The objective of this paper is to understand whether variations in satisfaction across individuals can be attributed to the hedonic procedural effect of using traditional medicines, in which processes involved with its consumption are as important, if not more important, than measures of self reported health outcome. The study involved rolling out structured household questionnaires in late 2010 in Ghana. The key variables used in analysis include: life satisfaction to proxy utility, a binary variable indicating whether the individual used an accompanying procedure, and EQ5D health outcome measures, alongside control variables. Findings suggest that individuals who used accompanying procedures are more likely to report higher levels of utility than individuals who did not, even after controlling for health outcomes and socioeconomic indicators. The study shows that individuals’ health seeking behaviour should be evaluated using procedural, as well as outcome, utility.
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Defined as herbal medicines, animal parts and/or minerals and non medication therapies including spiritual therapies (WHO 2002:1).
The idea of procedural justice is old, harking back to Bentham (1789).
It follows that theories from cognitive behavioural theory/social psychology are central to understanding how people derive utility.
In the mid-twentieth century Beecher (1955) evaluated from 15 studies an average 35 % of medical effectiveness of drugs were due to placebo and another, more recent study, found that patients showed signs of improvements in health even when told the pill was placebo (‘honest placebo’) (Kaptchuk et al. 2010). Moerman (1983) similarly finds up to 90 % of drug effectiveness can be accredited to placebo, but that only half this is due to active substances while the remaining half is to ‘general medical effectiveness’.
However, the placebo concept itself is not without criticism. In a systematic review, Hrobjartsson and Gotzsche (2010) do not find placebo interventions to have clinical effects in general, although some patient reported outcomes such as pain and nausea are positively affected through placebo. Kienle and Kiene (1997) argue that a range of factors can explain why individuals feel better for having used inert substances. Among these, spontaneous improvement, fluctuation of symptoms, additional treatment and neurotic or psychotic misjudgement are put forward as biological explanations, whilst statistical and methodological issues are also raised in the form of irrelevant response variables, answers of politeness and conditioned answers.
For example, (1) ‘how satisfied was (first name) with the outcome?, with answers ranging from very satisfied to very dissatisfied and (2) please indicate (first name)’s overall level of satisfaction with health after utilizing the TM/H. A very high correlation between all three answers were achieved, indicating that asking the same question in different ways did not yield dissimilar results.
Level eight was chosen as representative of high satisfaction, as there were very few observations for levels 9 and 10.
Only shorter tables (without displaying controls) are presented henceforth.
Individuals were asked to rate their level of agreement about certain attitudes and beliefs related to TM/H and this was made into an index using principal components analysis. Higher values indicate more negative cultural attitudes towards TM/H.
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Appendix 1: Control Variables Included in Analysis and Summary Statistics
A dummy variable ‘severity’ indicates an individual’s self assessed severity of illness (denoted 1 if he/she believed the symptoms to be very serious; 2 serious; 3 not serious or not serious at all), while the ‘chronic’ dummy indicates type of illness (chronic or not). Two measures of financial capability are additionally included; log equivalised income, calculated using a formula taking into account number of children and adults in the household, and a dummy to indicate whether the individual holds health insurance. Indicators of societal environment are also added: ‘culture’ indicates an index of cultural attitudes and beliefs towards TM/HFootnote 9, whilst ‘community group’ asks whether anyone in the household belongs to a community group (0 no 1 yes) to assess the level of social interaction. Other socio-demographic variables include: sex (0 male 1 female); highest level of education completed or currently attaining (‘education_cat’; 0 none, 1 primary, 2 junior, 3 senior+); occupation (‘occupation’; 1 farmer, 2 office worker, 3 own business owner or 4 unemployed); religion (‘religion’: 1 Christian, 2 Muslim, 3 other or 4 none), age group (‘ageg’: 1: 0–11; 2:12–17; 3:18–34; 4: 35–54; 5: 55+), whether the individual is married (‘married’ 0 no 1 yes) and the relationship to the head of the household (‘head_cat’: 1 head; 2:spouse; 3:child; 4:other). Finally, two locational dummies are incorporated into the model: ‘urban’, denoted 1 if the household is located in one of two district capitals and 0 otherwise and lastly, a regional dummy Upper West, omitting Greater Accra.
|Question||Self reported or not/retrospective or measured||Description||Coding||Full sample|
|Lifeafter||‘Using a scale of 0 to 10, where 0 indicates absolute dissatisfaction and 10 indicates absolute satisfaction: please indicate (first name)’s overall level of satisfaction with life after utilising the TM/H’||Self reported or household head reported/retrospective||Life satisfaction after TM/H utilisation||0–10. 0 absolute dissatisfaction, 10 absolute satisfaction||6.701299||1.764862||231|
|Procedure||‘Did you/the TH carry out any rituals or healing processes? (acupuncture, meditation, cantations, massage, touch therapies, religious activities, body-mind therapy, folk therapy etc.)’||Self reported or household head reported/retrospective||Whether individual experienced rituals or other healing processes||0 = no; 1 = yes||0.229437||0.421384||231|
|Mobility||Please indicate (first name)’s state of health before and after treatment in the following five dimensions: mobility; self-care; usual activities; pain/discomfort and anxiety/depression||Self reported or household head reported/retrospective||Whether individual felt better in mobility dimension following utilisation||0 = no, got worse or saw no change; 1 = yes, got better||0.606061||0.489683||231|
|Selfcare||As above||Self reported or household head reported/retrospective||Whether individual felt better in selfcare dimension following utilisation||0 = no, got worse or saw no change; 1 = yes, got better||0.601732||0.490604||231|
|Activity||As above||Self reported or household head reported/retrospective||Whether individual felt better in activity dimension following utilisation||0 = no, got worse or saw no change; 1 = yes, got better||0.670996||0.470872||231|
|Pain||As above||Self reported or household head reported/retrospective||Whether individual felt better in pain dimension following utilisation||0 = no, got worse or saw no change; 1 = yes, got better||0.796537||0.403448||231|
|Anxiety||As above||Self reported or household head reported/retrospective||Whether individual felt better in anxiety dimension following utilisation||0 = no, got worse or saw no change; 1 = yes, got better||0.647826||0.47869||230|
|Chronic||‘Has anyone in this household ever been told by a doctor or other health care provider that they have a chronic disease? A chronic disease is an illness that will not go away or takes a long time to go away, even when treated’||Self reported and healer or physician reported/measured||Whether illness was chronic||0 = no; 1 = yes||6.521072||1.354331||215|
|Self assessed severity||‘How serious do you think this illness was?’||Self reported or household head reported/measured or retrospective||Perceived severity of illness||1: very serious; 2: serious; 3: not serious||1.848485||0.727405||231|
|Insurance||Does (first name) have health insurance?||Self reported or household head reported/retrospective||Whether individual has health insurance||0 = no; 1 = yes||0.597403||0.491486||231|
|Income (x)||Please state the amount your household spent in total last month. Please include all food, rent, school fees, health expenditures etc.||Self reported or household head reported/retrospective||Log equivalised income||3.933266||1.049867||202|
|Culture||Self reported or household headreported/measured||Index of cultural attitudes towards traditional medicines/healers||Positive score increasing with dislike or negativity towards TM/H||6.521072||1.354331||215|
|Communitygroup||‘Please state whether any household members belong to the following groups: local church/place of worship; local sports team; money lending schemes; Any other community or political groups/affiliations’||Self reported or household head reported/measured||Whether anyone in household belongs to a community group||0 = no; 1 = yes||0.285714||0.452735||231|
|Sex||‘Please state the sex of every member of the household’||Self reported or household head reported/measured||Gender||0 = male; 1 = female||0.606061||0.489683||231|
|Education_cat||‘Please state the level of education attained or currently attaining, of every member of the household’||Self reported or household head reported/measured||Highest level education completed or currently attaining||0 = none; 1 = basic primary; 2 = junior; 3 = junior+; 4 = other||1.069565||1.103561||230|
|Occupation||‘Please state the occupation, of every member of the household’||Self reported or household head reported/measured||Occupational group||1 = farmer/fisherman; 2 = office worker; 3 = own business; 4 = unemployed||2.774892||1.241133||231|
|Religious_group||‘Please state the religion of every member of the household’||Self reported or household head reported/measured||Religious group||1 = Christian; 2 = Muslim; 3 = other; 4 = none||1.458874||0.821873||231|
|Ageg||‘Please state the age of every member of the household’||Self reported or household head reported/measured||Age group||1 = 0–11; 2 = 12–17; 3 = 18–34; 4 = 34–55; 5 = 55+||3.46875||1.355575||224|
|Married||‘Please state the marital status of every member of the household’||Self reported or household head reported/measured||Whether individual is married||0 = no; 1 = yes||0.4329||0.496553||231|
|Head_cat||‘Please state the relationship to the head of every member of the household’||Self reported or household head reported/measured||Relationship to head of household||1 = head; 2 = spouse; 3 = child 4 = other||2.367965||1.110666||231|
|Region||Measured||Region dummy||0 = Greater Accra; 1 = Upper West||0.450217||0.498596||231|
|Urban||Whether major city within region||Measured||Urban dummy||0 = no; 1 = yes||0.601732||0.490604||231|
Appendix 2: Statistical Exposition of Ordered Probit Model
In an ordered probit model, threshold values (τ i ) represent cut-off points where an individual moves from belonging in one satisfaction level to another. Where the lowest (highest) possible value of the threshold is minus (plus) infinity, and a constant term is suppressed, it is possible to model an eleven (0–10 inclusive) category ordered probit thus:
where βs and τs are to be estimated with robust standard errors, clustered by radius to account for sampling methodology and ϕ represents the probit link function and estimation is by maximum log likelihood. A positive coefficient indicates an individual will display higher latent satisfaction and is therefore more likely to report higher levels of satisfaction whereas a negative coefficient implies the opposite. To quantify magnitudes, marginal effects for any level of outcome are calculated, with regressors set at mean values.
See Table 3.
See Table 4.
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Sato, A., Costa-Font, J. The Hedonic Procedural Effect of Traditional Medicines. J Happiness Stud 15, 1061–1084 (2014). https://doi.org/10.1007/s10902-013-9464-5
- Process utility
- Procedural utility
- Traditional medicine use