Cultural Practices and Health Consequences: Health or Habits, the Choice Is Ours

Human beings are social animals with an innate desire to conform to socially accepted norms and values. Over periods of time, some of these norms become standards that all members of the community are expected to adhere to. Deviance from these standards is seen as absurd, wrong, or frankly abnormal. However, many of these cultural mores have no scientific basis and, some of them actually promote behaviors with negative health consequences. This chapter examines the cultural practices of some communities in Africa and their health consequences and, explores ways to address the challenges.


Introduction
Human beings are social animals with an innate desire to conform to socially accepted norms and values. Over periods of time, some of these norms become standards that all members of the community are expected to adhere to. Deviance from these standards is seen as absurd, wrong, or frankly abnormal. However, many of these cultural mores have no scientific basis and, some of them actually promote behaviors with negative health consequences. While the health consequences of many of these practices may not be of public health significance, some have major short and long term impact on the health of individuals in the community. The more difficult ones to appreciate are those practices that do not immediately appear to have deleterious health consequences but, may have direct and indirect long term impact on the health of individuals, families and the community.
It must be appreciated that not all cultural practices are deleterious to health. Some are actually beneficial. For example, many communities in rural Africa forbid intimacy between a newly delivered mother and her partner for some months. This practice encourages child spacing and allows the mother to adequately breastfeed the new baby [1].
Cultural practices are varied across different contexts. They have usually been viewed as the normal way of life and may be actively encouraged in the communities.
This chapter is a review of literature on some cultural practices with overt health consequences. It seeks to highlight some of these practices in Africa as prototype and explore ways they can be addressed at public health level. This is a cultural practice that has attracted worldwide concern due to its profound deleterious consequences on the health, reproductive ability and psychological wellbeing of women [2]. It is a cultural practice common in parts of Africa, Asia and Middle East. Part of, or the entire external female genital is cut off as a cultural practice believed to reduce libido and enhance the chastity of women. More than 200 million girls and women mostly from the above mentioned areas have experienced FGM. The procedure is usually done by traditional attendants using unsterile devices on girls from the ages of infancy to about 15 years of age. Apart from the risk of infections from the unhygienic way the procedure is carried out and the unsterile equipment used, there can be severe bleeding, injuries to the urinary tract as well as subsequent increased risk of complicated childbirth and death of the newborn [1]. The paradox of the practice is that rather than promote sexual chastity as believed by the practitioners, FGM actually causes painful sexual intercourse and difficulties achieving sexual satisfaction. It has absolutely no health benefit for the women and it has been associated with depression, anxiety, post-traumatic stress disorder and low self-esteem [1].

The Wodaabe's wife stealing night dance
This is a cultural practice found among the Wodaabe tribe, a sub-group of the Fulani ethnic communities of the northern parts of Nigeria, northeastern Cameroon, the western region of Central African Republic and southwestern Chad [3]. The tribe holds a cultural dancing festival at night. While dancing, a man is allowed to steal and carry home any woman he likes whether the woman is married or not. The health implication of this cultural practice is obvious. Sexually transmitted infections including HIV as well as unwanted pregnancies may result, with attendant consequences.

The Chawe cultural corpse washing ritual
Among the Chawe community, a Bantu tribe mostly found in Malawi, when a member of the tribe dies, the throat of the corpse is sliced open and water is run through then squeezed out until it comes out looking clear [3]. This water from the corpse is collected and used to prepare a meal for the entire community.
The health implication of this cultural practice is the spread of infectious diseases, which may have led to the death of the deceased tribal member in the first instance. Gastrointestinal diseases like gastroenteritis, food poisoning, hepatitis, enteric fever or cholera among others, may result from this cultural practice.

The Banyankole tribe's potency test
In many tribes of Africa, older females play advisory roles as matrons to newly wedded couples [3]. They usually advise on how the woman especially, should relate to her husband so that they can avoid marital frictions. Some of these advice include how the woman is expected to behave in bed with her husband so that he does not stray out for sexual satisfaction. However, the Banyankole tribe of Uganda take this innocuous and possibly helpful cultural practice to another dimension. The older female who plays the role of the matron to the couple is required to test the sexual potency of the intending husband by having sexual intercourse with him. In addition, she has to test the "purity" of the intending wife by examining for her hymen before they are allowed to marry.
Here again, this cultural practice may promote sexually transmitted infections, female genital tract infection as well as lower the self-esteem of the vulnerable young couple, who may be ridiculed if declared to have fall short by the more experienced matron.

Bull jumping ritual in Ethiopia
Young boys in some communities in Ethiopia are required to prove their manliness by stripping naked, running and jumping on the back of a bull [3]. This is followed by running on the backs of a line of several bulls held by their horns and tails by the adults. This cultural practice is called Hamar. Female friends of the young boy are then required to prove their loyalty to him by smearing their bodies with ochre mixed with fat and dancing while being given several lashes on their bare backs.
This cultural practice may result in trauma, fractures or even loss of life. Infections like tetanus may result from contamination of the injuries and abrasions caused by the lashes.

Sharo beating ritual of Benin
Among the Fulani tribe of Benin, an intending husband may be required to endure severe beating to prove his worthiness of the wife [3]. If the husband is unable to endure the flogging, the marriage is called off.
Many intending husbands have died from the flogging ritual and consequently, it is no longer a compulsory requirement for marriage. Apart from a fatal consequence, the Sharo beating cultural practice portends physical and psychological trauma to the intending husband.

The wife exchanging culture of northern Namibia
The nomadic tribes of Ovahimba and Ovazimba communities of Kunene and Omusati regions in northern Namibia, express their appreciation of their friend or visitor by giving the friend or visitor their wife to have sexual intercourse with for the night [4]. This cultural practice is called okujepisa omukazendu. This practice is deeply rooted in the communities, they believe that it deepens their friendship and prevents promiscuity.
In a country with one of the highest prevalence of HIV infection, a cultural practice like this may be contributing to the spread of the disease. It will be interesting to find out if the wives given as sexual gifts to friends and visitors have a say in the decision and, if they appreciate the cultural practice.
The cultural practices described above are examples of the obvious ones with possibly deleterious health consequences. Some others are not as obvious but nevertheless may have significant adverse heath impact. An example is the cultural upbringing of male children to assume dominant and aggressive roles in relationship with the more docile brought up female partner. This cultural practice is common in many parts of Africa and has been associated with tolerance in the communities for violence by husbands on their wives and, intimate partner violence [5][6][7].

How do we address cultural practices with adverse health consequences?
Female genital mutilation (FGM) was declared a public health concern due to the widespread practice of the culture and, the huge number of girls and women whose physical, psychological, and reproductive health have been adversely affected [2]. The international collaborative response to the practice involved the World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA). The modality for the concerted efforts to stamp out FGM includes [1]: • wider international involvement to stop FGM; • international monitoring bodies and resolutions that condemn the practice; and • revised legal frameworks and growing political support to end FGM (this includes a law against FGM in 26 countries in Africa and the Middle East, as well as in 33 other countries with migrant populations from FGM practicing countries).
Though the sustained and collaborative efforts resulted in reduced prevalence of the cultural practice, research revealed that if the communities that practice FGM themselves decide to abandon the cultural practice, FGM will be quickly eradicated [2].
So, how then do we get communities to be aware of the health consequences of aspects of their culture that have adverse consequences on health? I propose a multi-dimensional, sustained and motivational approach; similar to the motivational interviewing used medically to influence changes in individual behaviors that have undesirable health consequence [8].
This approach requires identification of influential individuals and stakeholders in the community and developing a relationship of respect and mutual trust in these identified people. Then, without being overtly critical of their cultural practice, they can be made aware of the health impact of the practice using subtle methods such as drama, movies and carefully prepared literature [7]. When the influential individuals and stakeholders are motivated to appreciate the harmful effects of the cultural practice, they may then be involved in peer influence of others in their