Research Study Results From Northern Ghana

Although the visual outcome of couching has been widely studied in sub-Saharan Africa, there has been virtually no examination of why individuals opt for this traditional treatment.  This report by Global Impact Fellow Lauren Wallace explores the results of a study that she completed through the Unite for Sight Global Impact Lab Program in partnership with Eye Clinic of Tamale Teaching Hospital.  The IRB-approved research study examined the factors involved in individuals’ choice of couching for cataract treatment in northern Ghana.(1) 

Study Population

Results were collected based on the responses of 16 Dagomba participants. The average age of the participants was 69 with a 3:2 proportion of males to females.  All participants originated in rural villages surrounding Tamale. None of the participants had received any formal education. Participants’ religious affiliation was predominantly Muslim, although four participants identified as traditional believers and one as Christian. Based on scores from the Poverty Scorecard – the food line plus the costs of essential non-food goods and services – the median poverty likelihood for households was estimated at 60.8% (see http://www.microfinance.com/English/Papers/Scoring_Poverty_Ghana_EN_2005.pdf for further explanation).

Methods

Recruitment of the sample was completed through rural eye care outreaches conducted by the Eye Clinic of Tamale Teaching Hospital (TTH).  Purposive sampling was used as a result of time constraints and difficult access to couching patients. During outreach, the ophthalmic nurse identified those patients who had couching performed.  Potential research participants were also contacted outside of rural eye screenings, via patient records kept by TTH. It was made clear that participation in the research study was completely optional and was in no way connected to eye treatment.

Standardized informed consent was obtained for all study participants; consent was verbal because literacy rates in the northern region are low.  A semi-structured interview guide (see below) developed to probe specifics of personal experience was used, and each interview lasted approximately 20 minutes. The outreach coordinator served as a translator and research assistant throughout the study.  When the outreach coordinator was not available to translate, a community member identified by TTH was used.  Participants were given an opportunity to playback and review their responses following the interview.  To ensure confidentiality, each participant was assigned a numbered code, which was used in place of a name in all files; in addition, the translator and/or research assistant signed a confidentiality agreement before beginning to assist with the research. Anonymity was afforded to participants through the assignment of pseudonyms to village names in the voice and written records. No compensation was given for participation. Data analysis was generated manually, using thematic analysis. Audio files were manually transcribed and computer copies were generated. Common themes and topics emerged. Codes were developed and applied to the raw data to compare relative frequencies of themes or topics.

Semi-Structured Interview Guide

Findings Related To Couching

For the majority of participants, the couching had occurred more than 10 years ago.  Most participants (63%) had bilateral couching.  The cost of the procedure varied widely. Eight participants (50%) paid in cash, ranging from 2 Cedis to 70 Cedis –$1.30 to $46 U.S. Four participants (25%) traded other non-monetary items for the procedure; these included cloth, kettles, groundnuts, and livestock, including sheep and fowl.  The remaining 25% could not recall what they paid for the procedure, or were not aware of the cost because their families had paid.  Overall, the results show that the cost of the couching procedure is normally less than the cost of cataract surgery in the northern region – 120 Cedis, approximately $80 U.S.

Most participants (75%) described travelling to the village where the couching man was located to receive the procedure, while some received the procedure when an itinerant couching provider came to their village. The majority of participants (81%) had the procedure completed by the same couching provider. The results of the procedure varied widely. When asked if their vision was better or worse following couching, ten participants (63%) said that their vision was better, and indicated that they had enough vision to complete daily tasks. For example, walking alone, or cooking. 

Cataract surgery represents the best option for cataract treatment due to the inconsistency of the visual outcome of couching and its potential range of severe negative side effects and full sight loss.  However, this finding supports studies which show that when couching does not cause complications, and the lens is carefully dislocated downwards, vision loss is less likely.(2),(3)

Four participants (25%) said that their vision was worse and described complications such as pain, or lens in pupil.  One participant noted: “there were so many pains, and when the pains finished, my eye went off. My vision went bad, and I could only see white, white things”.  Two participants (12%) said that their vision was better immediately after the procedure but had decreased over time. This finding resonates with Brandt and colleagues, who examined 100 couched eyes in Nepal. They reported that for the eyes they examined in which vision remained following couching, vision was preserved for the first year, but there was a subsequent yearly loss of vision of less than 10%.(4)

Beliefs Related to Eye Disease

When participants were asked about the origin of their eye problem, several different causes were described. Most frequently, participants explained that they did not know what had caused their blindness (38%). The next most frequent response was witchcraft. Two participants (13%) believed their blindness was as a result of witches completing spiritual acts that destroyed their eye(s) (see What Constitutes Traditional Medicine and a Traditional Healer?).  Two participants suggested that it was God’s will which had caused their blindness, and two participants linked their blindness to their occupation as farmers. The latter two explained that their blindness was as a result of sweat falling into their eyes while they were working hard in the fields, which caused their eyes to become itchy. Moreover, two participants linked their blindness to known biomedical causes of cataract – working with smoke, and old age. One participant stated that the cause of their blindness was a strong headache. Finally, one participant said her blindness was as a result of dirgu, which translates from Dagbani to English to mean blindness caused by pain in the head. When asked what dirgu is and how it causes blindness, she stated:

It is a small thing in the head going round. I can’t see it. I can’t describe it. But it is something like an insect or an animal, a living thing, in the head...When it is a living thing in the head and when it starts to move you have pains, itching, headache, so many things – troubles in the eye ...and that is always the cause of blindness

The health beliefs of the Dagomba people noted in this study are in aligned with those reported by Bierlich (2000). He notes that witchcraft is a common belief among the Dagomba.  In addition, illnesses are named and determined based on their signs and symptoms, and their location in the body. Dagomba people rarely regard the specific cause or “why” of their illness as important. (5)  This might explain why when asked about the cause of their blindness, many participants stated they did not know. Instead some linked their eye problem with symptoms starting in the head, such as headache, pain in the eye or itchiness. Although dirgu specifically was not mentioned by Berlich, its description may reflect some of the potential signs or symptoms of eye disease.

Factors Involved in the Choice of Couching

Factors involved in the choice of couching were classified according to either external or internal origin. External factors (a) were identified as decisions made according to influential people – for example family members, friends, community members, or couching men – and radio announcements. Internal factors (b) were described as beliefs regarding eye disease, for example, spiritual or non-spiritual causes, and previous knowledge of/experience with modern or traditional therapeutic modality.  Barriers to hospital treatment noted were the availability of cataract surgery, difficulty arranging travel, and cost of cataract surgery.  Multiple converging factors and barriers were usually recorded to explain the decision-making process for each participant.

External Factors

The most influential external factor in participants’ choice of couching for cataract treatment was the influence of other people. Fourteen of the participants’ (88%) mentioned that the influence of either family members, friends or other community members and/or the couching man was critical in their decision to opt for couching. Participants described how these individuals had sent them to the couching man, or arranged for him to come to their community after they had regained their sight or heard of others whose eyes had been “opened” in nearby places. Five of the participants (31%) also cited radio announcements advertising couching as a major push factor. Although couching is illegal in Ghana, some individuals reported that radio announcements advertising the procedure are still common.

Internal Factors

The most influential internal factor for participants’ choice of couching for cataract treatment was previous knowledge of or experience with modern or traditional cataract therapy. Fifteen participants (94%) reported that prior to their couching treatment, they did not know that hospital treatment was available. The nine participants (56%) who had experience with the hospital after couching reported that they would recommend hospital treatment over couching.  Forms of experience with hospital treatment included personally undergoing cataract surgery or other biomedical care, such as treatment for hernia or eye drops (89%), or witnessing the positive results when others in their community underwent cataract surgery (11%). For example, one man, who had been treated by a couching provider and three other traditional healers and had received drops from the hospital, explained:

The hospital gave me the eye drops and the pains decreased. The pain is severe, in terms of [the traditional healers]. After the eye drops, all the pain subsided so I have now realised that the hospital treatment is better. It is just that I did not know this before they [the traditional healers] destroyed my eyes. 

The perceived outcome of the couching procedure was also strongly linked with participants’ current views on hospital and traditional treatment for eye care. Eight participants (50%) reported that their vision was worse or not as good as expected following the couching procedure. These participants were much more likely to express a preference for hospital treatment. On the other hand, five participants (31%) reported no experience with hospital treatment. Three of these individuals expressed no preference for either cataract surgery or couching and two said they would recommend couching.  Those who regarded the cause of their blindness as spiritual – i.e. caused by witchcraft – or caused by a local illness such as dirgu, (19%) did not express a preference for traditional treatment. Rather, as discussed above, the findings suggest that participants’ prior experience with traditional or biomedical treatments determined their initial decision to opt for couching and their current preference for a specific treatment form.

Barriers to Cataract Surgery

In terms of the barriers to cataract surgery cited, 32% of participants noted that high cost of cataract surgery was involved in their decision to pursue the less expensive traditional treatment, while three (19%) described that the lack of availability of transportation to the hospital was a factor. Two participants (13%) described how cataract surgery was not available in the region at the time they were first blind, therefore couching was their only option for cataract treatment. 

Based on participants’ responses, the availability of hospital treatment for cataracts appears to be a minor factor in patients’ choice of couching. However, twelve participants (75%) had the couching procedure before 2004. This was prior to the existence of an ophthalmologist in the northern region – Dr. Seth Wanye did not begin his work at the Eye Clinic of Tamale Teaching Hospital until 2004.  This reveals that the majority of study participants had no choice between couching and surgery for cataract treatment. Couching was their only option.  It is likely that a large proportion of the participants who stated that they did not know about hospital treatment during their decision to opt for couching because there was no ophthalmologist available at the time. In addition, although 75% of participants had the procedure completed before cataract surgery was available in the region, 32% of participants discussed the high cost of cataract surgery as a factor in their choice of couching for cataract treatment. This anomalous result suggests that some participants displayed a memory bias, losing recollection of their decision-making process over time.

Study Limitations

Most participants were elderly and had the procedure completed 10 or more years ago. Thus, it is likely that a memory bias affected several aspects of the study. Regardless, the results of the interviews with these participants remain significant. The results support the importance of influential individuals and previous knowledge or experience with hospital treatment as important in healthcare decision-making. 

It is important to note that a study conducted with people who live in an urban area would be expected to produce different responses, and thus, the findings of this study do not necessary represent the attitudes of all Ghanaians. However, they are representative of healthcare decision-making in the northern region, one of the poorest, rural, plural health settings in the country.

Conclusions and Recommendations

It has been subtly suggested by some in the medical community that those who opt for couching are ignorant and superstitious. However, this study shows that healthcare decision-making in the Ghanaian context is based on a rational process according to advice from others, treatment experience and resource availability. The influence of the popular opinions of family, friends and community members on healthcare decision-making in resource-poor contexts is strong. Community eye health programs must provide comprehensive eye health education involving the entire community. This should also include education sessions in schools, which will ensure that children understand the implications of couching and encourage their family members to opt for cataract surgery. Simultaneously, community eye health programs should build the capacity of local health systems and address economic and transport barriers to cataract surgery.  This can be accomplished by partnering with local eye clinics to reduce the cost of surgery and providing free transportation to and from the hospital for patients who require surgery.

Given the variety of beliefs about health and illness, health education should refrain from framing concepts in only the biomedical view. To avoid being authoritarian and ineffective, community eye health programs must strive to understand and appreciate local theories of disease causation. Mobilizing these concepts will improve health education and avoid insisting on the validity of only the biomedical point of view.

Moreover, this study demonstrates that when couching is performed well, it can present a somewhat viable alternative to cataract surgery. The small increase in sight which can be gained from couching represents a significant increase in autonomy for blind individuals. Where cataract surgery is not available, individuals have no choice but to opt for couching. Continued framing of those who opt for traditional treatment as ignorant and superstitious by the medical community will only serve to divert ophthalmic resources away from the areas they are most needed, exacerbating blindness and its associated socioeconomic burden.

Acknowledgements

This study would not have been possible without the assistance of many individuals. Alhassan Aliyu Mohammed’s knowledge and support as the research assistant and Unite for Sight’s outreach coordinator was essential in data collection. I would also like to extend my gratitude to the research participants for their willingness to tell their stories. Thanks to the staff at Unite for Sight and Dr. Seth Wanye at the Tamale Teaching Hospital for making this research opportunity possible through the Unite for Sight Global Impact Fellowship Program and for their continued support and guidance throughout the development of the study. Finally, a big thanks is extended to Dr. Alastair Summerlee, President and Vice Chancellor at the University of Guelph for his supervision of the study.

Footnotes

(1) Wallace, Lauren & Summerlee, Alastair. “Factors Involved in the Choice between Surgery and Couching for Cataract Treatment in northern Ghana.”  (manuscript in preparation).

(2) Girard L. “Dislocation of Cataractous Lens by Enzymatic Zonulolysis: A Suggested Solution to the Problem of the 18 Million Individuals Blind from Cataracts in Third-World Countries.” Ophthalmic Surgery. (1995): 26.4 343-345.

(3) Belyaev V., Barachkov V. "A Modern Experience with Couching for Cataract.” Annals of Ophthalmology. (1982): 14.8 742-745.

(4) Brandt F., Henning A., Prasad L., Rai N., Upadhyay M. “Ergebnisse der operativen Reklination der Linse (Eine Studie aus Nepal).” Klinische Monatsblatt Augenheilkunde. 185 (1984): 543-546.

(5)Bierlich, B., “Notions and Treatment of Guinea Worm in northern Ghana.” Social Science & Medicine41.4 (1995): 501–509.