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Sundararajan R, Hooda M, Lai Y, Nansera D, Audet C, Downs J, Lee MH, McNairy M, Muyindike W, Mwanga-Amumpaire J. Traditional healer support to improve HIV viral suppression in rural Uganda (Omuyambi): study protocol for a cluster randomized hybrid effectiveness-implementation trial. Trials 2024; 25:430. [PMID: 38956628 PMCID: PMC11218186 DOI: 10.1186/s13063-024-08286-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Rural African people living with HIV face significant challenges in entering and remaining in HIV care. In rural Uganda, for example, there is a threefold higher prevalence of HIV compared to the national average and lower engagement throughout the HIV continuum of care. There is an urgent need for appropriate interventions to improve entry and retention in HIV care for rural Ugandans with HIV. Though many adults living with HIV in rural areas prioritize seeking care services from traditional healers over formal clinical services, healers have not been integrated into HIV care programs. The Omuyambi trial is investigating the effectiveness of psychosocial support delivered by traditional healers as an adjunct to standard HIV care versus standard clinic-based HIV care alone. Additionally, we are evaluating the implementation process and outcomes, following the Consolidated Framework for Implementation Research. METHODS This cluster randomized hybrid type 1 effectiveness-implementation trial will be conducted among 44 traditional healers in two districts of southwestern Uganda. Healers were randomized 1:1 into study arms, where healers in the intervention arm will provide 12 months of psychosocial support to adults with unsuppressed HIV viral loads receiving care at their practices. A total of 650 adults with unsuppressed HIV viral loads will be recruited from healer clusters in the Mbarara and Rwampara districts. The primary study outcome is HIV viral load measured at 12 months after enrollment, which will be analyzed by intention-to-treat. Secondary clinical outcome measures include (re)initiation of HIV care, antiretroviral therapy adherence, and retention in care. The implementation outcomes of adoption, fidelity, appropriateness, and acceptability will be evaluated through key informant interviews and structured surveys at baseline, 3, 9, 12, and 24 months. Sustainability will be measured through HIV viral load measurements at 24 months following enrollment. DISCUSSION The Omuyambi trial is evaluating an approach that could improve HIV outcomes by incorporating previously overlooked community lay supporters into the HIV cascade of care. These findings could provide effectiveness and implementation evidence to guide the development of policies and programs aimed at improving HIV outcomes in rural Uganda and other countries where healers play an essential role in community health. TRIAL REGISTRATION ClinicalTrials.gov NCT05943548. Registered on July 5, 2023. The current protocol version is 4.0 (September 29, 2023).
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Affiliation(s)
| | - Misha Hooda
- Weill Cornell Medicine, 1300 York Ave, New York, NY, 10065, USA
| | - Yifan Lai
- Weill Cornell Medicine, 1300 York Ave, New York, NY, 10065, USA
| | - Denis Nansera
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carolyn Audet
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Jennifer Downs
- Weill Cornell Medicine, 1300 York Ave, New York, NY, 10065, USA
| | - Myung Hee Lee
- Weill Cornell Medicine, 1300 York Ave, New York, NY, 10065, USA
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Galvin M, Chiwaye L, Moolla A. Religious and Medical Pluralism Among Traditional Healers in Johannesburg, South Africa. JOURNAL OF RELIGION AND HEALTH 2024; 63:907-923. [PMID: 36971902 PMCID: PMC10040931 DOI: 10.1007/s10943-023-01795-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Abstract
Religion and spirituality are powerful social forces in contemporary South Africa. Traditional Health Practitioners (THPs) are commonly consulted for both spiritual and medical ailments as a first line of care. Many studies have assessed African traditional health seeking behaviors but few have examined beliefs, practices, and behaviors of THPs themselves. This study sought to explore spiritual worldviews among South African THPs. Semi-structured in-depth interviews were conducted with 18 THPs in Johannesburg, South Africa between January and May, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 12 software and thematically analyzed. The majority of THPs interviewed indicated that initiation as a THP was almost always preceded by a sickness accompanied by dreams/visions that represented an "ancestral calling" to become a healer. Most THPs also trained as both sangomas-who healed according to traditional beliefs-and prophets-who healed according to Christian beliefs. This reflects a syncretic relationship between traditional African beliefs and Christianity. However, not all churches are accepting of traditional beliefs and subsequently these THPs are members only at non-Pentecostal AIC churches who blend both African and Christian practices. Similar to these forms of religious pluralism melding Christianity and traditional beliefs, many THPs also often practice medical pluralism, mixing Western treatments with traditional practices/medicines. THPs are able to adapt elements of Western and African beliefs into healing practices that span multiple religious and medical fields. Thus, collaborative and decentralized healthcare services may be highly acceptable among such a pluralistic community.
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Affiliation(s)
- Michael Galvin
- Health Economics and Epidemiology Research Office (HE2RO), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Psychiatry, Boston Medical Center (BMC), Boston, USA.
- Harvard T.H. Chan School of Public Health, Boston, USA.
| | - Lesley Chiwaye
- Health Economics and Epidemiology Research Office (HE2RO), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Aneesa Moolla
- Health Economics and Epidemiology Research Office (HE2RO), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Schedwin M, Furaha AB, Hildenwall H, Elimian K, Malembaka EB, Yambayamba MK, Forsberg BC, Van Damme W, Alfvén T, Carter SE, Okitayemba PW, Mapatano MA, King C. Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002896. [PMID: 38502678 PMCID: PMC10950234 DOI: 10.1371/journal.pgph.0002896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.
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Affiliation(s)
- Mattias Schedwin
- Department of Global Public Health, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Aurélie Bisumba Furaha
- Paediatric Department, Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Helena Hildenwall
- Department of Global Public Health, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Karolinska Institutet, Intervention and Technology, Stockholm, Sweden
| | - Kelly Elimian
- Department of Global Public Health, Stockholm, Sweden
- Exhale Health Foundation, Abuja, Nigeria
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Marc K. Yambayamba
- Vetsuisse Faculty, Section Epidemiology, University of Zurich, Zurich, Switzerland
- Department of Epidemiology and Biostatistics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tobias Alfvén
- Department of Global Public Health, Stockholm, Sweden
- Sach’s Children and Youth Hospital, Stockholm, Sweden
| | - Simone E. Carter
- Public Health Emergencies, UNICEF, Kinshasa, Democratic Republic of Congo
| | - Placide Welo Okitayemba
- Programme National d’Elimination du Choléra et de Lutte Contre les Autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of Congo
| | - Mala Ali Mapatano
- Department of Nutrition, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Carina King
- Department of Global Public Health, Stockholm, Sweden
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Audet CM, Seabi T, Oyekunle T, Hove J, Wagner RG. A individually randomized controlled trial comparing Healer-led vs. clinician- led training to improve personal protective equipment use among traditional healers in South Africa. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002945. [PMID: 38394119 PMCID: PMC10889871 DOI: 10.1371/journal.pgph.0002945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
Like allopathic healthcare workers, healers are also exposed to patients' blood and body fluids. A widespread practice is the traditional "injection," in which the healer performs subcutaneous incisions to rub herbs directly into the bloodied skin, resulting in 1,500 blood exposures over their lifetime. We tested the impact of healer-led PPE training, staffed by trained traditional healers who reported using PPE during each risky clinical encounter vs. healthcare worker (HCW)-led PPE training sessions. We randomized 136 healers into one of the two study arms (67 in the healer-led group, 69 in the HCW-led group) and assessed the impact of trainer on PPE skills and use over a six-month period. All healers received one in-person day of didactic and practical training followed by three sessions at the healers' home. Participants were largely female (80%), averaged 51 years old, and practiced as a healer for an average of 17 years. Almost 44% either disclosed themselves as HIV+ or received a positive HIV test result at study initiation. Healers in the HCW arm showed equivalent PPE scores as those trained by traditional healers at baseline and at seven months. Healers in both arms self-reported high levels of glove use during"injections," with no statistical difference of use by study arm. When we assessed actual gloves and razor blades disposed of each month, a similar trend emerged. No one seroconverted during the study period. The need for PPE support among traditional healers cannot be ignored. Traditional healers can be trained to effectively disseminate PPE knowledge and skills to other traditional healers. With an estimated 200,000 traditional healers in South Africa, it is imperative that all of them have access to PPE training and supplies to prevent HIV, HCV, or HBV infections. Trial registration: ClinicalTrials.gov, NCT04440813. Registered 17 June 2020, https://clinicaltrials.gov/ct2/show/NCT04440813.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, United States of America
| | - Tshegofatso Seabi
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Taofik Oyekunle
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, United States of America
| | - Jennifer Hove
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ryan G. Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Apangu T, Candini G, Abaru J, Candia B, Okoth FJ, Atiku LA, Griffith KS, Hayden MH, Zielinski-Gutiérrez E, Schwartz AM, McCormick DW, Mead PS, Kugeler KJ. Engagement with Traditional Healers for Early Detection of Plague in Uganda. Am J Trop Med Hyg 2023; 109:1129-1136. [PMID: 37783460 PMCID: PMC10622458 DOI: 10.4269/ajtmh.23-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/15/2023] [Indexed: 10/04/2023] Open
Abstract
In rural Uganda, many people who are ill consult traditional healers prior to visiting the formal healthcare system. Traditional healers provide supportive care for common illnesses, but their care may delay diagnosis and management of illnesses that can increase morbidity and mortality, hinder early detection of epidemic-prone diseases, and increase occupational risk to traditional healers. We conducted open-ended, semi-structured interviews with a convenience sample of 11 traditional healers in the plague-endemic West Nile region of northwestern Uganda to assess their knowledge, practices, and attitudes regarding plague and the local healthcare system. Most were generally knowledgeable about plague transmission and its clinical presentation and expressed willingness to refer patients to the formal healthcare system. We initiated a public health outreach program to further improve engagement between traditional healers and local health centers to foster trust in the formal healthcare system and improve early identification and referral of patients with plaguelike symptoms, which can reflect numerous other infectious and noninfectious conditions. During 2010-2019, 65 traditional healers were involved in the outreach program; 52 traditional healers referred 788 patients to area health centers. The diagnosis was available for 775 patients; malaria (37%) and respiratory tract infections (23%) were the most common diagnoses. One patient had confirmed bubonic plague. Outreach to improve communication and trust between traditional healers and local healthcare settings may result in improved early case detection and intervention not only for plague but also for other serious conditions.
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Affiliation(s)
| | | | - Janet Abaru
- Uganda Virus Research Institute, Arua, Uganda
| | | | | | | | | | - Mary H. Hayden
- National Center for Atmospheric Research, Boulder, Colorado
| | | | - Amy M. Schwartz
- Centers for Disease Control and Prevention, Fort Collins, Colorado
| | | | - Paul S. Mead
- Centers for Disease Control and Prevention, Fort Collins, Colorado
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Sundararajan R, Ponticiello M, Birch G, Nuwagaba G, Alaiku R, Nansera D, Mwanga-Amumpaire J, Muyindike W. Adaption and pilot testing of a lay HIV supporter program for traditional healers: a mixed methods study in rural Uganda. Implement Sci Commun 2023; 4:87. [PMID: 37501077 PMCID: PMC10373386 DOI: 10.1186/s43058-023-00469-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Half of people living with HIV (PLWH) in sub-Saharan Africa default from care within two years. In Uganda, and across sub-Saharan Africa, traditional healers (TH) are ubiquitous and often serve as the first line of health care. We hypothesized that with lay support training, TH could support relinkage to HIV care and ART adherence among rural Ugandan PLWH who have defaulted from HIV care. METHODS Following the ADAPT-ITT framework, we adapted an evidence-based layperson HIV support program from South Africa for delivery by Ugandan TH. The ADAPT-ITT framework consists of (1) Assessment of needs; (2) Deciding which evidence-based interventions to adapt; (3) Adaptation of interventions; (4) Production of drafted adapted interventions; (5) Topical expert feedback; (6) Integration of expert feedback; (7) Training personnel; and (8) Testing the adapted intervention. The Testing phase was completed via a pilot mixed methods prospective cohort study. The study population included 12 TH practicing in Mbarara Township and 20 adult PLWH with suboptimal ART adherence (CASE adherence index score < 10) who received care from a participating TH and who resided in Mbarara Township. Primary outcome was re-linkage to HIV care within 14 days. Secondary outcomes were ART re-initiation, ART adherence, retention in care after 9 months, and implementation measures. Qualitative interviews were conducted with all participants. RESULTS Data from the Assessment phase indicated that logistical challenges played an important role in disengagement from care among PLWH who receive care from TH, notably geographical distance to clinics and transportation costs. Additionally, HIV-related stigma and lack of social support were identified as barriers to entering and remaining in HIV care. Two core elements of the intervention were identified during the Production phase: (1) TH facilitating rapid re-linkage to HIV care and (2) TH provision of psychosocial support. In the pilot study phase, baseline median CASE adherence score was 3; only 5% of PLWH were adherent to ART via 4-day recall. The TH-delivered support achieved 100% linkage and ART initiation within 14 days, 95% ART adherence, and 100% of PLWH were retained in HIV care after 9 months. CONCLUSIONS The ADAPT-ITT framework successfully guided the adaption of a community health worker-delivered intervention for delivery by TH. TH successfully facilitated re-linkage to HIV care, support ART adherence, and retention in care for PLWH when trained as part of a lay support person program. Future studies are needed to evaluate scale-up and long-term impact.
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Affiliation(s)
- Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, NY, USA.
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA.
| | | | | | | | - Rinu Alaiku
- Weill Cornell Medical College, Weill Cornell Medicine, New York, USA
| | - Denis Nansera
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Juliet Mwanga-Amumpaire
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
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Abstract
In this Policy Forum, Anna Grimsrud and colleagues discuss the future of HIV testing in eastern and southern Africa, using insights gleaned from a 2021 expert consultation.
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Sundararajan R, Alakiu R, Ponticiello M, Birch G, Kisigo G, Okello E, Peck RN. Understanding traditional healer utilisation for hypertension care using the Andersen model: A qualitative study in Mwanza, Tanzania. Glob Public Health 2023; 18:2191687. [PMID: 36973183 PMCID: PMC10065353 DOI: 10.1080/17441692.2023.2191687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
ABSTRACTHypertension disproportionately affects people living in African countries, where there are many challenges to appropriate diagnosis and treatment, and many people with hypertension utilise traditional healers as their primary source of healthcare. In this study, we sought to understand factors driving healer utilisation among people with hypertension. We conducted 52 semi-structured interviews with traditional healers, patients and healthcare providers in the Mwanza region of Tanzania. We used the Andersen model of healthcare utilisation to organise our findings on factors driving utilisation of traditional healers for hypertension care. Traditional healers routinely provide care to hypertensive patients and are a critical component of the healthcare landscape. However, healers also operate independently of the biomedical healthcare system, and biomedical providers may hold negative perceptions of healers. Further, healers were described as preferential by patients due to the convenient locations of their practices and perceived improvement of hypertension symptoms with traditional treatment. Finally, healers expressed a desire for more formal collaboration with biomedicine to improve patient care. Our findings may guide future interventions in Tanzanian communities and elsewhere where traditional healers may act as partners to allopathic providers and patients in the continuum of hypertension care.
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Affiliation(s)
- Radhika Sundararajan
- Weill Cornell Medicine, Center for Global Health, New York NY USA
- Weill Cornell Medicine, Department of Emergency Medicine, New York NY USA
| | - Rinu Alakiu
- Weill Cornell Medical College, New York, NY USA
| | | | | | - Godfrey Kisigo
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- Bugando Medical Center, Mwanza, Tanzania
| | | | - Robert N. Peck
- Weill Cornell Medicine, Center for Global Health, New York NY USA
- Mwanza Intervention Trials Unit, Mwanza, Tanzania
- Bugando Medical Center, Mwanza, Tanzania
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Audet CM, Seabi T, Ngobeni S, Berhanu RH, Wagner RG. Pulmonary tuberculosis vs. Tindzhaka and Mafularha: A mixed methods inquiry of traditional healers' perceptions of tuberculosis in rural South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001611. [PMID: 37083848 PMCID: PMC10121049 DOI: 10.1371/journal.pgph.0001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/20/2023] [Indexed: 04/22/2023]
Abstract
Although awareness of tuberculosis (TB) is high in South Africa, delays in TB testing or treatment persist. Even those with symptoms of TB often delay testing, with one study in Mpumalanga revealing a median allopathic care-seeking delay of four weeks. We sought to understand how traditional healers perceived TB symptoms among their patients, if they treated the disease, and what (if any) illnesses they defined as being traditional may have overlapping presentation with TB in South Africa. Nineteen traditional healers completed an in-depth interview (IDIs); 133 completed a quantitative survey about their treatment practices. IDIs focused on lung diseases treated, disease causation, treatment, and prognosis. Survey questions investigated diagnosis of lung ailments, including those treated by the allopathic health system and those by traditional healers. Traditional healers reported that they could differentiate between TB and traditional illnesses, like Tindzhaka and Mafularha, that presented with similar symptoms. Few (7.5%) believed they could treat TB, but the majority (72.9%) believed they could successfully treat Tindzhaka and Mafularha. Tindzhaka and Mafularha are interconnected illnesses that are reportedly caused by breaking social rules around death, sex and using the belongings of someone who recently passed away. Both, if not treated, are considered fatal. While we have no definitive data, traditional healers may be contributing to delays in the diagnosis and treatment for people with active TB by incorrectly diagnosing TB as Tindzhaka or Mafularha. Overcoming issues of trust and compensation, while respecting different forms of knowledge, are some of the challenges we face in successfully engaging with healers.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Tshegofatso Seabi
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sizzy Ngobeni
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Rebecca H Berhanu
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Ryan G Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Steinhorst J, Tianyi FL, Habib AG, Oluoch GO, Lalloo DG, Stienstra Y. Uniting behind a common goal: Collaboration between traditional healers and allopathic health care workers to improve rural snakebite care. Toxicon X 2022; 16:100140. [PMID: 36353448 PMCID: PMC9637966 DOI: 10.1016/j.toxcx.2022.100140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/12/2022] [Accepted: 10/22/2022] [Indexed: 12/12/2022] Open
Abstract
Snakebite envenoming is an acute medical emergency which affects hundreds of thousands of people worldwide, primarily in remote rural areas of low-and middle income countries in the Global South. A considerable proportion of snakebite patients turn to traditional healers (THs) for help, driven by a number of push and pull factors. These include socio-cultural factors, geographical proximity, and the absence or inaccessibility of overstretched and often costly allopathic healthcare services. Although traditional healers and allopathic healthcare staff share a common focus -the recovery and well-being of their patients- both systems operate largely in parallel to each other with collaborations being an exception rather than the rule. This is to the detriment of snakebite patients, who frequently find themselves being caught-up in the dualism between the two separate systems. Given the right circumstances, snakebite patients could benefit from elements of care from both modalities. Here, we have reviewed the role of THs in snakebite care and explored how their integration into the formal healthcare system could improve the implementation and outcome of care. The effective recruitment of THs to aid in disease control and treatment efforts in diseases other than snakebite underscores the potential benefits of this strategy. Carefully devised proof of concept studies are needed to test our hypothesis that collaborations between the formal healthcare sector and THs are feasible and improve outcomes in snakebite care.
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Affiliation(s)
- Jonathan Steinhorst
- University of Groningen, Department of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, Groningen, the Netherlands
| | - Frank-Leonel Tianyi
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Abdulrazaq Garba Habib
- Infectious Disease and Tropical Medicine Unit, Department of Medicine, College of Health Science, Bayero University Kano, Nigeria
| | - George O. Oluoch
- Kenya Snakebite Research & Intervention Centre, Institute of Primate Research, Karen, Nairobi, Kenya
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ymkje Stienstra
- University of Groningen, Department of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, Groningen, the Netherlands,Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom,Corresponding author. CSRI Liverpool School of Tropical Medicine, Pembroke Place Liverpool L3 5QA, United Kingdom.
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Kisigo GA, Mcharo OC, Robert JL, Peck RN, Sundararajan R, Okello ES. Understanding barriers and facilitators to clinic attendance and medication adherence among adults with hypertensive urgency in Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000919. [PMID: 36962785 PMCID: PMC10021323 DOI: 10.1371/journal.pgph.0000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022]
Abstract
Hypertensive urgency is a major risk factor for cardiovascular events and premature deaths. Lack of medication adherence is associated with poor health outcomes among patients with hypertensive urgency in resource-limited settings. To inform the development of tailored interventions to improve health outcomes in this population, this study aimed at understanding facilitators and barriers to clinic attendance and medication adherence among Tanzanian adults with hypertensive urgency. We conducted in-depth interviews with 38 purposively selected participants from three groups: 1) patients with hypertension attending hypertension clinic, 2) patients with hypertension not attending hypertension clinic, and 3) clinic health workers. Interviews were conducted using a semi-structured guide which included open-ended questions with prompts to encourage detailed responses. In their narrative, patients and healthcare workers discussed 21 types of barriers/facilitators to clinic attendance and medication adherence: 12 common to both behaviors (traditional medicine, knowledge and awareness, stigma, social support, insurance, reminder cues, symptoms, self-efficacy, peer support, specialized care, social services, religious beliefs); 6 distinct to clinic attendance (transport, clinic location, appointment, patient-provider interaction, service fragmentation, quality of care); and 3 distinct to medication adherence (drug stock, side effects, medicine beliefs). The majority of identified barriers/facilitators overlap between clinic attendance and medication adherence. The identified barriers may be surmountable using tailored supportive intervention approaches, such as peer counselors, to help patients overcome social challenges of clinic attendance and medication adherence.
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Affiliation(s)
- Godfrey A. Kisigo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Onike C. Mcharo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - John L. Robert
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Robert N. Peck
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
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Matungwa DJ, Hong R, Kidola J, Pungu D, Ponticiello M, Peck R, Sundararajan R. Understanding the role of traditional healers in the HIV care cascade: Findings from a qualitative study among stakeholders in Mwanza, Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000674. [PMID: 36962758 PMCID: PMC10021224 DOI: 10.1371/journal.pgph.0000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
Tanzania is HIV-endemic, with 5% prevalence. However, less than half of Tanzanians are aware of their HIV status, and only 75% of adult Tanzanians living with HIV are on antiretroviral therapy (ART). Informal healthcare providers, such as traditional healers, frequently serve as the first line of healthcare in Tanzania. How traditional healers interact with people living with HIV (PLWH) remains unknown. This study sought to understand gaps in HIV care and explore how traditional healers interface with PLWH along the HIV care cascade. We conducted a qualitative study in Mwanza, Tanzania, between November 2019 and May 2020. We invited 15 traditional healers, 15 clients of traditional healers, 15 biomedical healthcare facility staff, and 15 PLWH to participate in a single qualitative interview. Two community focus groups were held with eight male and eight female participants. Participants were 18 years of age or older. Individual experiences with traditional healers and biomedical healthcare facilities, as well as perceptions of traditional healers with respect to HIV care, were explored through interviews. Using a content-analysis approach, codes were grouped into a framework that characterized how traditional healers engage with PLWH throughout the HIV care cascade. PLWH engaged with traditional healers throughout the HIV care cascade, from pre- to post-HIV diagnosis. Traditional healers were described in some cases as facilitating HIV testing, while others were described as delaying testing by providing traditional treatments for HIV symptoms. Traditional medications were frequently used concurrently with ARTs by PLWH. There was concern that healers contributed to ART nonadherence as some PLWH used traditional therapies in search of a "cure" for HIV. Our findings suggest that traditional healers interact with PLWH throughout the HIV care continuum and that collaboration between traditional healers and biomedical healthcare professionals and facilities is needed to improve HIV treatment outcomes.
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Affiliation(s)
- Dunstan J. Matungwa
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
- Department of Anthropology, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Richie Hong
- Weill Cornell Medical College, New York, New York, United States of America
| | - Jeremiah Kidola
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Daniel Pungu
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States of America
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Robert Peck
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States of America
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
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PONTICIELLO M, MWANGA-AMUMPAIRE J, TUSHEMEREIRWE P, NUWAGABA G, NANSERA D, KING R, MUYINDIKE W, SUNDARARAJAN R. How informal healthcare providers improve uptake of HIV testing: qualitative results from a randomized controlled trial. AIDS 2022; 36:1161-1169. [PMID: 35442219 PMCID: PMC9262827 DOI: 10.1097/qad.0000000000003227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Uganda is HIV-endemic with a prevalence of 5.7%. Lack of epidemic control has been attributed to low engagement with HIV testing. Collaborating with informal healthcare providers, such as traditional healers, has been proposed as a strategy to increase testing uptake. We explored acceptability and implementation of an HIV testing program where traditional healers delivered point-of-care testing and counseling to adults of unknown serostatus (clinicaltrials.gov NCT#03718871). METHODS This study was conducted in rural, southwestern Uganda. We interviewed participating traditional healers ( N = 17) and a purposive sample of trial participants ( N = 107). Healers were practicing within 10 km of Mbarara township, and 18+ years old. Participants were 18+ years old; sexually active; had received care from participating healers; self-reported not receiving an HIV test in prior 12 months; and not previously diagnosed with HIV infection. Interviews explored perceptions of a healer-delivered HIV testing model and were analyzed following a content-analysis approach. RESULTS Most participants were female individuals ( N = 68, 55%). Healer-delivered HIV testing overcame structural barriers, such as underlying poverty and rural locations that limited use, as transportation was costly and often prohibitive. Additionally, healers were located in villages and communities, which made services more accessible compared with facility-based testing. Participants also considered healers trustworthy and 'confidential'. These qualities explain some preference for healer-delivered HIV testing, in contrast to 'stigmatizing' biomedical settings. CONCLUSION Traditional healer-delivered HIV testing was considered more confidential and easily accessible compared with clinic-based testing. Offering services through traditional healers may improve uptake of HIV testing services in rural, medically pluralistic communities.
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Affiliation(s)
- Matthew PONTICIELLO
- Department of Emergency Medicine, Weill Cornell Medicine, New York, USA
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, USA
| | | | | | | | | | - Rachel KING
- University of California, San Francisco, San Francisco CA USA
| | | | - Radhika SUNDARARAJAN
- Department of Emergency Medicine, Weill Cornell Medicine, New York, USA
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, USA
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Zhang C, Li H, Niu Q, Xie Y, Hu J, Liu C, Shang X, Li X. Commentary: Chinese Herbal Medicine Usage Reduces Overall Mortality in HIV-Infected Patients With Osteoporosis or Fractures. Front Pharmacol 2022; 13:870855. [PMID: 35685631 PMCID: PMC9171357 DOI: 10.3389/fphar.2022.870855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Xiuhui Li
- *Correspondence: Xiuhui Li, ; Xiaofei Shang,
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Matungwa DJ, Kidola J, Pungu D, Ponticiello M, Latulipe R, Lee MH, Peck R, Sundararajan R. A Cluster-Randomized Trial of Traditional Healer-Delivered Counseling and Rapid HIV Testing in Tanzania. AIDS Behav 2022; 26:3700-3712. [PMID: 35553286 DOI: 10.1007/s10461-022-03700-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
Abstract
Collaborations with traditional healers have been proposed to improve HIV testing uptake. We hypothesized that healer-delivered HIV testing would improve HIV testing uptake, compared with referral to clinic-based HIV testing. We conducted a cluster randomized trial to determine the effectiveness of traditional healers delivering counseling and HIV testing in Mwanza, Tanzania (ClinicalTrials.gov NCT#04071873). Intervention arm healers provided counseling and offered point-of-care HIV tests to adult clients of unknown HIV serostatus. Control arm healers provided referral for clinic-based testing. Primary outcome was receipt of an HIV test within 90 days of enrollment. Secondary outcomes were new HIV diagnosis and linkage to care. In the intervention, 100 clients (100%) received an HIV test, compared with 73 (73%) of control participants (p < 0.001). Two intervention arm participants (2%) had a new diagnosis compared with zero in the control arm (p = 0.50). Engaging traditional healers might provide a culturally concordant opportunity to improve HIV testing uptake.
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Affiliation(s)
- Dunstan J Matungwa
- National Institute for Medical Research, Mwanza, Tanzania
- Department of Anthropology, Rutgers University, New Brunswick, NJ, USA
| | | | - Daniel Pungu
- National Institute for Medical Research, Mwanza, Tanzania
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Ryan Latulipe
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
| | - Myung Hee Lee
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Robert Peck
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA.
- Weill Cornell Center for Global Health, Weill Cornell Medicine, New York, NY, USA.
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Sundararajan R, Ponticiello M, Nansera D, Jeremiah K, Muyindike W. Interventions to Increase HIV Testing Uptake in Global Settings. Curr HIV/AIDS Rep 2022; 19:184-193. [PMID: 35441985 PMCID: PMC9110462 DOI: 10.1007/s11904-022-00602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/16/2022]
Abstract
Purpose of Review HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings. Recent Findings Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV. Summary Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.
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Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA. .,Weill Cornell Center for Global Health, New York, NY, USA.
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
| | - Denis Nansera
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Winnie Muyindike
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
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Campain N, Mabedi C, Savopoulos V, Payne SR, MacDonagh R. Understanding the cultural and logistical context for urologists in low‐income countries. BJU Int 2022; 129:273-279. [DOI: 10.1111/bju.15690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/30/2021] [Accepted: 01/06/2022] [Indexed: 11/30/2022]
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Boum Y, Kwedi-Nolna S, Haberer JE, Leke RRG. Traditional healers to improve access to quality health care in Africa. LANCET GLOBAL HEALTH 2021; 9:e1487-e1488. [PMID: 34678184 DOI: 10.1016/s2214-109x(21)00438-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Yap Boum
- Epicentre, Yaoundé BP 12069, Cameroon; Faculty of Medicine and Biomedical Research, University of Yaoundé 1, Joseph Tchooungui Akoa, Yaoundé, Cameroon.
| | - Sylvie Kwedi-Nolna
- Faculty of Medicine and Biomedical Research, University of Yaoundé 1, Joseph Tchooungui Akoa, Yaoundé, Cameroon
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rose R G Leke
- Faculty of Medicine and Biomedical Research, University of Yaoundé 1, Joseph Tchooungui Akoa, Yaoundé, Cameroon
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