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A quick powerpoint explaining what a business plan is, how it is used, and why it is important to a business.

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Starting a Business: Contents of a Startup Business Plan (GCSE)

Last updated 22 Mar 2021

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For a start-up there are usually two kinds of business plan - a simple one and a detailed one. Some businesses need to produce both.

The simple business plan is rarely shown to outsiders of the business. It is written by the entrepreneur, for the entrepreneur. The simple plan helps summarise the key aims and targets of the business and the actions required to make the business a reality. It is likely to be written in quite an informal way. What would go into the simple plan? Areas such as:

  • The idea - a simple description of the proposed business
  • Where the idea came from and why it is a good one
  • Key targets for the business - sales, profit, growth (gives a sense of direction for the business), ideally for the next 3-4 years
  • Finance required - how much from the founder, how much to be loaned over how loan and from who
  • Market overview - main segments, market size (value, quantity), growth, market shares of main competitors (if known)
  • How the business will operate (location, premises, staff, distribution methods)
  • Cash flow forecast (important) + trading forecast

A detailed business plan is needed if a more complicated or larger business is planned as a start-up, or if the entrepreneur needs to raise money from business angels or get a substantial loan from a bank. Here is a summary of the key content:

Executive summary: a brief 1-2 page summary of the detail! Should contain nothing new, but highlight the key points

Market: a profile of the target market based on market research

Product: what it is and how it is different from the competition (the "unique selling point")

Competition: an honest description of the competition in the target market - what they do well, their weaknesses and their likely response

Protecting the idea: how the product and business can be protected from competition - e.g. patents, trademarks, distinctive approaches to marketing or distribution that competitors will find hard to replicate

Management team: a crucial area for any investor. Who is involved in the start-up and what will they be doing? What experience and expertise do they bring? Which management roles will need to be filled as the business grows?

Marketing: the key elements of the marketing mix should be explained here. Remember that for a start-up the marketing budget is likely to limited, so the plan should describe a credible approach to promoting the product and include realistic assumptions about how many customers will buy and at what price

Production /operations: this explains what is involved in the production process, what capacity is needed, who will supply the business, where it will be located etc.

Financial projections : a summary of the cash flow and trading forecasts. This section should highlight the key assumptions that have been made and also outline the main risks and opportunities in the forecasts (i.e. what might go wrong, or where things might prove better than forecast).

Sources of finance: here the figures from the cash flow forecast are taken and used to highlight what funding the business needs, and when.

Returns on investment: another key area for any investor. This is a description of how the entrepreneur expects investors to get a return on their investment. Who might eventually buy the business, when, and for how much?

  • Business plan

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Edexcel GCSE Business - Theme 1 - 1.4.4 Business plans

Edexcel GCSE Business - Theme 1 - 1.4.4 Business plans

Subject: Business and finance

Age range: 14-16

Resource type: Lesson (complete)

Mr. Zee's Resources

Last updated

21 June 2021

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purpose of business plan bbc bitesize

This lesson introduces learners to the contents and purpose of a business plan, we discuss the sections of a plan, we then go on to look at an infamous example of what it shouldn’t be like in Solomon’s plan presented to Claude Littner in the Apprentice. A 3 mark question with a model answer, a few short tasks before going onto creating a business plan in groups, a template has been provided. Students present back their plans to the class and the class are provided with a sheet to write WWW and EBI with their peers presentations.

A group task where they match parts of the business plan to the different areas of the business plan - answers included.

Colourful, concise and engaging slides!

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Edexcel GCSE Business - Theme 1 (FULL bundle updated for 2021)

A complete bundle, updated for 2021 with more engaging and colourful slides to cater for remote learning needs. The highest quality, unrivalled lesson experiences from start to finish. This bundle is filled with real life examples, scenarios, individual and group activities, exam style questions with model answers so students can self or peer assess from looking at the board. Engage your learners and improve their exam skills at the same time, rather than just going through theory slide after slide. Please subscribe to mrzeesresources.com and have a browse for the highest quality lessons and resources. Thank you School purchase orders can be sent to [email protected]

Edexcel GCSE Business - Theme 1 - 1.4 Making the business effective

This 6 lesson bundle covers: 1.4.1 The options for start-up and small businesses - 2 lessons 1.4.2 Business location 1.4.3 The marketing mix - 2 lessons 1.4.4 Business plans Filled with real life examples, case studies, questions and modelled answers to improve exam practice. All you need - open the powerpoint, run through it, and deliver quality lessons whilst saving precious time. Colourful, concise and engaging slides! - all files in zip folder. Please subscribe to mrzeesresources.com and have a browse for the highest quality lessons and resources. Thank you

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Business Plans

Business Plan

In this post

Business plans are used to outline the industry in which a business is working in as well as the economic structure of a company to give an idea of the financial prospects of a business. They are used primarily to organise the routes to market that a company will take and give projections on earnings and target dates for when the company expects to have a certain income.

Writing a strong business plan is important for any business, whether large or small, and is the perfect way to map out your route to success. Not only will the plan contain your aims and plans to attract new customers but it can also act as a strong tool for financial projections and help you to set out goals for your company. Throughout the units that we have already covered on this course we have seen a lot of aspects that could be included in a business plan, and including as much information as possible is key.

A lot of entrepreneurs fail to produce a clear business plan when they set up a new company and this can be a big issue further down the line. By not outlining your company and its operations you may affect the business in a negative way and be unable to keep track on the progress and route the business is taking. If you are seeking finance to launch your company it is more than likely that you will need to create a business plan to secure a loan, but this should not be thrown away once you have started the business. Your plan can be updated and adapted at any time and you must try to keep things relevant and up to date so you know the long-term aims of your company.

Why create a business plan?

Some entrepreneurs fail to create a business plan before starting a company because they feel it is a waste of time. They know what they want to do, how they want to do it and everything that is needed has been formulated in their heads. This is a very good skill to have, but without your thoughts and projections down on paper it can be very easy for them to become misinterpreted, forgotten or skewed. Simply having things thought out in your mind is not enough to convince others or explain your strategies to those you are working with. Business plans are used to organise your approach and produce a strategy that allows you the best possible chance of success. They should include:

  • Information about your company so that you can plan the structure and objectives which you have
  • Your relationships with others and how these can be used (e.g. banks, lenders and accountants)
  • To find weaknesses in your plans and areas where you must improve
  • Areas for discussion so that you can find out other people’s opinions and include them in the planning process

Some people start a business and want everything to be done immediately. With great confidence that they can do it all alone and have no input from experts, they may not stop and think about forming a clear plan that includes facts and figures to help them along the way. Doing this can be of massive detriment to any business and you need to gather as many opinions, facts and ideas as possible from those around you.

What to avoid

A business plan should include lots of information but there are a few things that should be avoided. You should put some restrictions on the long-term (over 1 year) predictions of your finances. A long-range prediction on the amount of money you will have coming into the business can be completely meaningless because it is very hard to predict how a business will perform far into the future.

Very few business plans get the figures projected spot on, so remember to give a good indication of what you expect to earn but try to be conservative with this. By exaggerating the earning potential of the company you will not be impressing anyone and this will make it difficult for you to plan your spending. Outline clear time frames and indicate your aims during these periods. Try to show what you will be working on at any time, for example if your business will take quite a lot of setting up then the first 6 months may be devoted solely to this and you should outline this in your plans and projections. Try to correctly anticipate the money and time that will be required for processes to be completed and always factor in a margin of error. By slightly exaggerating the money that will be required when completing a stage of expansion or setting more time than is needed, you will be well prepared if some unforeseen issue crops up.

Don’t just use the business plan to explain how great your product or service is. This alone will not turn your business into a big success (although it is very important). Identifying areas to improve and how you will market your company is much more important than simply relying on the uniqueness of your product.

The purpose of a business plan

The purpose of a business plan

Business plans are used for a variety of different reasons and the importance of these should not be underestimated. Creating a plan that is precise and includes information that is relevant to the new or existing business will ensure that ideas are implemented quickly. Without a solid business plan it will be much more difficult to judge the success of the new venture and the direction of the company will be hard for everyone to see.

Minimising risk

The risks when starting a new business can be huge. Money is invested into new businesses and time will also be spent on getting a company off the ground. Without a business plan in place, owners and employees could end up wasting their time in certain areas. Using resources inefficiently and having no clear direction for a business can lead to disaster very quickly. The best way to avoid this is with a clear outline of what the business needs to work on and what resources will be needed in order to make the venture work. A business plan will be used to set goals and objectives while losing no time in areas that do not see a large enough return on the investment.

Securing finance

Many people use business plans to secure finance for a new venture. This finance can come from several different sources such as banks, investors and start-up funds. Having a business plan that shows exactly how the business will operate and where money will be made will act as a way to convince potential investors to finance the company. With clear profits to be made and a route to market mapped clearly, investing in a business will be a much more desirable prospect for a potential investor.

Formats of business plans

There are many different formats which a business plan can be created in but the main areas to cover are:

Executive summary

Company summary, products and services, market analysis, strategy and implementation, management and personnel, financial plan.

Any business plan should include an executive summary which gives an outline of the business and the vision of the owners. Here you should briefly explain the business and its activities as well as the key areas that will help the company to succeed. A mission statement can be included to explain why your company will be unique in the market and what will give you the edge over your competitors.

You should also include some information about the financial aspirations of the company here to show the economic aims over the first few years in operation. Remember, these do not need to be hugely accurate and taking a realistic look at what can be earned is essential. It is usually best to complete the executive summary of the company last as you can include information from other sections in this part of the plan to give a good overview and concise insight into the business and your plans.

The company summary will explain key aspects of the operation of the company. This includes the owners of the business as well as where the business is located. Information about all directors must be included in this area of the plan and you should summarise their roles within the organisation. If you have any other personnel that will be involved at a senior level then they should be included also. In this part of the business plan you need to outline the funds required to set up and maintain the business also. By including information about the company’s location and operations you will be able to forecast the money required to get the company started and any investment that will be needed. Try to include a spreadsheet showing where the initial funding will come from and how much is being put into the business to start with. Remember, most new businesses make a loss in their first year due to the expenses involved in starting a new company, so be realistic. Plan the initial outlays and costs carefully and make sure you know the limits to how much you can put into the company to get started.

The location of the business can also be included here and any rent that you will be required to pay can be outlined and the costs per square foot for the company premises. Then you can go on to make projections about the sales required to cover all of your fixed costs such as office and equipment rentals.

Next we move on to explaining the things which will earn your business money – the goods and services that you have to offer. In this section you must include descriptions of what you can offer your customers and the prices you will be charging. Outline what makes your goods and services special and the key aspects that will influence potential clients and convert them into paying customers. It is also a good idea to compare your pricing structure to your competitors. It may be that you offer the same products but cheaper, or with any additional features to make your products more appealing. You should explore the need for your products and services to be better than any of the competition. As a new business you may struggle to compete unless you have something that nobody else has. By bringing to the market something which is already selling well with another company that has established its brand in the marketplace, you might struggle to take a large enough section of the market to warrant starting a whole new company. If this is the case then you must compare your pricing to your biggest competitors and ensure that you are competitive.

In this section you can also include any products and services that you may offer in the future. Explain your product development processes and how you will be able to innovate and bring new products or services to the marketplace.

Next you need to carry out some market analysis to identify your potential customers . In this section of the business plan you need to include information about your ideal customers and what sort of people they will be. Think about the earnings of your potential clients, the type of lifestyles they will live and the products and services they expect from a business. This part of your plan is great for you to use figures about your market and show any growth projections for the sector in the future.

Explain market trends and analyse the need for your goods/services in this sector. Attempt to find some facts about the disposable income of your potential customers and target certain people who will be interested in what your company offers. Think about how you will be attracting your customers and the potential for growth over the first 3 years in operation. Make estimations about the number of people in the area where you will be offering your products and services to get a good idea of how many different potential clients you can attract. Having a good understanding of your target market will give you the tools to design marketing strategies and techniques to attract the maximum number of customers to your business.

Having outlined your market and explained who your products/services will attract, it is time to explain your techniques when doing this and show how you are going to market your company. Explain the key aspects of what you offer and the main selling points that should be tailored to suit the target clients that you have in mind. Products designed for the more affluent will need to be luxurious and have an exclusivity about them, whereas items that are for people with limited incomes will need to offer greater value for money. Try to understand a clear link between the market in which you will be operating, your potential clients and the main aspects of your business which you should focus on.

Ensuring that your business suits the needs of customers is essential to getting the most customers. For example, opening up a luxury spa in an area where there is high unemployment and typically lower incomes will encounter lots of issues as the potential customers (those within a 15-mile radius) will have no need for this service and may not be able to afford what you have to offer. You will need to come up with at least five ways of promoting your business that will appeal to your target market and attract clients. Remember all of the techniques and skills we discussed on marketing and try to link what you know about your potential clients to the advertising methods you will use.

Here you can also outline the potential sales forecasts and investments which you will make when promoting your goods and services. Come up with some realistic projections about the money to be spent on advertising and increasing awareness of your brand as well as any sales targets you may wish to set. Be conservative with your sales projections as it takes time for any business to get a good level of customers and building brand awareness does not happen overnight. Your sales in year 1 will normally be fairly low and you need to take this into account when projecting your income and the amount it will cost to set up your company.

The next thing to plan is the personnel involved in your business. This will include the owners and directors as well as any senior managers that are to be involved in the company. Explain the team structure and hierarchy of your new company and the number of employees you will be hiring. Knowing the team behind the company and their individual duties will let you outline the various skills that your team possesses and establish each person’s duties within the organisation.

Outlining the duties of each person and giving a brief job description is a good way for you to understand the team dynamic and responsibilities of each member. Most new companies make the mistake of hiring too soon, but with a clear plan of the business personnel that will be involved in your company you will be able to ensure each person is needed for the business to operate. Establishing a business will require you to be frugal in your approach and employing staff that are not needed can have a terrible impact on your profits and end up costing you tens of thousands of pounds a year.

Outline the wages of your employees and then come up with some totals for staffing costs that can be used when writing your executive summary.

Your financial plan will provide a clear breakdown of all the income and outgoings of the business that you expect. These will only be projected figures so will be likely to change in reality, but you should be able to predict fairly accurately using your knowledge of costs incurred and the pricing and potential customer base for your products/services.

Make projected figures for your fixed and variable costs as well as the profits you expect to earn from sales. This will then help you to create a break-even analysis for your company that will show the amount of money required to cover all of your outgoings. Remember that your first year will have fixed and variable costs as well as additional outgoings which come from setting up your company. You will also have a limited number of sales during the first 12 months as you build up your customer base, so the projected net profit for year 1 will be lower than any other year. Try to think about the most popular goods/services you offer and come up with an average sale price for your customers. This will then help you to identify the number of customers you need in your first year to break even.

Come up with some cash flow and profit and loss charts (look over our work in Unit 1.3 to help) to project how much money you can expect to see in the business each year. This will help you to come up with clear and concise predictions for how much money you will be making in your first three years.

Financial plan

Reformulating a business plan

If you do ever happen to make a slight error in judgement on your initial business plan this can always be altered and the plan changed as required. The chances of figures being completely correct in your first projections are very slim and there will be certain things that you miss or random payments to be made when setting up your business which you did not account for. This is the main reason why being conservative with your income projections and adding in a ‘safety net’ figure to your costings will help you to deal with these circumstances. Business plans should be flexible and are a working document, so chopping and changing them is fine. When doing this try to use what you already have to create a new plan for the next few years rather than just altering figures to make it look like you got the initial plan correct.

Business plans are working documents, so they should be altered and added to as time goes by to determine where your company is heading and how it will get there. Being understanding of the nature of business and the fact that you will not be able to predict certain outcomes will give you an edge and allow you to put in place certain measures to help if you ever do come up against any problems.

reformulating a business plan

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research paper on holy water

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Balinese Indigenous Knowledge about Water : A Way to Achieve Water Sustainability

For the Balinese, water is essential for their ritual-based culture. Water is an entity to complete Balinese everyday life, especially the spiritual aspects that need holy water for rituals. This study aims to analyze the influence of Balinese indigenous knowledge about groundwater management, membership of the indigenous organizations, perception of the catchment areas, and water resources alternatives to groundwater resource conservation amongst Balinese. To address this, a survey of a representative sample of 139 Balinese adults in SARBAGITA (Denpasar Regency, Badung Regency, Gianyar Regency, and Tabanan Regency) has been conducted. With logistic regression model, this study found that knowledge and method used in respondents' households when water is limited are the most significant factor that affects respondents' willingness to participate in sacred springs conservation program.

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In 6th century Italy, saints were said to perform an unusual number of water miracles. Paleoclimatological data from a stalagmite may reveal why.

PROSES PELAKSANAAN RITUAL KAKADIU BUKUNO KAMOKULANO LIWU PADA MASYARAKAT BOMBONAWULU DI KELURAHAN BOMBONAWULU KECAMATAN GU KABUPATEN BUTON TENGAH

Abstract: The purpose of this study is to study and describe the kakađiu βukuno kamokulano liwu ritual process in Bombonawulu community, Gu District, Buton Tengah Regency. The study uses qualitative methods by presenting them in the formof descriptions. The location of this research is in Bombonawulu Village, Gu District,Central Buton Regency. Data collection with interviews, observations and documentation. This study, the authors used qualitative data analysis techniques. The results of this study indicate that the process of carrying out the kakađiu βukunokamokulano liwu ritual consists of five stages, namely: (1) the preparatory stage includes the preparation of the complete kakađiu βukuno kamokulano liwu ritual as well as checking the completeness of the ritual at the Daduwali Palace; (2) the steps to the βukuno kamokulano liwu burial place, including: the procession of ritual executives, starting with the black flag bearer, the ritual executor and the group of men, then the group of women and white flag bearers, (3) stages in the dwelling place, including: doing worship, cleaning themselves, climbing the cliff, worshiping again and continuing to open the cover that wraps the βukuno kamokulano liwu frame and (4) the bathing stage, includes: scraping the frame with coconut milk, then smearing it with coconut oil and water the bones with holy water ngkolaki, (5) haroa stage, including: reading congratulations and eating together.Keywords:  Implementation,  Ritual, Kakadiu, Bukuno, Kamokulano,Liwu

Case Report: A rare cause of vaginal bleeding at Keren Zonal Referral Hospital, Eritrea

Vaginal bleeding due to leech infestation is a very uncommon but important gynaecological problem. This report presents the case of a 65-year-old woman who presented to Keren Regional Referral Hospital, Eritrea, with vaginal bleeding of two and half weeks duration, dizziness and fatigue. On the day of her admission complete blood count and speculum exam were done and she was diagnosed with anaemia due to cervical leech infestation. Routine speculum exam for vaginal bleeding is recommended in cases with history of holy water or springs visits to prevent unnecessary diagnostic tests and for rapid management.

Seasonal Variations of Lead and Chromium Concentrations in the Water Samples From Yamuna River in Delhi, India

Background: According to Hindu mythology, Yamuna River plays an impotent role as a holy water resource in Delhi, India. The lead and chromium concentrations were determined from the water samples collected from five different locations around this river in Delhi area. The contaminated water from this river is mostly used for drinking, agriculture, aquaculture, and storage as a holy water. Methods: The seasonal variations of heavy metal concentrations in the water samples collected from Yamuna river were determined for the summer, monsoon and winter supplies, using Inductively Coupled Plasma Mass Spectrometry (ICP-MS) and Atomic Absorption Spectroscopy (AAS). Results: In the summer water samples, we found greater concentrations of both heavy metals than those for the monsoon season. The concentrations of lead and chromium in the water samples were higher than the permissible limits recommended by the World Health Organization (WHO). The water quality was not safe for drinking, cleaning and agriculture, nor for the aquatic animals, such as fish, amphibians and others. Conclusion: The condition of the water in Yamuna river is of great health concerns. Therefore, it is vital to take necessary actions to decontaminate the water from this river, and to draw effective strategies to minimize or prevent the current and future contaminations added to this important water resource in India.

Two Holy Water Stoups Made from ‘Lepidolite’

Tirta amerta sari: syukuran and slametan for holy water, export citation format, share document.

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INTRODUCTION

Materials and methods, results and discussion, concluding remarks, acknowledgements, authors' contributions, data availability statement, conflict of interest, study of holy water consumed to treat gastrointestinal ailments in gold deposit areas of may-hibey, northwestern tigray, ethiopia.

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Goitom Gebreyohannes Berhe , Desta Berhe Sbhatu , Abraha Gebremariam; Study of holy water consumed to treat gastrointestinal ailments in gold deposit areas of May-Hibey, Northwestern Tigray, Ethiopia. H2Open Journal 1 September 2023; 6 (3): 403–413. doi: https://doi.org/10.2166/h2oj.2023.165

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In Ethiopia, holy water is used to treat various ailments. This study examined the safety of holy water in May-Hibey, NW Tigray, Ethiopia consumed to treat gastrointestinal ailments. Sensory observation, compositional and elemental analyses of rock samples, and analyses of physicochemical properties and inorganic constituents of holy water samples were conducted. Sensory observation revealed that the water had a musty taste and rotten egg-like odor. Its consumption in drinking rituals caused instant vomiting and loose bowels. Geological studies of rock samples via X-ray diffraction revealed Si (62.456%), Fe (15.441%), and S (7.912%) as major elements. Physicochemical analyses of the holy water samples showed that temperature, electrical conductivity, total dissolved solids, pH, total alkalinity, total hardness, and concentrations of calcium, magnesium, iron, and sulfate were above the permissible limits of the World Health Organization and the Ethiopian Standards Agency. These imply that holy water is unsafe and may cause health complications. Patients believe instant vomiting and diarrhea after drinking rituals are parts of the treatment process. But such effects might be due to the high sulfate content and other chemical properties of the holy water. Studies for establishing the physiological effects of holy water on patients with gastrointestinal ailments are required.

Physical observation of the holy water consumed for treatment rituals was suspected of harmful characteristics.

Study of its physicochemical characteristics and rock samples of the area showed high sulfur content with many drinking water parameters outside the permissible limits of the WHO and ESA.

This preliminary scientific study recommends that drinking rituals for extended duration are avoided.

Nearly 80% of the people in the developing world depend on traditional medicine for their healthcare needs due to its low cost, high efficacy, and accessibility ( Bodeker et al. 1997 ; WHO [World Health Organization] 2002 ). According to the World Health Organization (WHO), about 40–60% of the populace attending traditional medicine and healing have mental health illnesses ( WHO 2002 ; Baheretibeb et al. 2021 ). As is true for the developing world, four-fifths of the Ethiopian population is still dependent on traditional medicine ( Abebe & Hagos 1991 ). The Ethiopian traditional healthcare system mainly depends on the use of medicinal plants ( Abebe & Ayehu 1993 ; Osman et al. 2020 ). Holy water treatment is also a major part of the Ethiopian traditional healthcare system, especially among the Ethiopian Orthodox Christian community ( Teshome-Bahire 2000 ; Hannig 2013 ; Baheretibeb et al. 2021 ). Many mental health problems and medical mysteries that challenge modern knowledge of biomedicine and the medical community are often referred to as holy water (holy spring) treatment by traditional healers and Orthodox Christian priests regardless of the patients' religious affiliations.

Holy waters (holy springs) are naturally available in many forms, such as waterfalls, small streams, small reservoirs, and narrow pits. Treatment rituals are carried out in the holy water sites by getting hit by the holy waterfall on the head and shoulder, bathing or wetting oneself with the holy water, getting splashed on the face by the holy water by a priest, immersing oneself in a reservoir or pit of holy water, drinking the holy water, and a combination of these rituals. Holy water is believed to embody the spirit of Christ in its healing power and is often used to aid in exorcising demons and evil spirits ( Teshome-Bahire 2000 ; Hannig 2013 ). Thus, drinking is a rare treatment ritual. It is also believed that holy water loses its healing power if it is taken out of the holy spring site. The treatment rituals are carried out one to three times a day; often in the morning, early afternoon, and in the evening. The rituals can go for consecutive 3, 7, 14, or 21 days. Sometimes, patients may resist carrying out any of the treatment rituals by themselves. Relatives and attendants are involved in assisting or forcing them to carry out the rituals ( Baheretibeb et al. 2021 ). We, the authors of this article, have carried out the treatment rituals many times in our lifetimes and witnessed many patients cured by holy water treatment.

The spring water in May-Hibey is one of the holy waters (springs) in Tigray, Ethiopia. It is collected in three rocky, shallow reservoirs (ponds) along its 1.5 km stream. The holy water site is visited by hundreds and sometimes thousands patients with various ailments each year. Treatment rituals in this site are immersing in, and drinking of the holy water. The May-Hibey area is known for its gold deposits ( Giday & Konka 2017 ). Causal sensory observation also indicated that the area may have a high level of sulfur. The beds (floors) and the rims of the stream and the holy water reservoirs as well as the rock surfaces of the area are covered by yellowish coats. The air of the holy water site has also an unpleasant odor, characteristic of rotten eggs. Moreover, patients with gastrointestinal ailments drinking holy water lose their gastrointestinal contents instantly by vomiting and loose bowels (diarrhea). The yellowish rock surfaces of the area, the rotten egg-like odor of the air, and the instant vomiting and diarrhea effects of the holy water on the patients obliged us to suspect the presence of high sulfur levels in the holy water that can cause other health complications. Hence, the present study aimed to describe the characteristics of holy water samples collected from holy water reservoirs and to establish their safety for the drinking rituals. The findings of this preliminary exercise will serve as a stepping-stone for future large-scale research and development and for devising practical measures in regard to this public health concern.

The study area

The study area is located in the Northwestern Zone of Tigray Regional State, Ethiopia, which is around 294 km northwest of Mekelle city, capital of Tigray. It is nearly 9 km 2 , lies between 1,545,650 and 1,548,750 m N and between 387,130 and 390,000 m E. It is accessible by asphalt road from Mekelle via Enda-Selasse to Enda'abaguna and by all-weather gravel road from Enda'abaguna via Meli to the study area at May-Hibey ( Giday & Konka 2017 ).

The study area is characterized by moderately rugged topography with elevations ranging from 1,002 to 1,302 m and a dendritic drainage pattern. The mainstream of the study area, called May-Tsekente, flows from northwest to southeast.

The May-Hibey area forms the Neoproterozoic stratigraphy of northern Ethiopia. It comprises metavolcanic, metavolcaniclastic, metasediment, and intrusive syn-tectonic granites. The rocks are intruded by younger aplitic, mafic dykes, and quartz veins. Gold mineralization is interpreted as syn-orogenic lode gold type. As a gold deposit region, the area is characterized by deposits of metal sulfides ( Giday & Konka 2017 ).

Human activities

May-Hibey is home to a sparsely populated farming community that depends on crop cultivation and animal rearing ( Giday & Konka 2017 ). The study area is also a traditional gold mining site that attracts several dozen miners from near and distant places. Moreover, May-Hibey is a site of a holy spring (holy water) that attracts several hundred patients seeking holy water treatment and healing.

May-Hibey is a semi-arid to arid area and sparsely vegetated with thorny bushes. Its daily temperature ranges from 28 to 32 °C. Much of the land is punctured by gold mining pits. The soil is highly eroded. Nowadays, the stream dries up quickly after the end of the rainy season. The vegetation is exploited for fuel by the natives, miners, and patients.

Spring water trickles from the foot of the mountain and flows downstream for about 1.5 km. The water is regarded as ‘holy’ by the community and Ethiopian Orthodox Christian priests of the area. Hence, three simple, rocky reservoirs are constructed along the stream, which are around 500 m apart from each other. The reservoirs hold the holy water to be used for treatment and healing via drinking and immersing (wetting). The floors and walls of the reservoirs are covered by yellowish, rocky coats. Each reservoir is enclosed by curtains tied to simple, makeshift stands or trees. Patients take some water from the reservoirs and carry it to the banks of the stream to perform the wetting (rinsing) and drinking rituals.

Collection of samples

The study assessed the physicochemical characteristics of the holy water and rock samples collected from the floors of the holy water reservoirs, which are regarded as sampling sites.

Three holy water samples were collected in triplicate from each of the three reservoirs. Sample collection, preparation, handling, and analyses were carried out as per established methods on the topic ( Gebresilasie et al. 2021 ). The samples were labeled, preserved in an icebox at 4–10 °C, and shipped to the geochemical laboratory in the College of Natural and Computational Sciences (Mekelle University) and the analytical laboratory of Ezana Mining Share Company, Mekelle, Ethiopia, for analyses.

Rock samples

Rock samples were also collected from the floors of the three holy water reservoirs in triplicate and were packed in a dry paper box. The samples were shipped to the analytical chemistry laboratory of the College of Natural and Computational Sciences (Mekelle University) and spread on the laboratory bench for 1 week to dry up completely. Then 300 g of rock sample was crushed and ground in a disc mill to <74 μm diameter size in the analytical laboratory of Ezana Mining Share Company. The ground sample was packed in 100 g sample holder boxes for further study.

Qualitative observation

Ethical clearance.

The proposal for this study was reviewed and approved by the Ethical Review Committee of the Department of Chemistry, College of Natural and Computational Sciences, Mekelle University. Therefore, an on-site qualitative study was carried out by the first author using non-participant observation and organoleptic methods ( Liu & Maitlis 2010 ; Boskou 2015 ).

Non-participant observation

The author stayed in the holy water site for 1 day (from 6:00 AM to 6:00 PM) to observe the population of patients, their treatment rituals and reactions, and collect some qualitative data ( Liu & Maitlis 2010 ). He also carried out causal discussions with some patients who performed each of the treatment rituals and recorded their stories.

Organoleptic studies

This study was carried out by a panel of 20 volunteering patients who were carrying out the holy water drinking rituals ( Boskou 2015 ). All of them were adult males belonging to the Ethiopian Orthodox Christian community. After signing the informed consent document, each of them responded to a questionnaire on the taste and odor of the holy water. The responses of the panel of volunteers were used in establishing the organoleptic properties of the holy water.

Laboratory studies of samples

Compositional and elemental analyses of rock samples.

Compositional analyses of the processed rock samples were conducted via energy-dispersive X-ray fluorescence (EDXRF 2800) and flame atomic absorption spectroscopy (FAAS) in the laboratories of the Ethiopian Ministry of Mines (Addis Ababa, Ethiopia) and Ezana Mining Share Company (Mekelle, Ethiopia), respectively. Crystallinity of each rock sample was determined using X-ray diffraction (XRD) at Adama Science and Technology University (Oromia, Ethiopia). The XRD output was subjected to pattern processing and identification using Jade 6 software (MD, USA) and plotted using Origin 8.0 software (OriginLab Corp., USA).

Analyses of physicochemical properties and inorganic constituents of holy water samples

Holy water samples were analyzed for physicochemical properties and contents of inorganic elements and ions, namely, temperature, pH, turbidity, dissolved oxygen (DO), electrical conductivity (EC), total dissolved solids (TDS), total alkalinity (TA), total Ca, and Mg hardness, Ca, Mg, Na, K, chloride, sulfate, phosphate, and nitrate ions as well as heavy metals using standard analytical methods ( ESA [Ethiopian Standards Agency] 2013 ; Gebresilasie et al. 2021 ). pH was measured using a pH meter (HI-99130, Italy). EC was measured using a conductivity meter (JENWAY, Multi-3410, UK). Turbidity was measured by turbidimeter (AL 250T-IR, Germany). Temperature was measured on-site using a mercury thermometer. DO was determined using a multi-parameter (Multi-3410, Germany). TA was determined by the titrimetric method. The total, Ca, and Mg hardness were determined using the ethylenediaminetetraacetic acid (EDTA) titrimetric method. Chloride concentration was analyzed using argentometric titration. The concentrations of K and Na ions were determined using flame photometry (JENWAY, PFP7, UK). Likewise, the concentrations of sulfate, phosphate, and nitrate ions were measured through UV–visible spectrophotometer (Lambda, CE1021, Australia). Finally, concentrations of heavy metals were determined by FAAS (AA240FC, Australia).

Analyses and presentation of data

Collected data were analyzed using descriptive and inferential statistical methods with the help of SPSS (Version 20) software. Descriptive data obtained from EDXRF and FAAS were presented in percentages and mg/L. Inferential data on the physicochemical properties and concentrations of inorganic constituents of the holy water samples were analyzed using a t -test and presented in mean (±standard deviation) values. Finally, the mean (±SD) values were compared against the permissible limit set for drinking water by the ESA (2013) and the WHO (2010) .

Physical observation

According to the Ethiopian Christian Orthodox faith, many springs in the country, especially in Tigray, are regarded as holy. Members of the Ethiopian Christian Orthodox faith believe that bathing in and drinking holy waters (holy springs) cures patients of various physical and mental ailments ( Baheretibeb et al. 2021 ). Patients suffering from gastrointestinal ailments are advised by traditional healers and Orthodox Christian priests to drink the holy water for three or more days to get cured. Drinking holy water may make patients lose their gastrointestinal contents through instant vomiting and loose bowels (diarrhea). In the present study, patients who were carrying out the holy water drinking rituals affirmed that they were doing it to be cured of gastrointestinal ailments as per advice they received from priests and traditional healers. The first author observed many patients vomiting instantly after drinking the holy water. Many of them attested that their gastrointestinal discomforts were gone and they felt that they were cured. Instant diarrhea may be attributed to the laxative properties of the holy water ( Skipton et al. 2010 ). Studies with humans and experimental animals reported that the consumption of water containing higher amounts of sulfate for a few days to a few weeks did not cause any adverse effects except diarrhea or cathartic effects (e.g., Paterson et al. 1979 ; Gomez et al. 1995 ).

Organoleptic properties

All (100%) members of the panel of participants attested to the musty or swampy taste and rotten egg-like odor of the holy water samples. Sulfates occur naturally as part of many minerals, including iron pyrite (FeS), barite (BaSO 4 ), epsomite (MgSO 4 ·7H 2 O), and gypsum (CaSO 4 ·2H 2 O) ( Greenwood & Earnshaw 1984 ). These sulfate-containing minerals release some of their contents to water bodies including drinking water ( WHO 2004 ). Likewise, gold sulfide ores, which contain metal sulfides, can release hydrogen sulfide (H 2 S) into water bodies. In addition to the swampy taste and rotten egg-like odor of the holy water samples, the rocks on the beds and walls of the holy water reservoirs were yellowish. These indicate the presence of H 2 S in the holy water. H 2 S is easily detectable in water at concentrations as low as 0.5 mg/L. The U.S. EPA (United States Environmental Protection Agency) regarded sulfur at 250 mg/L concentration as a secondary water contaminant with no direct threat to human health at concentrations below 600 mg/L ( U.S. EPA [U.S. Environmental Protection Agency] 2003 ). Similarly, the WHO has established that less than 1.0 mg/L H 2 S gives water a musty (swampy) odor and 1.0–2.0 mg/L concentration gives it a rotten egg-like smell ( WHO 2010 ). Sulfates can have laxative effects that may lead to dehydration; and the rotten egg-like tastes and the odor of H 2 S can cause nausea ( Skipton et al. 2010 ; ESA 2013 ), leading to vomiting.

Geochemical observation

Compositional analyses of concentrated rock samples using EDXRF (%wt) and FAAS (mg/L)

XRD patterns of gold sulfide ore of the deposit.

XRD patterns of gold sulfide ore of the deposit.

Physicochemical analyses

Temperature.

Physicochemical characteristics and concentrations of metallic and non-metallic ions and heavy metals of holy water samples of May-Hibey

Heavy metals such as Cu, Zn, Mn, Ca, Pb, Cr, and Au are used in standard analytical methods.

NTUs, Nephelometric Turbidity Units; UoM, unit of measurement; WHO, the World Health Organization; ESA, the Ethiopian Standard Agency; SD, standard deviation; BDL, below the detection limit.

Turbidity is the measure of water resistance to the passage of light. Suspended soil and sediment particles, carbon-based substances released from gold sulfide deposits, and aquatic microbes enhance turbidity. High water turbidity, in turn, increases the light absorption capacity of the water to raise its temperature ( Hawkins & Mann 2007 ; Gebresilasie et al. 2021 ). In the present study, the mean turbidity values of the holy water samples ranged from 2.19 (± 0.02) to 2.51 (± 0.03) NTUs ( Table 2 ). The values were less than the 5.00 NTUs limit set for drinking water by the WHO (2010) and ESA (2013) . This implies that turbidity was less likely to be the principal cause of the high temperature of the holy water samples.

Electrical conductivity

EC is the function of dissolved inorganic matter in ionized form. The mean EC of the holy water samples in the present study ranged from 1,121.00 (±0.11) to 1,292.00 (±0.22) μS/cm ( Table 2 ). The values fall between the permissible limit set for drinking water by the WHO (2010) (i.e., 750.00 μS/cm) and the ESA (2013) (i.e., 1,500.00 μS/cm). High EC is attributed to the presence of high amounts of dissolved ions ( Gebresilasie et al. 2021 ). The high amount of dissolved ions is characteristic of gold deposit areas. EC has direct relationships with sulfate ion concentration, TDS, total hardness (TH), total alkalinity, and concentrations of polymetallic ions.

Total dissolved solids

TDS is the measure of all solutes in water. The mean TDS of the holy water samples ranged from 1,123.21 (±0.70) to 1,281.21 (±0.12) mg/L. The mean values were much higher than the tolerable limits set for drinking water by the WHO (2010) (i.e., 500.00 mg/L) and the ESA (2013) (i.e., 1,000.00 mg/L) ( Table 2 ). Such high levels of TDS in the holy water reservoirs might be attributed to the accumulation of dissolved metallic ions as a result of the dissolution of weathered constituents from metallic sulfides ( Sonkar & Jama 2019 ) such as silicon sulfide (SiS 2 ), pyrite (FeS 2 ), and hematite syn (Fe 2 O 3 ). The unpleasant tastes and odors of the holy water samples, affirmed by the respondents of the organoleptic study, might also be due to the presence of various inorganic ions that increased the level of TDS ( John et al. 2014 ; Gebresilasie et al. 2021 ). Water with high TDS content can have laxative effects ( Kataria et al. 2011 ; Benit & Roslin 2015 ; Yasin et al. 2015 ; Aniyikaiye et al. 2019 ).

The mean pH values of the holy water samples ranged from 4.92 (±0.11) to 5.10 (±021). The mean values were much lower than the range (i.e., 6.50 − 8.50) set for drinking water by the WHO (2010) ) and the ESA (2013) ( Table 2 ). Such low pH values, which make the holy water acidic, are expected in water samples with high EC and TDS. The low pH and other attributes (high EC and TDS) render the water unsuitable for drinking. Long-term holy water drinking rituals from this source can also be harmful.

Dissolved oxygen

DO is a vital water quality parameter. It is an indicator of water contamination due to microbes and corrosive chemical constituents. A reduced amount of DO is an indication of microbial contamination or corrosion because of chemical substances in the aquifer (U.S. EPA 2003 ; Gebresilasie et al. 2021 ). The mean DO values of the holy water samples in the present study ranged between 5.60 ± 0.01 and 5.87 ± 0.01 mg/L. The values were within the WHO's (2010) range for drinking water (i.e., 5.00–7.00 mg/L) ( Table 2 ). The level of DO in natural waters is highly reduced because of high temperatures and high concentrations of inorganic ions as a result of a high rate of decomposition of metallic sulfides ( Ebenezer 2014 ). At low DO levels and pH values of less than 7, sulfur occurs as H 2 S ( Skipton et al. 2010 ; Gebresilasie et al. 2021 ). Thus, the low DO and pH mean values can be regarded as the contributing factors for the musty taste and rotten egg-like smell of the holy water.

Total hardness

TH of water is the measure of dissolved polyvalent metallic ions of calcium and magnesium ( Spanos et al. 2015 ). Water below 150 mg/L TH is considered soft, whereas water above 200 mg/L TH is considered hard. The mean TH of the holy water samples in the present study ranged from 375.30 (±3.00) to 385.20 (±3.00) mg/L ( Table 2 ). The values were above the maximum allowable limit of 300.00 mg/L for drinking water set by the WHO (2010) and the ESA (2013) . The higher hardness of the holy water might be due to the dissolution of gypsum- and dolomite-containing rocks ( Kassa 2015 ; Gebresilasie et al. 2021 ). The hardness may be permanent as chloride, sulfate, and nitrate salts were present.

Total alkalinity

TA is a measure of the ability of water to neutralize acids mainly because of its carbonate and bicarbonate contents ( Gebresilasie et al. 2021 ). The mean TA of the holy water samples ranged between 208.00 (±5.00) and 221.00 (±5.00) mg/L ( Table 2 ). The mean values were above the allowable limit of the WHO (2010) (i.e., 120.00 mg/L) but within the allowable limit of the ESA (2013) (i.e., 200.00 mg/L) for drinking water. This is directly related to the TH of the holy water. The alkalinity of natural waters is the result of the dissolution of carbonate, bicarbonate, borate, silicate, and phosphate salts, and free hydroxyl ions ( Woldeamanuale 2017 ). Hence, TA is the function of calcium, magnesium, sodium, potassium, chloride, and sulfate ions ( Gebresilasie et al. 2021 ). However, the yellowish color of the rocky beds (floors) of the holy water reservoirs and the characteristic taste and odor of the holy water samples imply the presence of high amounts of metallic sulfides and low amounts of carbonates.

Analyses of inorganic ions and heavy metals

Calcium ion (Ca 2+ ) is one of the major components of various rock types. It is, thus, the most common constituent of natural waters ranging from zero to several hundred mg/L ( Ndamitso et al. 2013 ). The mean Ca ion contents of the holy water samples ranged from 85.11 (±0.13) to 92.11 (±0.12) mg/L. These values were within the acceptable limit set by the WHO (2010) (100.00 mg/L), but above the value set by the ESA (2013) (75.00 mg/L) for drinking water ( Table 2 ). Ca ion reaches groundwater by the natural dissolution of carbonate and decomposition of sulfate, phosphate, and silicate minerals and forms solid scaling on the floors or beds of water bodies ( Mensah 2011 ). Groundwater from gold deposit areas is often hard due to high Ca ion concentration ( Kassa 2015 ; Gebresilasie et al. 2021 ).

Magnesium ion (Mg 2+ ) is another major component of many rock types. It is the most common constituent in natural waters ( Ndamitso et al. 2013 ). The mean Mg ion contents of the holy water samples were 53.11 (±0.34) to 62.12 (±0.11) mg/L. They were above the permissible limits of the WHO (2010) and ESA (2013) (50.00 mg/L) set for drinking water ( Table 2 ). The main sources of Mg ions for underground waters in gold deposit areas are geological constituents such as dolomite and Mg-containing compounds ( Rahmanian et al. 2015 ).

The mean Na ion (Na + ) concentrations of the holy water samples were between 92.15 (±0.11) and 112.11 (±0.32) mg/L ( Table 2 ). These values are about halfway below the permissible limits established for drinking water by both the WHO (2010) and the ESA (2013) at 200.00 mg/L. When Mg and Na are combined with sulfate, they can have pronounced laxative effects ( Benit & Roslin 2015 ).

The mean K ion (K + ) concentrations of the holy water samples were between 8.23 (±0.14) and 9.62 (±0.82) mg/L ( Table 2 ). These mean values are slightly less than the upper allowable limit set for drinking water by the WHO (2010) (i.e., 10.00 mg/L) and nearly halfway less than the limit set by the ESA (2013) (i.e., 15.00 mg/L).

The mean Cl ion (Cl − ) contents of the holy water samples ranged from 67.11 (±0.02) to 81.02 (±0.22) mg/L. They fall within the permissible limit set by the WHO (2010) and the ESA (2013) for drinking water at 250.00 mg/L ( Table 2 ). The variations in Cl ion contents among the holy water samples might be because of variations in chloride salts in the gold deposits and sediments ( Gebresilasie et al. 2021 ).

Sulfur is found in most groundwater bodies in different forms such as sulfate, bisulfide, and hydrogen sulfide depending on the amount of DO in the water and the degree of acidity (i.e., pH) of the water. If the DO level of the water is 1.00 − 2.00 mg/L, sulfur occurs as sulfate (S 6+ ) and sulfate molecules predominate. On the other hand, if the DO level is lower, it occurs as S 2− or HS −1 at pH > 7 and as H 2 S at pH < 7 ( John et al. 2014 ). In the present study, the mean sulfate ion (SO 4 ) −2 contents of the holy water samples ranged from 412.00 (±0.23) to 452.11 (±0.29) mg/L. The values were much higher than the permissible limit set for drinking water by the WHO (2010) and the ESA (2013) at 250.00 mg/L ( Table 2 ). The levels of sulfate in groundwater in many places are often less than 250 mg/L ( UNEP [United Nations Environmental Programme] 1990 ; U.S. EPA 1999 ). The high sulfate levels might come from sulfate-containing minerals such as iron and gold sulfides ( U.S. EPA 1999 ; Kataria et al. 2011 ; Obasi & Talabi 2015 ). They are collectively known as pyrite ores. Sulfate contents of spring waters are correlated to Ca, Mg, Na, and K ion contents. These constituents can lead to diarrhea, dehydration, and weight loss ( U.S. EPA 2003 ; WHO 2004 ; Kataria et al. 2011 ; Benit & Roslin 2015 ).

The concentrations of phosphate ion (PO 4 −2 ) in all the holy water samples ranged from 0.18 (±0.12) to 0.23 (±0.12) mg/L. The values were far lower than the permissible limit set for drinking water by the WHO (2010) and the ESA (2013) at 2.00 mg/L ( Table 2 ). The low concentration of the phosphate ion in the holy water samples is characteristic of gold deposit areas ( Obasi & Talabi 2015 ; Gebresilasie et al. 2021 ).

The mean nitrate ion (NO 3 −1 ) concentrations in the holy water samples were between 11.86 (±26) and 15.43 (±0.63) mg/L ( Table 2 ). These values were three to five times lower than the permissible limit set by the WHO (2010) at 45.00 mg/L and the ESA (2013) at 50.00 mg/L for drinking water.

Iron and other heavy metals

As naturally occurring constituents and synthetic pollutants, heavy metals are critical environmental and public health concerns ( Pazalja et al. 2021 ; Rasheed et al. 2022 ). In the present study, iron was the only heavy metal detected in the holy water samples with concentrations ranging from 24.16 (±0.11) to 28.11 (±0.23) mg/L ( Table 2 ). The values were about 80–95 times more than the permissible limit (i.e., 0.30 mg/L) set by the WHO (2010) and the ESA (2013) for drinking water. The higher amount of iron in the holy water could have come from the iron pyrite ore of the deposits. People consuming water containing high iron concentrations suffer from liver diseases ( Eruola et al. 2011 ; Ocheri et al. 2014 ). The concentrations of the other heavy metals, namely, copper, zinc, manganese, cadmium, lead, chromium, and gold, were below the permissible limit set by both organizations.

The yellowish rock surfaces and the beds (floors) of the holy water reservoirs and streams, the repulsive rotten egg-like odor of the air of the area, the musty (swampy) to rotten egg-like taste of the holy water, and the vomiting and loose bowel effects of the holy water on the patients need a plausible scientific explanation. The qualitative and quantitative examination of the geochemistry of the rock samples showed high levels of Si, Fe, S, and Au. Quantitative analyses of the physicochemical characteristics of the holy water samples showed high temperature, EC, TDS, TA, and TH and low pH as compared to the allowable limit set for drinking water by the WHO (2010) and the ESA (2013) . Moreover, qualitative and quantitative studies of the inorganic ions of the holy water samples showed high levels of sulfate, calcium, magnesium, and iron ions.

At present, the plausible scientific explanation for the vomiting and loose bowel effects of the holy water is the presence of a high level of sulfur compounded by other physicochemical conditions such as high temperature, high EC, high TDS, low pH, high total alkalinity, and high total hardness as well as high concentrations of calcium, magnesium, and iron ions. Studies on the effects of sulfates on human health conducted between the 1970s and early 2000s ( WHO 2004 ) showed that sulfate concentration as high as 1,500 mg/L has no serious effects except catharsis, diarrhea, and some dehydration ( UNEP 1990 ; Esteban et al. 1997 ; U.S. EPA 1999 ). This implies that the vomiting and loose bowel reactions among the patients may not be linked to the healing effects of the holy water per se . Hence, patients carrying out drinking rituals have to concurrently seek medical attention. Moreover, the patients should be advised to avoid holy water drinking rituals for an extended time. Exploring the effects of the holy water on the physiology of the patients as well as against known gastrointestinal parasites and the normal human gut microbial flora may yield better empirical evidence on the effects of the holy water on gastrointestinal ailments.

The authors are highly indebted to Mekelle University, Mekelle, Ethiopia for funding this study. They are also thankful to the managers of laboratories of Mekelle and Adama Science and Technology universities, the Ethiopian Ministry of Mines, and Ezana Mining Share Company for letting us conduct the analyses.

G.G.B., D.B.S., and A.G. conceived the problem of the study. Both authors prepared research proposals and developed the design of the experiments. G.G.B. prepared the first draft of the manuscript and D.B.S. and A.G. reviewed it. D.B.S. edited and produced the submitted manuscript.

This study was supported by Mekelle University through Grant No. CRPO/MU/CNCS/Rec/Medium/13/2019-2021.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.

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  • v.7(3); 2021 May

Holy water and biomedicine: a descriptive study of active collaboration between religious traditional healers and biomedical psychiatry in Ethiopia

Yonas baheretibeb.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia

Dawit Wondimagegn

Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada

Associated Data

For supplementary material accompanying this paper visit http://dx.doi.org/10.1192/bjo.2021.56.

The data that support the findings of this study are available from the corresponding author, Y.B., upon reasonable request.

Religious and traditional healers remain the main providers of mental healthcare in much of Africa. Collaboration between biomedical and traditional treatment modalities is an underutilised approach, with potential to scale up mental healthcare.

To report the process and feasibility of establishing a collaboration between religious healers and psychiatrists in Addis Ababa, Ethiopia. To gain insight into the collaboration through studies of patient demographics, help-seeking patterns, nature of illness and receptivity of the project.

This case study describes the process and challenges in establishing a collaborative psychiatric clinic for patients who are simultaneously receiving treatment with holy water, including an examination of basic clinical records of 1888 patients over a 7-year period.

The collaboration is feasible and has been successfully implemented for 8 years. A majority (54%) of the clinic's patients were seeing biomedical services for the first time. Patients were brought in largely by families (54%); 26% were referred directly by priest healers. Most patients had severe mental illness, including schizophrenia (40%), substance misuse (24%) and mood disorders (30%). A vast majority (92.2%) of patients reported comfort in receiving treatment with holy water and prayers simultaneously with medication, and 73.6% believed their illness was caused by evil spirit possession.

Conclusions

A cross-system collaborative model is a feasible and potentially valuable model to address biomedical resource limitations. Provider collaboration and mutual learning are ultimately beneficial to patients with severe mental illness. Open-minded acceptance of cultural benefits and strengths of traditional healing is a prerequisite. Further study on outcomes and implementation are warranted.

The World Health Organization (WHO) estimates that >80% of the population in Africa attend traditional healers for healthcare, and 40–60% of these are for mental illnesses. 1 The high reliance on traditional healers, especially in the rural, low-resource settings that dominate the mostly low- and middle-income countries (LMICs) of Africa, make traditional healers the de facto backbone of the mental healthcare system. 2 – 4 In Ethiopia, an LMIC country of >110 million, 5 the most common mental illness treatment involves holy water, an Orthodox Christian approach believed to embody the spirit of Christ in its healing power. 6 Holy water is used by people of Orthodox Christian faith (43.5% of the population) 7 and the general population at large, 8 as there is a largely shared cultural, cross-religious belief (i.e. illness explanatory model) that evil spirit possession is responsible for mental health issues, and holy water is used as an aid to exorcise such demons. 9 Studies have shown that the majority of Ethiopians prefer traditional and alternative healing methods such as holy water, to biomedical services for their major illnesses, and particularly for mental compared with physical illnesses; 10 , 11 up to 98% of first encounters in mental health help-seeking are with traditional practitioners, such as holy water healers. 12

Like much of Africa, Ethiopia has a limited biomedical mental health infrastructure. The number of psychiatrists, for example, is at 0.08 per 100 000 people, far below those in middle-income countries like China (2.2), or high-income countries like Canada (14.7). 13 For schizophrenia, the treatment gap for those who could have benefitted from biomedical treatment, but never received any, was 90%. 14 For those who did eventually receive psychiatric care, the average ‘delay’ in help-seeking was around 38 weeks. 15 Nevertheless, efforts to scale up mental health services in LMICs have shown some modest success. Examples include utilising and strengthening existing community treatment resources, such as rehabilitation programmes; using non-specialists to optimise basic care and case identification; task-shifting or task-sharing to expand front-line mental healthcare capacity; psychoeducation of families and advocating for prioritisation and funding. 16 – 20 However, these solutions tend to be focused on the biomedical side alone, ignoring the other, parallel and often more popular and culturally accepted side of traditional healers. Another possible innovation for scaling up biomedical care may be collaboration between the two modalities. 21 Yet, although many have advocated for this, examples of actual collaborations are rare. One study in Nigeria showed that providing traditional healers with basic training led to traditional healers recognising more symptoms of major mental illnesses, better understanding the aetiological concepts of mental illness, reducing the habit of beating their patients as a form of treatment, and increasing their collaborative outlook. 22 More recent collaborative work with traditional healers in Kenya for patients with depression, 23 – 25 and mental health-related task expansion with traditional birth attendants, 26 have shown very positive and inspiring results, and have highlighted this important topic. 27 , 28 The current study reports on a now well-established collaboration in Addis Ababa, Ethiopia, and focuses on the process for initiating a successful collaboration. It uses patient data to show that this approach may create a new pathway to treatment, in which biomedical and traditional belief systems can cooperate.

Study design

This study describes the process that led to the creation of a collaborative clinic for patients receiving holy water treatment, and examines the available basic clinical records (including demographic, diagnosis and medication information) for patients who have attended this clinic over the past 8 years.

Creation of a collaborative clinic

Study setting.

Biomedical mental health practitioners from the Ethiopian Mental Health Society (EMHS, a non-governmental organisation) and the Department of Psychiatry at Addis Ababa University have worked in collaboration with traditional healers, including priests and patient attendants of St Michael's Church and St Mary's church (two closely located holy water treatment sites) in Addis Ababa, Ethiopia, for 8 years. The two holy water treatment sites form a community, with approximately 1000 patients; they reside in simple dwellings near the two churches. Both church sites have a natural supply of spring water that has been deemed holy through historically recorded healing miracles. At St Michael's, for example, the miracle involved a severely ill man, who appeared to suffer from a mood disorder, taking in the waters and recovering. Alongside spiritual cleansing through water, various forms of exorcism and religious-based counselling are also offered. The services are provided for free. Positive word of mouth, developed over years of working with people with mental stress, contributes to the enduring and strong cultural belief that treatment with holy water is useful.

Participant roles

The patients are individuals who are seeking or brought to the two sites for holy water treatment. They participate in regular (up to daily) treatments, often aided by their attendants. Rituals vary, and typically involve drinking, immersing or washing in the water. The water temperature can be cold for washing, especially for early morning rituals. Some of the patients appreciate treatment, but some resist and want to leave, and some refuse to carry out any of these rituals or even fight the priests. At times, treatment is involuntary and some patients are held in place by the attendants. In extreme cases, the patients are chained to their residence to prevent them escaping.

The Orthodox Christian priests performing holy water treatment are highly respected in Ethiopian society, a status achieved through the central position of the Church and their extensive studies of the bible, philosophy, music and the healing arts. They are inspired by St Paul, the apostle who was a physician, and believe that holy water is part of the sacrament, related to the fluids that flowed from the body of Christ when he was on the cross, symbolising purity and holding healing power. Their healing role is well-entrenched and almost never challenged (i.e. no government or public health policy would try to dissuade people from using holy water as treatment for any illness). The priests perform all holy water treatment-related activities, as well as chanting, blessing, praying and very light ceremonial smacking with a religious cloth, to symbolise exorcising of evil spirits. The priests involved in the project generally hold an open and accepting stance toward biomedicine, citing biblical teachings that unconditionally encourage people to seek help when ill.

Across Ethiopia, families provide the bulk of care for patients with mental illness, as there are no formal community mental health services. Families bring their ill members to holy water sites when they are overwhelmed; they find and pay attendants for services, and typically return to visit regularly; although for most, the residential treatment is a welcomed form of respite.

Attendants are personal care-takers, paid by the family, to look after the patients staying at holy water sites for the duration of their treatment. They negotiate housing and services for the families and patients, and provide multiple forms of care, including supervision of patients, accompanying patients during the holy water rituals, helping with prayers, and sometimes administering restraints for those involuntary patients at risk of escaping or for those patients who become violent. The attendants facilitate communication between the families, patients and priests.

The EMHS was established by families who have severely mentally ill family members. It provides support and advocates for those with similar struggles. As an Ethiopian community-based, non-governmental organisation sharing a common mission with the priests, the EMHS is a key partner of this project, facilitating communication and relationship-building between the priests and psychiatrists, and financing the bulk of medications.

Participating psychiatrists and residents are affiliated with the Department of Psychiatry at Addis Ababa University, which contributes staff time, some medications and academic guidance. The department is an academic and clinical leader in the region, with five affiliated teaching hospitals and a 3-year residency training programme with a capacity of 15 students per year.

Building mutual understanding and relationships via workshops

Initial meetings between the first author (Y.B.) and leaders of the two churches were facilitated by the EMHS and the headquarters of the Ethiopian Orthodox Church. As a first step, participants agreed to a series of five workshops and consultation rounds at each other's locations of practice. The first workshop was closely planned by the university faculty and the priests, and was hosted at the church, with invitations extended to all of the priests and attendants. About 100 people came, including 50 priests. It achieved the goal of introducing each group to the respective perspectives and understanding of mental illness in biomedical and traditional explanatory models. The atmosphere of the meeting was mutually respectful, participants shared lunch and established a working relationship. Booklets and education materials about severe mental illness written in Amharic, the national language, were shared.

The second consultative workshop took place at a nationally known teaching hospital, the Tukur Anbessa Specialist Hospital. The biomedical partners presented their scientific knowledge and treatment approaches in more detail. One of the highlights was a religious blessing conferred by an Orthodox Christian priest from the Church headquarters.

The remaining workshops focused on common clinical issues. The third looked at stigma, experienced as a common barrier for patients seeking help in both traditions. The highlight was acknowledging that, because holy water treatment was much more culturally accepted, it may be associated with lower stigma. The fourth workshop focused on abuses encountered by patients with mental ill health as part of their treatment and care, and the need for raising awareness of their struggles and an end to poor therapy practices. Both groups acknowledged challenges in managing involuntary patients who might be dangerous to themselves or others. Each group shared strategies that had been effective, and noted possible synergies. In the safe space of the workshop, some priests and attendants reflected that they regretted beating some patients out of frustration, and sought to change their practice; the psychiatrists also shared their versions of mistreatments in hospitals, and a wish to improve.

The fifth and final workshop allowed both parties to summarise their mutual learnings, and come to an agreement on a model for ongoing collaboration, in the form of a clinic in the holy water treatment community site. To promote the collaborative clinic, the project leads invited journalists to write stories of healing and to interview priests, attendants, psychiatrists and members of the EMHS for local radio shows and print media. Media coverage was positive for both general mental health awareness and the initiative.

Creating the clinic

The clinic was created close to the two churches that offered holy water treatment in 2012, with a mandate to welcome any patient seeking holy water treatment who was also interested in receiving biomedical consultations and possible treatments. Based on the relationship established in the workshops, priests and attendants began making referrals or assisted patients to attend the clinic. Notably, the church priests and personnel were not threatened by the biomedical model, and saw most activities as mutually beneficial. Building and maintaining this wider trust and rapport has been a crucial, ongoing priority for the biomedical practitioners.

The clinic operates once every 2 weeks, for 6–7 h. The team consists of a senior psychiatrist, a senior psychiatric resident, a clinical psychology student, a mental health nurse and an administrative clerk. The clinic also offers selected free medications, including essential antipsychotics and antidepressants that are widely available in Ethiopia, so treatment continuity is possible and costs are relatively sustainable. When patients leave the concurrent holy water and clinic treatment, a referral is made to their regional local health centre or hospital for continued care. The clinic has steadily grown in popularity, growing from an average of 15 patients per clinic day in 2012, to 39 in 2019.

Understanding patients served by the clinic: an overview

Hard copies of the basic clinical records of all 1888 patients who attended the clinic between 2012 and 2019 were manually examined. The records contained limited sociodemographic and clinical data. Psychiatric diagnoses were reviewed and updated during the chart review, based on the DSM-5.

Ethical approval

This research project involved retrospective, anonymous chart reviews, and presentation of aggregate data; no direct individual participant informed consent was sought. The methodology was approved by the Ethics Board of the School of Medicine, University of Addis Ababa.

Demographics

Male patients outnumbered female patients by about four to one, and the majority of patients (82%) were aged 18–35 years. The vast majority (81.8%) of patients came from the city of Addis Ababa; the rest came from further afar, drawn by the reputation of the sites (within 125 km, and a few from further away). Most of the patients (80%) were single and educated (91% completed high school, which was much higher than the national rate, likely reflecting the urban status). Most patients (83.3%) were Orthodox Christians, 12.7% were Muslims and 4% were Protestant Christians. Almost all patients (98.7%) resided in the holy water treatment community; most stayed for less than a year (68%), typically 2–5 months, but 24% stayed for 1–5 years and 8% stayed for >5 years.

Clinical diagnoses and duration of illness

The most common psychiatric disorder seen at the clinic was schizophrenia (40%), followed by substance use disorder (24%; mainly combinations of alcohol, qat, cigarettes and caffeine – different from the typical Western content of substance use disorder), bipolar disorder type 1 (18%), major depressive disorder (12%) and seizure disorders (6%). In terms of duration of illness before their visit to the clinic, 24% of patients reported a history of <1 year, 50% reported 1–10 years and 26% reported ≥11 years.

Pathways of referral

More than a quarter (26%) of the clinic's patients were directly referred by priests from holy water sites or other churches; 13% were brought there by their holy water treatment attendants, often because their behaviour was disruptive or violent; and 7% came by themselves. Combined, 46% of the clinic's patients came from within the holy water treatment community, a brand-new source of referral since the creation of the clinic. The other 54% of the patients were brought to the clinic by family members. Although not specifically included on charts, it was observed that some of these patients were new to biomedical treatment, and others came because they sought help first at regional hospitals, but were turned away because of a lack of resources. Both groups were receptive to the availability of biomedical services alongside holy water treatment.

History of mental health help-seeking and medication adherence

Regarding help-seeking pathways, 88% of the clinic's patients had their first-ever mental health contact at a non-biomedical source (faith-based prayer centres, general community traditional healers and holy water sites). By the time they came to the clinic, 48% of the patients had some form of previous contact with biomedical treatment but now came to holy water treatment instead. Of these, 89.2% had discontinued their biomedical medications; the main reasons were side-effects (55%), unaffordable costs (23%), a general refusal to take medication (10%) and a lack of improvement (7%). It was not feasible to track medication adherence rate at the clinic, but the general impression was a moderately high adherence, given the clinic's free medication, psychoeducation, supervision by the attendants and endorsement by the priests. Further, 52% of the clinic's patients had their first-ever contact with biomedical treatment through this very project. The general impression of the clinical and research staff was that the priests and attendants contributed greatly to these first encounters.

Insight, explanatory model of illness and receptivity of collaborative treatment

Of those who received medications at the clinic, 71.9% had no awareness or insight to their mental illness. Most of these needed supervision by their attendants to take their medications. In terms of explanatory models, 73.6% of patients believed that they were possessed by evil spirits and trusted that the holy water would help exorcise those evil spirits. However, the vast majority of patients (92.2%) were comfortable in using holy water treatment and medication at the same time, and most patients (91%) swallowed their medications with holy water and performed their prayers before taking their medications. In terms of ongoing collaborative approaches, 41.3% of patients received one-to-one counselling from priests, 34.3% received psychoeducation and brief eclectic psychotherapy from the clinic, and 24.4% received counselling support from both.

There have been many calls-to-action to create more collaborative care to scale up mental healthcare, 29 but few examples of what that looks like in practice, or models of how to achieve the goal. 30 , 31 The current case study of combined holy water and biomedical clinic treatment provides a potential model for how a cross-system collaboration can work in practice, and tests strategies that emphasise mutual respect and learning. Our collaborative project has run for 8 years, and shows that people from a diverse social, religious, age and educational backgrounds are amenable to an innovative, dual-model approach in the treatment of their mental illness, with growing attendance.

Our findings highlight the sociocultural reality that the vast majority of patients chose traditional forms of healing over a biomedical approach when they made first contact in help-seeking. This is likely because of the high cultural acceptability and low social stigma associated with traditional treatment, as well as its relatively easy availability and low cost, a belief in the traditional explanatory models of mental distress, distrust of the biomedical model and family decisions on behalf of the patient. 25 We also confirmed that biomedical mental health services remain in their nascent state in Ethiopia, even for those who accept such an approach and are geographically within reach of psychiatric care.

Many families wish to seek a residential form of care, likely because of high level of burden in caring for a family member with severe mental illness, and a need for respite and more intensive care. 32 The clinic added to available support for a very ill population, most of them struggling with schizophrenia, addiction and bipolar disorder. Our study's preliminary data indicate that patients, families and attendants are accepting of biomedical treatment, and most importantly, that it received the endorsement and recommendation of the holy water priests. This is a reflection of the project's success, and is motivation to continue this valuable collaboration.

The engagement with the clinic did not significantly displace patients’ traditional views of mental illness or explanatory models. It is important to note that changing or displacing a culturally ingrained, and practically beneficial, low-stigma belief system is not a goal of the clinic. The goal is for new patients and referral sources to consider a combination model of treatment. The focus is on mutual respect and acceptance regarding the patients’ understanding of causality of mental illness, and based on these conditions, patients can feel comfortable ‘swallowing medication with holy water’.

When considering the barriers contributing to the relative scarcity of collaboration with traditional healers, there is a common belief among biomedical practitioners that the scientific model is superior, and a tendency to disregard traditional practices as irrational. There are also concerns that such a collaboration would have the appearance of condoning, or tacitly endorsing, certain practices that may be less consistent with ethical ideals, such as chaining patients or beating them – issues that came up as part of the consultation process. 33 However, our study argues that such separation of the two models may result in missed opportunities to realise the considerable potential benefits of engagement. These include learning how traditional healers, often preferred by patients, connect with patients through a strong command of cultural understanding of the illness models and local knowledge of their needs and desires. These capacities are often undervalued in a biomedical approach, assuming that rational scientific thought is always superior. 34 Also, among the core tenets of Ethiopian Orthodox Church, equality and a deep respect for the person are strongly emphasised by the priest healers, translating into an accepting and empathic attitude toward all patients. This ethical framework is consistent with Western ethics although certain practices may not align. It has been our observation that foundational respect and acceptance contribute to attenuating the stigma and discrimination experienced by the patients. This is worthy of reflection by both systems of practitioners.

At a conceptual level, this project has illustrated the possibility of garnering synergies from two seemingly opposing and irreconcilable practices. The merging of the two healing paradigms demonstrates the possibility of a complementary system of care.

Limitations and next steps

The current study describes the clinic's creation, patients’ social demographic information and clinical diagnoses, results of the collaborative efforts, and the philosophical orientation and positive acceptance of such a model. It shows a promising example of cooperation between the two modalities; however, it regrettably lacks data in the basic clinical records to demonstrate effectiveness of the clinic. More outcome measures to show whether patients who attended the clinic had meaningful and sustained clinical improvement, or change in functioning level, would be ideal. The study is also limited by only having the perspective of the biomedical clinic, and the descriptive data has limited depth. We hope to address these limitations in more thoughtfully designed studies in the future. For example, comparisons between those who used the clinic and those who did not – in terms of changes in duration or course of illness, quality of life, functioning level, help-seeking, medication adherence, follow-up attendance and satisfaction level of the patient and their family – would be valuable. In addition, learning the strengths and weaknesses of the current model, and applying a quality improvement perspective to the collaborative model, would be useful. Qualitative understanding and reflections that inform further improvement of the collaboration among the priests, attendants, families and psychiatrists would be very desirable.

Acknowledgements

The authors thank the colleagues and collaborators from the St Michaels and St Mary's churches of Addis Ababa and the Ethiopian Mental Health Society; the families and attendants who participated in the consultations, workshops and treatment process; and staff and residents who contribute to this enduring project.

Author contributions

Y.B. and D.W. contributed to the founding and development of the project, research formulation and data collection and analyses, and paper writing. S.L. contributed to consulting on the resident education, research development, data analysis and paper writing.

The authors report no internal or external funding was involved in supporting this research project.

Data availability

Declaration of interest, supplementary material.

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    Edexcel GCSE Business - Theme 1 - 1.4 Making the business effective. This 6 lesson bundle covers: 1.4.1 The options for start-up and small businesses - 2 lessons 1.4.2 Business location 1.4.3 The marketing mix - 2 lessons 1.4.4 Business plans Filled with real life examples, case studies, questions and modelled answers to improve exam practice ...

  13. Business Plans

    Reformulating a business plan. Business plans are used to outline the industry in which a business is working in as well as the economic structure of a company to give an idea of the financial prospects of a business. They are used primarily to organise the routes to market that a company will take and give projections on earnings and target ...

  14. Task

    4. Page4of4. There are lots of ways to plan what you are going to write - some of them are fancy, some of them are simple, but the most important thing is to write your main idea down. This is the idea that underpins the reason for your text, you could call it your 'controlling idea'. If you don't write this down, it is easy to lose focus.

  15. Mission, values and public purposes

    The Charter also sets out our five public purposes: 1. To provide impartial news and information to help people understand and engage with the world around them. The BBC should provide duly ...

  16. purpose of business plan bbc bitesize

    1 2 The role and importance of a business plan Jaap talks about being a self-employed carpenter and about business success, profit and independence A business plan is a document created..... GCSE AQA The purpose and nature of businesses Entrepreneurs may choose to set up a business for a number of reasons and there are a number of business sectors that it can be in.

  17. GCSE Business

    Find your added subjects in My Bitesize. The purpose and nature of businesses - AQA Entrepreneurs may choose to set up a business for a number of reasons and there are a number of business sectors ...

  18. 1.4.4 Business Plans

    A business plan is a document produced by the owner at start-up, which provides forecasts of items such as: The business idea ( sub-topic 1.1.1) The business aims and objectives ( sub-topic 1.3.1) The target market ( sub-topic 1.2.2) The forecast revenues, costs and profits ( sub-topic 1.3.2) The cash-flow forecast ( sub-topic 1.3.5)

  19. PDF KS4 Business Studies Curriculum Map

    Students will learn about the purpose of business activity, the role of business enterprise and entrepreneurship, and the dynamic nature of business. ... BBC Bitesize video Why start a business - BBC Bitesize article ... Plan any next steps or catchup required and the best way to do it. Section 3.1: Business in the Real World Page 7 . Section ...

  20. 3.1 .6 Business Planning

    3.1.6 Business Planning. understand the reasons why businesses create plans, including importance in setting up a new business, raising finance, setting objectives and detailing how functions of a business will be organised. understand the main sections of a business plan. analyse the benefits and drawbacks of business planning.

  21. Annual plan

    The Annual Plan is an essential part of our accountability to licence fee payers and is a key document in the relationship between the BBC and Ofcom, which is our regulator. It provides a ...