Ethnomedical survey of Berta ethnic group Assosa Zone, Benishangul-Gumuz regional state, mid-west Ethiopia

Traditional medicine (TM) has been a major source of health care in Ethiopia as in most developing countries around the world. This survey examined the extent and factors determining the use of TM and medicinal plants by Berta community. One thousand and two hundred households (HHs) and fourteen traditional healers were interviewed using semi-structured questionnaires and six focused group discussions (FGDs) were conducted. The prevalence of the use of TM in the two weeks recall period was 4.6%. The HH economic status was found to have a significant effect while the educational level and age of the patients have no effect either on the care seeking behavior or choice of care. Taking no action about a given health problem and using TM are common in females with low-income HHs. Forty plant species belonging to 23 families were reported, each with local names, methods of preparation and parts used. This study indicates that although the proportion of the population that uses TM may be small it is still an important component of the public health care in the study community as complementary and alternative medicine.


Background
Since time immemorial, human beings have found remedies within their habitat, and have adopted different therapeutic strategies depending upon the climatic, phytogeographic and faunal characteristics, as well as upon the peculiar cultural and socio-structural typologies [1].
Ethiopian traditional medicine (TM) comprises of the use of plants, animals and mineral products as well as beliefs in magic and superstition, although ethnobotany is the major one [2,3]. Studies reported that a significant proportion of the Ethiopian population still depends on TM for its health care services [4,5] and more than 95% of traditional medical preparations are of plant origin [6]. Docu-menting traditional medical knowledge is important to facilitate discovery of new sources of drugs and promote sustainable use of natural resources. On the other hand, the knowledge of the factors involved in the selection of treatment options at household (HH) level is important for health service planning and to incorporating herbal medicine in a country's health care delivery system. Despite its significant contributions, TM in Ethiopia has attracted very little attention in modern medical research and development, and less effort has been made to upgrade the role of TM practice [7]. This study, therefore, attempts to identify and document factors determining the use of TM and medicinal plants used by Berta ethnic groups, Assosa Zone, mid-west Ethiopia.

Study area
Benishangul Gumuz Regional State (BGRS) is one of the nine Federal States of Ethiopia located in the mid-western part of the country and having a total area of about 50,382 Km 2 . According to the 2001 Population and Housing Census of Ethiopia, the total population of Benishangul-Gumuz region was 460,459 which gives a population density of 9/Km 2 . Assosa zone, one of the three zones and two special Woredas (second from lowest administrative units in government structure) in the region, has a total area of 1,519 Km 2 and a population of 28, 970 (population density of 19.1/Km 2 ).
The indigenous population of BGRS consists of five ethnic groups: Gumuz, Berta, Shinasha, Mao and Komo accounting for 23.4%, 26.7%, 7.0%, 0.6% and 0.2% of the total population, respectively. The Berta ethnic group resides mainly in the 7 Woredas of Assosa Zone ( Figure 1) and more than 96.3% of the population of this ethnic group is Muslims [8].
The livelihood of nearly 95% of the population is subsistence farming. The enhancement of even this subsistence farming is precluded by the small number of livestock, which is commonly attacked by enzootic diseases, and frequently by paroxysms of epizootic episodes [9].

Data collection and analysis
The Institutional Ethical Board Review of the School of Pharmacy has given permission to conduct the study prior to the commencement of the survey. Information on demographic characteristics, prevalence of perceived illnesses, factors associated with preference of health care seeking options, medicinal plants used and hoarded as well as some healers' socio-economic characteristics were collected using two sets of semi-structured questionnaires -one for HH heads and the other for traditional healers. Moreover, focused group discussions (FGDs) were conducted with six heterogeneous groups with respect to sex, age and income levels. Each FGD consists of 7-9 members.
From the 7 Woredas of Assosa Zone, two Woredas namely, Menge and Komehsa were selected by simple random sampling technique. Proportionate to the size of the population, 7 Kebeles (lowest administrative units) from Menge and 3 Kebeles from Komehsa were selected randomly. The number of HHs included from each selected Kebele was again determined based on the size and identified using systematic random sampling techniques where every nth HH was taken until the required size was met in each Kebele. A total of 1,200 HHs were selected.
Map of Assosa Zone (Finance and Economic Bureau, Benishangul-Gumuz Region) Similarly, fourteen key informant healers were selected on the basis of their healing reputation with the help of Kebele administrators, health professionals in the area and community elders. Data collectors, who are high school students with knowledge of local language, were given training for two days on the data collection instrument.
Oral consent was obtained from each study participant before conducting the interview. Variables like sociodemographic characteristics of HH respondents, HH size, existence of illness during the past two weeks preceding interview date, choice of treatment options, names and parts of plants used, etc were entered in EPI info statistical software and analyzed.

Summary of FGDs
Results of the six FGDs, conducted in six Kebeles of the two Woredas; Abora, Kudiyu and Belmeguha from Menge and Algela, Dareselam and Tselenkor Kebeles of Komesha Woreda are summarized below (the local names of illnesses written in italics and their major signs and symptoms or their closer meanings are shown in Appendix 1).
According to the respondents of the three groups, Menge Woreda, the major health problems identified by FGD participants were Birde, Kulalite, Malaria, Gunfan, Ikek, Azurite, Kurtemat, diarrhoea, Cheguara and Ashmem. In the other three discussions held in Komesha Woreda; malaria, Gunfan, Ikek, diarrhoea and Birde are listed as most prevalent illnesses in the localities. The common illnesses mentioned in both Woredas are similar, the only difference being the rare occurrence of some of these illnesses in Menge Woreda.
Most of the respondents of Menge agreed that modern medicine is the first choice during an episode of illness. They underlined that treatment recommended by modern medicine is strictly followed for the duration of the treatment and in case no improvement was observed from this treatment they would then resort to consulting traditional healers. Two respondents deviated from the opinions of members of their group in that for most of the illness episodes home made remedies were tried before going to health institutions and they even reported that for certain illnesses such as Ashmem, modern medicines are not believed to work at all.
Most of the respondents in all of the groups in Komehsa agreed that the choice of resorting to traditional healers depends on the specific illness episode to be addressed. For instance, modern treatment is the first choice for illnesses known to have been effectively cured by modern medicine. Malaria and pregnancy related problems are cited as best examples of illnesses with established signs and symptoms and which can be cured by modern medicine. On the other hand, Setan beshita, is believed to be an illness that can only be treated by traditional healers. Three respondents from two independent groups argued that for every illness episode, the use of home remedies is the first choice before consulting traditional healers. The patient only resorts to traditional healers only if the symptoms persist for two days or more following the administration of the home remedies. These deviants, however, agreed that modern medicine might be the first choice in case no one in the family or neighborhood claims to know TM for that specific illness.
Most of the medicinal plants, according to the respondents of Menge, are obtained from wild sources and there is no special protection or care given to these plants and they are treated just like any other plant that has no claims to medicinal values. Almost all of the respondents of Komesha also agreed that medicinal plants are obtained from wild sources except for some of the medicinal plants that are cultivated for added values. According to the respondents, the wild medicinal plants are treated just like other wild trees although some of these are even available only during the rainy season.
The members of all groups in Menge reported that the transfer of knowledge from generation to generation was by word of mouth, a practice that is being less commonly used these days. They admitted, however, that their forefathers collected and used medicinal plants for most of the illnesses that are treated today by modern medicine. The younger generation today has no or little interest in acquiring knowledge in TM and resort to it only after exhausting all treatment options by modern medicine.
All of the respondents in Komehsa agreed that knowledge of TM is given to mankind by God and transferred from generation to generation by word of mouth. However, they admit that this method for the transfer of knowledge is declining at a very fast rate from generation to generation. The respondents underlined that medicinal plants in use today are known to only a limited number of people in the communities and that the majority of users depend on either proxy knowledge or purchase herbs for illnesses they very well know to be effectively cured by herbs. This decline in the preservation of knowledge about TM is the result of lack of trust and confidence in the use of TM by the young generation on the one hand and, unwillingness on the part of traditional practitioners to share their traditional knowledge with the younger generation on the other.
The FGD participants reported that TM is an important alternative health care to the society for two reasons: a) Some diseases are not treatable by modern medicines (for instance, Ashmem) for which TM is the only option and, b) In some health facilities there is shortage of adequate diagnostic facilities and drugs, as a result of which appropriate treatment cannot be provided to the patients, who would then resort to TM.
As explained above, while the role of TM for the health care of the society is quite evident, traditional healers and members of the society believe that TM practice is not encouraged by the government which is in the opinion of the respondents tantamount to a criminal act.

Perceived illnesses and patterns of resort
Among the 7,130 people in the HHs studied, a total of 570 illness episodes were reported, which gives a prevalence rate of 8.0%, in the two weeks recall period preceding the interview date. Females (57.5%), had more morbidity than males (42.5%). In response to the perceived illnesses, 85.8% went to health institutions, 3.5% went to healers and 1.1% used home made remedies while 9.6% took no action (Table 1). TM was found to be a more frequent choice of care for females (5.2%) than males (3.7%) with perceived illnesses in the two weeks recall period.
Among the respondents who claimed to have used TM, most (54.8%) believed that TM is more effective, 24.2% claimed the use of TM only when modern medicine failed, while 19.1% preferred TM because of its low cost and the remaining 1.9% claimed that lack of access to modern medicine prompted them to resort to TM.

Factors associated with patterns of actions taken
As shown in Table 2, economic status of the HHs appears to influence the health seeking behavior and preference of treatment options. In this regard, there was a decrease in the percentages of no action respondents from 58.2% among low-income group to 30.9% and 10.9% among middle income and higher income groups, respectively. The economic status of the HHs was found to have a significant influence on whether to take actions or not during episodes of illnesses (X 2 = 9.98, P < 0.05) ( Table 3).
The influence of education on treatment preference was analyzed and it was found that although non-literates tended to use TM more than literates, the relationship was not statistically significant (Table 3 and table 4) In the study community there was a preferential care seeking behavior both by sex and age in which children below the age of 15 are given priority over adults and males over females. The stratified analysis (income as stratification variable) showed that actions taken against illness had significant association with sex in low-income respondents, and age did not show significant association with action taken against illness (Tables 3 and 5).

Use of medicinal plants
A total of 40 species of plants with claimed medicinal values were collected and botanically identified during the course of this study. HH respondents reported the use of 37 plant species (Table 6) while only 10 herbs were found to be utilized by healers (Table 7). Among these plants, 28 are fully identified by their scientific names while 12 are identified at the genus level only. The identified plants fall under twenty-three plant families with the largest number falling under Fabaceae followed by Euphorbiaceae and Asteraceae.
According to the HH respondents, root was the most widely used plant part (46.4%) followed by seed (14.3%), leaf (12.2%), fruit (11.2%), bark (7.7%), and stem (3.6%) while in the remaining (4.6%) combination of one or more plant parts were used. Healers also reported use of roots in 63.3%, seeds in 17.1% and leaves in 14.6% of the plants.

Discussion
A number of surveys indicated that some illnesses are believed not to be cured by modern health care. For instance, demon possession and infertility are typical health problems for which people visit traditional healers in Kalabo District, Zambia [12]. Similarly, in this study society, Ashmem, Setan and Ebdet are believed to be cured only by TM. Therefore, TM remains important component of public health care in the study community.
Even if there are variabilities among study designs, recall periods and seasonal variations in disease frequency and associated choice of treatment options, most studies proved high rates of TM use [13,14]. Contrary to these findings, the prevalence of herbal drug use was found to be low (4.6%) in this study. This could be due to either under-reporting of use as a result of community's belief that traditional practice is unlawful act or high prevalence of illnesses is believed to be treatable by modern care in the study period.
Even though low prevalence of herbal drug use was reported in this study, the reasons for preferring herbal drugs were perceived to be due to efficacy of TM, and perhaps also due to economic and geographic inaccessibility of modern medicine. These reasons of preference and the fact that more females (7.2%) prefer visiting traditional healers than males (5.6%) are consistent with finding of other studies conducted in different communities in Ethiopia [5,14,15].
This study showed an increase in the rate of "no actions taken" against illness episodes with a decrease in economic status (negative relationship) and this association is found to be statistically significant (P < 0.05). Other studies also came up with a statistically significant association between socio-economic status and choice of health care provider, and health care is less likely to be sought when the individual or HH is poor [16,17].  This study, consistent with a study conducted in Zambia [12], showed that educational level has no significant effect on the choice of health care, while other studies reported the existence of a statistically significant association between educational level and choice of health care provider [5,17].
In this study, a significant association existed between female and no-action taking during illness in the lowincome HHs (P < 0.05). A study conducted in Nepal also indicated that illness reporting, choosing an external care, choosing a specific health care provider, and spending money to treat the sick child are all associated with sex of the patient [18]. Moreover, being a woman is more highly associated with visiting traditional healers than modern health facilities [5,19]. Even though a priority in resource allocation for children (<15 years) in preference to adults was reported by participants of group discussion, the association of the age of the patient with health care seeking pattern was not statistically significant in all income groups (P > 0.05).
Similar to other studies carried out in northwestern Ethiopia among the people of Shinasha, Agew-awi and Amhara, the family Fabaceae was reported to have the largest number of plant species used for medicinal purposes among the Bertha ethnic group [20]. Awas et al. [21] also reported that the Fabaceae is the most widely used plant family among the Bertha and Gumez people.
In agreement with other ethnomedical studies conducted in different parts of Ethiopia, the present study has also documented the roots as the most commonly sought-after plant parts [22][23][24]. Moreover, the results of the present study are consistent with reports in previous studies done in south-western Ethiopia where a large proportion of medicinal plants are collected from wild sources [25][26][27]. It is well recognized by conservationists that medicinal plants primarily valued for their root parts and those which are intensively harvested for their bark often tend to be the most threatened by over-exploitation [28]. Thus, it is recommended that an urgent and concerted action be taken to conserve widely used medicinal plants in general and those plants for which the roots constitute the primarily valued part in particular before they are lost irretrievably.

Conclusion
In conclusion, Assosa zone harbors high diversity of medicinal plants most of which are rare species and seasonal plants. Despite the reported low prevalence of TM use, herbal medicine remains important component of public health care in the study community as it is the only option for some illnesses and also the next alternative when modern medicine fails. Since roots are the most widely used plant parts and plants are mostly collected from wild sources, the risk of loss of biodiversity in the Zone is high. Doses are not established or are approximate for most treatments and most herbs are stored for unspecified period. Thus there is a risk of treatment failure due to loss of potency, if any, during storage with possible formation of poisonous products. The risk of loss of indigenous knowledge appears to be high in connection with lack of transfer of knowledge among family members and    (4) Root Bark Root is ground, dispersed in water and drunk; bark is eaten as it is Etseya shemegna * Setan (4) Root Dried root is put on fire and patient is exposed to the smoke Etsegne shalew Bone fracture (2) Root is ground and drunk with water and also tied around the fractured bone Umusihir Abdominal cramp Seed Powdered seed is dispersed in water and drunk Bark is eaten as it is; powdered root is dispersed in water and drunk Syzygium guineense (Willd.) DC.

Myrtaceae
Abulmitse TF-008 * Yehitsan beshita Stem Powdered, dispersed in water and drunk; also applied on the body Tamarindus  (Illnesses with asterisks are in local terms and the major signs and symptoms or closer meanings are presented in Appendix 1). friends. Therefore, it is important that the government create awareness among community members about the significance of preserving traditional knowledge and conserving medicinal plants before they disappear, and thereby ensure the rights of people to use their traditional practices which are known for their proven safety and effectiveness.