Explanatory Model for the Use of Traditional Medicines in Kilimanjaro, Tanzania

Introduction: Traditional medicines are one of the most important means of achieving total health care coverage globally, and their importance in Tanzania extends beyond the impoverished rural areas. Their use remains high even in urban settings among the educated middle and upper classes. They are a critical component healthcare in Tanzania, but they also can have harmful side effects. Therefore we sought to understand the decision-making and reasoning processes by building an explanatory model for the use of traditional medicines in Tanzania.

Methods: We conducted a mixed-methods study between December 2013 and June 2014 in the Kilimanjaro Region of Tanzania. Using purposive sampling methods, we conducted focus group discussions (FGDs) and in-depth interviews of key informants, and the qualitative data were analyzed using an inductive Framework Method. A structured survey was created, piloted, and then administered it to a random sample of adults. We reported upon the reliability and validity of the structured survey, and we used triangulation from multiple sources to synthesize the qualitative and quantitative data.

Results: A total of five FGDs composed of 59 participants and 27 in-depth interviews were conducted in total. 16 of the in-depth interviews were with self-described traditional practitioners or herbal vendors. We identified five major thematic categories that relate to the decision to use traditional medicines in Kilimanjaro: healthcare delivery, disease understanding, credibility of the traditional practices, health status, and strong cultural beliefs.

A total of 473 participants (24.1% male) completed the structured survey. The most common reasons for taking traditional medicines were that they are more affordable (14%, 12.0-16.0), failure of hospital medicines (13%, 11.1-15.0), they work better (12%, 10.7-14.4), they are easier

to obtain (11%, 9.48-13.1), they are found naturally or free (8%, 6.56-9.68), hospital medicines have too many chemical (8%, 6.33-9.40), and they have fewer side effects (8%, 6.25-9.30). The most common uses of traditional medicines were for symptomatic conditions (42%), chronic diseases (14%), reproductive problems (11%), and malaria and febrile illnesses (10%). Participants currently taking hospital medicines for chronic conditions were nearly twice as likely to report traditional medicines usage in the past year (RR 1.97, p=0.05).

Conclusions: We built broad explanatory model for the use of traditional medicines in Kilimanjaro. The use of traditional medicines is not limited to rural or low socioeconomic populations and concurrent use of traditional medicines and biomedicine is high with frequent ethnomedical doctor shopping. Our model provides a working framework for understanding the complex interactions between biomedicine and traditional medicine. Future disease management and treatment programs will benefit from this understanding, and it can lead to synergistic policies with more effective implementation.

Integrating simultaneous prosocial and antisocial behavior into theories of collective action.

Trust and cooperation constitute cornerstones of common-pool resource theory, showing that "prosocial" strategies among resource users can overcome collective action problems and lead to sustainable resource governance. Yet, antisocial behavior and especially the coexistence of prosocial and antisocial behaviors have received less attention. We broaden the analysis to include the effects of both "prosocial" and "antisocial" interactions. We do so in the context of marine protected areas (MPAs), the most prominent form of biodiversity conservation intervention worldwide. Our multimethod approach relied on lab-in-the-field economic experiments (n = 127) in two MPA and two non-MPA communities in Baja California, Mexico. In addition, we deployed a standardized fishers' survey (n = 544) to verify the external validity of our findings and expert informant interviews (n = 77) to develop potential explanatory mechanisms. In MPA sites, prosocial and antisocial behavior is significantly higher, and the presence of antisocial behavior does not seem to have a negative effect on prosocial behavior. We suggest that market integration, economic diversification, and strengthened group identity in MPAs are the main potential mechanisms for the simultaneity of prosocial and antisocial behavior we observed. This study constitutes a first step in better understanding the interaction between prosociality and antisociality as related to natural resources governance and conservation science, integrating literatures from social psychology, evolutionary anthropology, behavioral economics, and ecology.