (at separate times) and invited to take part in the project. All healers declined the offer. There may have been a number of reasons for their unwillingness to participate: (i) ebino extractions have been made illegal in some areas of Uganda and it is possible that the healers feared legal ramifications should they admit to being involved with, or discussed their role in, ebino extractions; (ii) ebino extractions are a profitable business for traditional healers, with the removal of four deciduous canine tooth buds bringing in upwards of 35 000 Ugandan shillings ($US20; the average monthly wage in Uganda is 48 000 shillings) [1]; traditional healers may have declined to take part out of fear that it may impact negatively on their business: four of the eight traditional healers in the local region had recently performed ebino extractions that had resulted in severe injury—in two cases death—of the child recipients. The reputations of such healers in performing traditional medical practices were beginning to be questioned by some community members. It is possible that the traditional healers preferred to keep a low profile in the community so that memories of the child trauma inflicted might dissipate. It should be noted that without involvement of the traditional healers in the intervention, it is not realistic to expect that the practice of ebino will be permanently eradicated in this Ugandan region.
A second shortcoming of the initiative was that 1.5 years was an insufficient time period in which to gauge the true impact of the programme. Real results will depend on the community health workers maintaining regular ebino education seminars in the communities and for the discourse among community members to remain active. It has been documented that long-term health behaviour changes of any group will only occur when health education schemes are accepted and owned by the people they are designed to benefit [26]. A third shortcoming was that focus group discussion volunteers may not have been representative of the general community in that they had more interest and awareness of ebino (and therefore agreed to take part in the discussions) at the outset. A degree of caution should therefore be exercised when considering whether to generalize from this study's findings.
In planning the ebino education initiative it was essential to realize that the strongest limiting factors were behavioural (as opposed to biomedical), and that these were related to deeply rooted and value-laden perceptions of child health and illness in communities where the initiative took place. The ultimate goal of the programme was to change carers' attitudes in a way that would benefit their children's lives. More specifically, the project attempted to empower community members to exercise control and to make choices that were conducive, not destructive, to their children's health by using education tools generated from local perceptions and beliefs. Programme sustainability was at the heart of the initiative, and it would appear that, in the short term at least, some success to this end was achieved. It is hoped that, from this example, successful ebino education programmes in other regions of Uganda (and elsewhere in the world where ebino extractions occur) may be developed.
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References |
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Received on April 13, 2005; accepted on November 2, 2005
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