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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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2
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Castillo-Laborde C, Hirmas-Adauy M, Matute I, Jasmen A, Urrejola O, Molina X, Awad C, Frey-Moreno C, Pumarino-Lira S, Descalzi-Rojas F, Ruiz TJ, Plass B. Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review. Public Health Rev 2022; 43:1604796. [PMID: 36120091 PMCID: PMC9479461 DOI: 10.3389/phrs.2022.1604796] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives. Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed. Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education. Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.
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Affiliation(s)
- Carla Castillo-Laborde
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Carla Castillo-Laborde,
| | - Macarena Hirmas-Adauy
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Isabel Matute
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Anita Jasmen
- Biblioteca Biomédica, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Oscar Urrejola
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Xaviera Molina
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Camila Awad
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Catalina Frey-Moreno
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Sofia Pumarino-Lira
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Fernando Descalzi-Rojas
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Tomás José Ruiz
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Barbara Plass
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
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3
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Lambert VJ, Kisigo GA, Nzali A, Laizer E, Paul N, Walshe L, Kalokola F, Okello ES, Sundararajan R, Mwakisole AH, Downs JA, Peck RN. Religious Leaders as Trusted Messengers in Combatting Hypertension in Rural Tanzanian Communities. Am J Hypertens 2021; 34:1042-1048. [PMID: 34022044 DOI: 10.1093/ajh/hpab080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/20/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities. METHODS We conducted 31 in-depth interviews with Christian (n = 17) and Muslim (n = 14) religious leaders in rural Tanzania. Interviews focused on religious leaders' perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders' perspectives on, and experiences with, hypertension. RESULTS Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders. CONCLUSIONS Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.
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Affiliation(s)
- Valencia J Lambert
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
| | - Godfrey A Kisigo
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
| | - Aneth Nzali
- Mwanza Christian College , Mwanza , Tanzania
| | | | - Ndalloh Paul
- Department of Medicine, Bugando Medical Centre , Mwanza , Tanzania
| | - Louise Walshe
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
| | | | - Elialilia S Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research , Mwanza , Tanzania
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
- Department of Emergency Medicine, Weill Cornell Medicine , New York, New York , USA
| | | | - Jennifer A Downs
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
- Department of Medicine, Bugando Medical Centre , Mwanza , Tanzania
| | - Robert N Peck
- Center for Global Health, Weill Cornell Medicine , New York, New York , USA
- Department of Medicine, Bugando Medical Centre , Mwanza , Tanzania
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Sserwanja Q, Mutisya LM, Olal E, Musaba MW, Mukunya D. Factors associated with childhood overweight and obesity in Uganda: a national survey. BMC Public Health 2021; 21:1494. [PMID: 34344336 PMCID: PMC8330108 DOI: 10.1186/s12889-021-11567-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/29/2021] [Indexed: 01/19/2023] Open
Abstract
Background Childhood obesity is an emerging public health problem globally. Although previously a problem of high-income countries, overweight and obesity is on the rise in low- and middle-income countries. This paper explores the factors associated with childhood obesity and overweight in Uganda using data from the Uganda Demographic and Health Survey (UDHS) of 2016. Methods We used Uganda Demographic and Health Survey (UDHS) 2016 data of 4338 children less than 5 years. Multistage stratified sampling was used to select study participants and data were collected using validated questionnaires. Overweight and obesity were combined as the primary outcome. Children whose BMI z score was over two were considered as overweight while those with a BMI z score greater than three were considered as obese. We used multivariable logistic regression to determine factors associated with obesity and overweight among children under 5 years of age in Uganda. Results The prevalence of overweight and obesity was 5.0% (217/4338) (95% CI: 4.3–5.6), with overweight at 3.9% (168/4338: 95% CI: 3.2–4.3) and obesity at 1.1% (49/4338: 95% CI: 0.8–1.5). Mother’s nutritional status, sex of the child, and child’s age were associated with childhood obesity and overweight. Boys were more likely to be overweight or obese (aOR = 1.81; 95% CI 1.24 to 2.64) compared to girls. Children who were younger (36 months and below) and those with mothers who were overweight or obese were more likely to have obesity or overweight compared to those aged 49–59 months and those with underweight mothers respectively. Children from the western region were more likely to be overweight or obese compared to those that were from the North. Conclusion The present study showed male sex, older age of the children, nutritional status of the mothers and region of residence were associated with obesity and overweight among children under 5 years of age.
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Affiliation(s)
- Quraish Sserwanja
- Programs Department, GOAL, Arkaweet Block 65 House No, 227, Khartoum, Sudan.
| | - Linet M Mutisya
- Maternal and Child Health Project, Swedish Organization for Global Health, Mayuge, Uganda
| | | | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Busitema University, Mbale, Uganda
| | - David Mukunya
- Department of Community and Public Health, Busitema University, Mbale, Uganda.,Sanyu Africa Research Institute, Mbale, Uganda
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Mutyavaviri SN, Mensah KB, Marume A, Boamah Mensah AB, Bangalee V. Price, Availability, and Affordability of Antineoplastic Medicines in Harare's Public and Private Institutions: Implication for Access. Value Health Reg Issues 2021; 25:118-125. [PMID: 33965656 DOI: 10.1016/j.vhri.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine the price, availability, and affordability of antineoplastic medicines in private and public sector pharmacies in Harare Metropolitan Province, Zimbabwe. METHODS The study was based on the methodology recommended by the World Health Organization and Health Action International. A total of 32 antineoplastic medicines in 3 public central hospitals and 150 private pharmacies were surveyed. The median price ratio, percentage availability, affordability, and percentage markups were calculated. RESULTS Availability at the public institutions was 28%, whereas the private sector ranged from 1.3% to 42.7%. The median price ratio in the private sector ranged from 0.6 to 11, whereas the public sector ranged from 0.73 to 2.25. Affordability in the public sector ranged from 1 to 10 days wage and from 1 to 490 days wage in the private sector. The average percentage markup was 51.3% in the private sector and 34% in the public sector. CONCLUSION Antineoplastic medicines were more available in the private sector than in the public sector, but more affordable in the public sector. The average percentage markups for antineoplastic medicines demonstrated that medicines were not overpriced in the public sector, but in the private sector were sold at prices higher than the international reference price.
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Affiliation(s)
- Sly Ngoni Mutyavaviri
- St Mary's Clinical Research Site, Chitungwiza, Zimbabwe; Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kofi Boamah Mensah
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Kwame Nkrumah University of Science and Technology, Ghana.
| | - Amos Marume
- Pharmacology and Pharmacoeconomics, Paraclinical Department, Faculty of Veterinary Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Adwoa Bemah Boamah Mensah
- Department of Nursing, Faculty of Allied Health Sciences, Kwame Nkrumah University of Science and Technology, Ghana
| | - Varsha Bangalee
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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6
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Olatunya OS, Babatola AO, Adeniyi AT, Lawal OA, Daramola AO, Agbesanwa TA, Olumuyiwa Ojo T, Ajayi PO, Ibijola AA, Komolafe AK, Adekile A. Determinants of Care-Seeking Practices for Children with Sickle Cell Disease in Ekiti, Southwest Nigeria. J Blood Med 2021; 12:123-132. [PMID: 33664607 PMCID: PMC7921626 DOI: 10.2147/jbm.s294952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Due to the chronic nature of sickle cell disease (SCD), affected individuals may seek help from diverse places thus raising the need to understand their health-seeking behavior (HSB) in order to design an appropriate management policy for them. Aim The aim of this study was to evaluate the HSB among pediatric SCD patients relative to their non-SCD counterparts attending a tertiary facility in Southwest Nigeria and identified predictors of poor HSB among SCD patients. Methods A total of 110 children with SCD were recruited and studied for their HSPs which were compared with 110 non-SCD patients with other chronic medical conditions. Questionnaires were used to obtain self-reported information on participants’ socio-demographic data and HSB. Logistic regression was used to determine the predictors of poor HSB among the SCD cohort. Results More SCD patients received treatments at private hospitals, patent medicine stores and faith-based centers compared to their non-SCD counterparts (p=0.0052; 0.006; and 0.007), respectively. No difference was observed in the patronage of traditional care centres 10 (9.1%) vs 6 (5.5%). More SCD patients 61 (55.5%) vs 35 (31.8%) exhibited poor HSB (p=0.0004). SCD patients who were not enrolled on health insurance scheme were 18 times more likely to have poor HSB (OR=18.38, 95% CI (4.41–76.57), p value= <0.0001) while absence of VOC within the preceding year reduces the risk of poor HSB by 91.5% (OR=0.085, 95% CI (0.028–0.258), p value= <0.0001). Conclusion SCD patients in the study locality had poor HSB. This raises the need for their education on proper HSB. More enrollment into health insurance scheme and the prevention of VOC will lessen the burden of poor HSB. The high patronage of non-hospital care facilities in this study raises the need for stakeholders to monitor activities and train the operators at these informal care centres.
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Affiliation(s)
- Oladele Simeon Olatunya
- Department of Paediatrics, College of Medicine, Ekiti State University, Ado Ekiti, Nigeria.,Department of Paediatrics, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
| | - Adefunke Olarinre Babatola
- Department of Paediatrics, College of Medicine, Ekiti State University, Ado Ekiti, Nigeria.,Department of Paediatrics, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
| | - Adewuyi Temidayo Adeniyi
- Department of Paediatrics, College of Medicine, Ekiti State University, Ado Ekiti, Nigeria.,Department of Paediatrics, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
| | - Olubunmi Adeola Lawal
- Department of Paediatrics, Federal Teaching Hospital, Ido Ekiti, Ekiti State, Nigeria
| | - Alaba Olanrewaju Daramola
- Department of Hematology and Blood Transfusion, Ekiti State University, Ado Ekiti, Ekiti State, Nigeria
| | - Tosin Anthony Agbesanwa
- Department of Family Medicine, College of Medicine, Ekiti State University, Ado Ekiti, Ekiti State, Nigeria
| | - Temitope Olumuyiwa Ojo
- Department of Community Health, Obafemi Awolowo University Ile-Ife, Ile-Ife, Osun State, Nigeria
| | - Paul Oladapo Ajayi
- Department of Community Medicine, College of Medicine, Ekiti State University, Ado Ekiti, Ekiti State, Nigeria
| | - Adeleke Ajayi Ibijola
- Department of Hematology, Federal Teaching Hospital, Ido Ekiti/Afe Babaloa University, Ado Ekiti, Ekiti State, Nigeria
| | | | - Adekunle Adekile
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
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7
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Taylor J, Bradbury-Jones C, Ogik P, Kawuma F, Betts J, Lund P. Reactions to and explanations for the birth of a baby with albinism: a qualitative study in Busoga, Uganda. BMJ Open 2021; 11:e040992. [PMID: 33622943 PMCID: PMC7907870 DOI: 10.1136/bmjopen-2020-040992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 01/05/2021] [Accepted: 01/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Babies born with the genetic condition albinism lack pigment in their hair, skin and eyes due to compromised melanin production. This leads to poor vision and the risk of early death due to skin cancer. In Uganda, one of the least developed countries in the world, their lack of pigmentation makes them very different in appearance within their communities. Local explanations of albinism include links to witchcraft and the supernatural. We aimed to explore reactions to the birth of a baby with albinism in Uganda. DESIGN Secondary analysis of birth stories derived from qualitative interviews and focus group discussions in sharing circles. SETTING Interviews took place in the Busoga subregion (kingdom) in the eastern part of Uganda. PARTICIPANTS Seventy-three (73) participants took part in eight sharing circles (n=56) and 17 individual interviews. Participants included people with albinism, parents of people with albinism and a range of other interested parties, including local leaders and teachers. RESULTS Reactions were generally those of shock and rejection, although cases of acceptance were also recorded. The varied explanations given to account for this unexpected event included accounts involving witchcraft, ghosts, animal familiars and religion, as well as genetics. In a framework surmising that someone must possess a dark skin to be intrinsically valued in African societies a baby with albinism does not fulfil this requirement of 'personhood'. The mother was often blamed for having produced some 'thing' that is not a proper person. CONCLUSIONS We argue that a biomedical explanation, although unlikely to displace other understandings, helps to establish a baby with albinism as a real person with a genetic difference, and hence fosters greater acceptance.
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Affiliation(s)
- Julie Taylor
- School of Nursing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - C Bradbury-Jones
- School of Nursing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Peter Ogik
- Source of the Nile Union for Persons with Albinism, Jinja, Uganda
| | - Fazira Kawuma
- Source of the Nile Union for Persons with Albinism, Jinja, Uganda
| | | | - Patricia Lund
- School of Life Sciences, Coventry University, Coventry, UK
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Smith CE, Kajumba M, Bobholz S, Smith PJ, Kaddumukasa M, Kakooza-Mwesige A, Chakraborty P, Sinha DD, Kaddumukasa MN, Gualtieri A, Nakasujja N, Onuoha E, Nakku J, Muhumuza C, Sanchez N, Fuller AT, Haglund MM, Koltai DC. Pluralistic and singular causal attributions for epilepsy in Uganda. Epilepsy Behav 2021; 114:107334. [PMID: 32839144 DOI: 10.1016/j.yebeh.2020.107334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions. METHODS In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then utilized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann-Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups. RESULTS Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a potential cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the patterns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a biological etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p < 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p < 0.01), and there were significant differences in income across specific groups (p < 0.01). CONCLUSIONS Pluralistic attributions for epilepsy are common in Uganda, with the majority of community members drawing from biomedical and traditional concepts to construct complex explanations for seizures that transcend discrete belief categories traditionally depicted in the literature. These findings emphasize the need to understand cultural beliefs about epilepsy in order to design contextually specific interventions and education programs, which respect the fundamental beliefs and values of the community. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".
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Affiliation(s)
- Caleigh E Smith
- Duke University Trinity College of Arts & Sciences, Durham, NC 27708, USA
| | - Mayanja Kajumba
- Department of Mental Health and Community Psychology, Makerere University School of Psychology, P.O. Box 7062, Kampala, Uganda
| | - Samuel Bobholz
- University of Wisconsin - Madison, Department of Neurology, 1685 Highland Avenue, Madison, WI 53705-2281, USA
| | - Patrick J Smith
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, DUMC Box 3119, Trent Drive, Durham, NC, USA
| | - Mark Kaddumukasa
- School of Medicine, College of Health Sciences, Makerere University. P.O. Box 7072, Kampala, Uganda
| | - Angelina Kakooza-Mwesige
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda; Department of Pediatrics and Child Health, Mulago National Referral Hospital, Pediatric Neurology Unit, Kampala, Uganda
| | - Payal Chakraborty
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Duke Global Health Institute, 310 Trent Dr, Durham, NC 27710, USA
| | - Drishti D Sinha
- Duke University Trinity College of Arts & Sciences, Durham, NC 27708, USA
| | - Martin N Kaddumukasa
- School of Medicine, College of Health Sciences, Makerere University. P.O. Box 7072, Kampala, Uganda; Department of Medicine, Mulago National Referral Hospital, Neurology Unit, Kampala, Uganda
| | - Alex Gualtieri
- Duke University Medical Center, Clinical Neuropsychology Service, Box 3333, Durham, NC, USA
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Erica Onuoha
- Duke University Trinity College of Arts & Sciences, Durham, NC 27708, USA
| | - Juliet Nakku
- Butabika National Referral Mental Hospital, P.O. Box 7017, Kampala, Uganda
| | - Christine Muhumuza
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Makerere University School of Public Health, Department of Epidemiology and Biostatistics, New Mulago complex, P.O. Box 7072, Kampala, Uganda
| | - Nadine Sanchez
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Duke Global Health Institute, 310 Trent Dr, Durham, NC 27710, USA
| | - Anthony T Fuller
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Duke Global Health Institute, 310 Trent Dr, Durham, NC 27710, USA; Duke University, School of Medicine, 3100 Tower Blvd, Durham, NC 27707, USA
| | - Michael M Haglund
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Duke Global Health Institute, 310 Trent Dr, Durham, NC 27710, USA; Duke University, School of Medicine, 3100 Tower Blvd, Durham, NC 27707, USA
| | - Deborah C Koltai
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA; Duke University, Department of Neurology, 3116 N Duke St, Durham, NC 27704, USA; Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, DUMC Box 3119, Trent Drive, Durham, NC, USA.
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9
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Stakeholder views of the practical and cultural barriers to epilepsy care in Uganda. Epilepsy Behav 2021; 114:107314. [PMID: 32758404 DOI: 10.1016/j.yebeh.2020.107314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Epilepsy is one of the most prevalent, treatable neurological diseases globally. In sub-Saharan Africa, people with epilepsy (PWE) frequently seek treatment from traditional or pastoral healers, who are more accessible than biomedical care providers. This often contributes to the substantial time delay in obtaining adequate biomedical care for these patients. In Uganda, the few biomedical providers who can treat epilepsy cannot meet the great need for epilepsy care. Additionally, patients are often hesitant to seek biomedical care, often preferring the easily accessible and trusted sociocultural treatment options. This study sought to elucidate the barriers to biomedical care for PWE as well as identify potential solutions to overcome these barriers from various stakeholder perspectives. METHODS This study used qualitative research methods. Semistructured interviews and focus group discussions were conducted with four major stakeholder groups: PWE or family members of PWE, neurologists and psychiatrists, traditional healers, and pastoral healers. All interviews and focus group discussions that were in English were audio recorded and transcribed verbatim. Those that were not in English were translated live and audio recorded. A translator later translated the non-English portion of audio recording to ensure proper interpretation. Two independent coders coded the dataset and conducted an inter-rater reliability (IRR) assessment to ensure reliable coding of the data. Thematic analysis was then performed to discern themes from the data and compare nuances between each of the study design groups. RESULTS Participants discussed several different causes of epilepsy ranging from spiritual to biological causes, often incorporating elements of both. Commonly endorsed spiritual causes of epilepsy included witchcraft and ancestral spirits. Commonly endorsed biological causes included genetics, fever, malaria, and brain injury. For patients and families, beliefs about the cause of epilepsy often played a role in whom they chose to seek treatment from. Three major barriers to biomedical care were discussed: practical barriers, medical infrastructure barriers, and barriers related to stigma. Practical barriers related to issues such as transportation, cost of medical care, and distance to the nearest healthcare facility. Under medical infrastructure, drug stock-outs and lack of access to antiepileptic drugs (AEDs) were the most consistent problems stated among patients. Stigma was heavily discussed and brought up by nearly every participant. Additionally, three significant solutions to improving epilepsy care in Uganda were highlighted by participants: collaboration among treatment providers, community sensitization efforts to address stigma, and building medical infrastructure. Within building infrastructure, all participant types, except traditional healers, proposed the development of an epilepsy clinic designed to specifically treat epilepsy. CONCLUSIONS Based on these findings, there are four critical interventions that should be considered for improving epilepsy care in Uganda: the creation of dedicated epilepsy clinics, infrastructure strengthening to address medication stock-outs, community outreach programs for sensitization, and collaboration between biomedical providers and traditional healers. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".
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Kuwawenaruwa A, Wyss K, Wiedenmayer K, Metta E, Tediosi F. The effects of medicines availability and stock-outs on household's utilization of healthcare services in Dodoma region, Tanzania. Health Policy Plan 2020; 35:323-333. [PMID: 31942625 PMCID: PMC7152726 DOI: 10.1093/heapol/czz173] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 12/14/2022] Open
Abstract
Low- and middle-income countries have been undertaking health finance reforms to address shortages of medicines. However, data are lacking on how medicine availability and stock-outs influence access to health services in Tanzania. The current study assesses the effects of medicine availability and stock-outs on healthcare utilization in Dodoma region, Tanzania. We conducted a cross-sectional study that combined information from households and healthcare facility surveys. A total of 4 hospitals and 89 public primary health facilities were surveyed. The facility surveys included observation, record review over a 3-month period prior to survey date, and interviews with key staff. In addition, 1237 households within the health facility catchment areas were interviewed. Data from the facility survey were linked with data from the household survey. Descriptive analysis and multivariate logistic regressions models were used to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Eighteen medicines were selected as ‘tracers’ to assess availability more generally, and these were continuously available in ∼70% of the time in facilities across all districts over 3 months of review. The main analysis showed that household’s healthcare utilization was positively and significantly associated with continuous availability of all essential medicines for the surveyed facilities [odds ratio (OR) 3.49, 95% confidence interval (CI) 1.02–12.04; P = 0.047]. Healthcare utilization was positively associated with household membership in the community health insurance funds (OR 1.97, 95% CI 1.23–3.17; P = 0.005) and exposure to healthcare education (OR 2.75, 95% CI 1.84–4.08; P = 0.000). These results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, PO Box 78 373, Dar es Salaam, Tanzania.,Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland.,Swiss Centre for International Health (SCIH), Basel, Switzerland
| | - Karin Wiedenmayer
- Swiss Centre for International Health (SCIH), Basel, Switzerland.,Health promotion and System Strengthening (HPSS), Dodoma, Tanzania
| | - Emmy Metta
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, PO Box 78 373, Dar es Salaam, Tanzania.,School of Public Health and Social Sciences (SPHSS), Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
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Seeley J, Kabunga E, Ssembatya J, Tomlinson L, Fabian J, Smeeth L, Nyirenda M, Newton R, Kalyesubula R, Bukenya D. Understanding kidney disease in rural central Uganda - Findings from a qualitative study. Glob Public Health 2020; 15:1566-1577. [PMID: 32352888 PMCID: PMC7613296 DOI: 10.1080/17441692.2020.1758186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
As part of a multicentre study on kidney disease (ARK) undertaken in Malawi, South Africa and Uganda we undertook a social science component in Uganda to gather information on people's understandings and perceptions of a diagnosis of kidney dysfunction, treatment and treatment seeking. We recruited 46 people who had been given information about kidney dysfunction and had been found to have some, usually early, signs of mild impairment. Data were collected during two in-depth interviews. Most participants had heard of the condition, but half denied knowledge of the health status of their kidneys or receiving results of tests from the clinic team. This response may have been linked to a lack of symptoms, for those with early stage kidney dysfunction. The treatment people reported receiving caused some uncertainty about condition severity. This may be because several people were treated for other conditions (such as urinary tract infections) and did not require treatment specifically for kidney disease. In our study, participants assessed illness severity based on symptoms and treatment and compared with the progression of other conditions.
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Affiliation(s)
- Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | | | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Global Health, London School of Hygiene & Tropical Medicine, UK
| | - June Fabian
- Wits Donald Gordon Medical Centre, Parktown, Johannesburg, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Global Health, London School of Hygiene & Tropical Medicine, UK
| | - Moffat Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Global Health, London School of Hygiene & Tropical Medicine, UK
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Health Science, University of York, UK
| | - Robert Kalyesubula
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Global Health, London School of Hygiene & Tropical Medicine, UK
- Makerere University College of Health Sciences, Kampala, Uganda
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Mugisha JO, Seeley J. "We shall have gone to a higher standard": Training village heath teams (VHTs) to use a smartphone-guided intervention to link older Ugandans with hypertension and diabetes to care. AAS Open Res 2020; 3:25. [PMID: 35036832 PMCID: PMC8729021 DOI: 10.12688/aasopenres.13049.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background: It is not clear whether village health teams (VHTs) can be empowered to participate in interventions to prevent and control hypertension and diabetes in older adults in Uganda. We conducted this study in rural Uganda to establish the experiences of VHTs in managing older adults with health problems, their knowledge of hypertension and diabetes and their understanding of referral systems. We also explored their experiences with smartphones and whether VHTs could be effectively trained to use a smartphone-guided intervention to link older adults with hypertension and diabetes mellitus to care. Methods: We conducted in-depth interviews (IDIs) with and trained 20 VHTs randomly selected from Bukulula sub-county in Kalungu district from October 2017-December 2018. We used interview guides to explore topics relevant to our study objectives. VHTs were trained to measure blood sugar and blood pressure using digital machines. VHTs were trained on identifying symptoms of diabetes mellitus. Data from IDIs were analysed using thematic content analysis. Competence tests were used to evaluate the training. Results: Most of the VHTs were female (75%). All VHTs had some knowledge on hypertension and diabetes and other chronic diseases. They did not have any experience in treating older adults since they had been trained to deal mainly with children. Half of the VHTs owned smartphones. All were willing to participate in an intervention using a smartphone to link older adults with hypertension and diabetes mellitus to care. By the end of the training, all but three participants could comprehend the symptoms of diabetes and measure blood sugar and blood pressure. Conclusion: Village health teams in the study setting need training in managing the health needs of older adults before engaging with an intervention using smartphones to link older adults with diabetes mellitus and hypertension to care.
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Affiliation(s)
- Joseph Okello Mugisha
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, P.O.Box 49, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, P.O.Box 49, Entebbe, Uganda
- Department of Global Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Mugisha JO, Seeley J. "We shall have gone to a higher standard": Training village heath teams (VHTs) to use a smartphone-guided intervention to link older Ugandans with hypertension and diabetes to care. AAS Open Res 2020; 3:25. [PMID: 35036832 PMCID: PMC8729021 DOI: 10.12688/aasopenres.13049.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background: It is not clear whether village health teams (VHTs) can be empowered to participate in interventions to prevent and control hypertension and diabetes in older adults in Uganda. We conducted this study in rural Uganda to establish if VHTs could be effectively trained to use a smart phone guided intervention to link older people with hypertension and diabetes to care. We also explored the experiences of VHTs in managing older adults with health problems, their knowledge of hypertension and diabetes and their understanding of referral systems. We also explored their experiences with smartphones. Methods: We conducted in-depth interviews (IDIs) with and trained 20 VHTs randomly selected from Bukulula sub-county in Kalungu district from October 2017-December 2018. We used interview guides to explore topics relevant to our study objectives. VHTs were trained to measure blood sugar and blood pressure using digital machines. VHTs were trained on identifying symptoms of diabetes mellitus. Data from IDIs were analysed using thematic content analysis. Competence tests were used to evaluate the training. Results: Most of the VHTs were female (75%). All VHTs had some knowledge on hypertension and diabetes and other chronic diseases. They did not have any experience in treating older adults since they had been trained to deal mainly with children. Half of the VHTs owned smartphones. All were willing to participate in an intervention using a smartphone to link older adults with hypertension and diabetes mellitus to care. By the end of the training, all but three participants could comprehend the symptoms of diabetes and measure blood sugar and blood pressure. Conclusion: Village health teams in the study setting need training in managing the health needs of older adults before engaging with an intervention using smartphones to link older adults with diabetes mellitus and hypertension to care.
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Affiliation(s)
- Joseph Okello Mugisha
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, P.O.Box 49, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, P.O.Box 49, Entebbe, Uganda
- Department of Global Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Nankya-Mutyoba J, Aizire J, Makumbi F, Ocama P, Kirk GD. Hepatitis B virus perceptions and health seeking behaviors among pregnant women in Uganda: implications for prevention and policy. BMC Health Serv Res 2019; 19:760. [PMID: 31655575 PMCID: PMC6815411 DOI: 10.1186/s12913-019-4516-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/09/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With most countries in sub-Saharan Africa (SSA) lagging behind schedule to implement a comprehensive viral hepatitis elimination strategy, several barriers to accurate information and hepatitis B virus (HBV) services still exist, that are unique to different regions. In an obstetric population of a high HBV burden SSA setting without antenatal HBV services, we systematically evaluated perceptions and prevention behavioral intentions in relation to HBV and liver cancer. METHODS Eligible consenting pregnant women were recruited from public health care facilities in the central and northern regions of Uganda, between October 2016 and December 2017. Standardized procedures and instruments based on the health belief model and theory of planned behavior were used to collect data on socio-demographic characteristics, HBV perceptions and behavioral intentions. Descriptive analysis using Chi-square tests was done to obtain distribution of respondents by levels of perceived risk of HBV and liver cancer for themselves, their child under 5 years and their spouse. Modified Poisson regression analyses were used to evaluate relationships between perception variables and different behavioral outcomes (intention to screen, vaccinate and treat HBV). RESULTS Perceived risk (PRR = 0.95(0.90-1.00), p = 0.055) was inversely associated with intention to screen for HBV. Conversely, perceived self-efficacy showed a consistent association with intention to screen for HBV (PRR = 1.18(1.10-1.23) p = 0.005), to vaccinate (PRR = 1.20(1.05-1.36) p = 0.006) and to seek treatment for HBV (PRR = 1.40(1.18-1.67) p < 0.001). Women from the north, compared to the central region (PRR = 1.76 (1.13-2.72) p = 0.012), and those who self-identified as Catholic (PRR = 1.85 (0.99-3.56) p = 0.056), and as Protestant, (PRR = 2.22 (1.22-4.04) p = 0.002), were more likely to have higher perceived self-efficacy, compared to Muslims. Age and education were not related to perceived self-efficacy. CONCLUSION Women in both regions hold incorrect perceptions of HBV and liver cancer risk, with women from the central reporting higher perceived risk than those from the north. High perceived self-efficacy influenced intention to participate in HBV prevention. Programs and policies geared towards enhancing HBV prevention in this sub-population may consider socio-cultural factors observed to influence prevention behaviors. These findings may guide HBV interventions aimed at improving capacity to seek HBV prevention services, thereby promoting HBV micro-elimination in this sub-population.
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Affiliation(s)
- Joan Nankya-Mutyoba
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick Makumbi
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Ponsiano Ocama
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Kwizera R, Musaazi J, Meya DB, Worodria W, Bwanga F, Kajumbula H, Fowler SJ, Kirenga BJ, Gore R, Denning DW. Burden of fungal asthma in Africa: A systematic review and meta-analysis. PLoS One 2019; 14:e0216568. [PMID: 31095641 PMCID: PMC6521988 DOI: 10.1371/journal.pone.0216568] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/23/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Asthma is one of the neglected diseases in Africa with a high prevalence. Allergic fungal diseases have been reported to complicate asthma progression and treatment outcomes. However, data about fungal asthma and its associated complications are limited in Africa. We aimed to estimate the burden of fungal asthma among adults and children in Africa using a systematic review. METHODS We first engaged the Institute for Health Metrics and Evaluation (IHME) to highlight the trend in morbidity and mortality attributed to asthma in Africa. We then searched PubMed, HINARI and Google Scholar for all studies of any design focusing on fungal asthma in any African country. Languages were restricted to English and French, but not year of publication. We estimated the weighted prevalence of allergic fungal infections among asthmatics with a 95% CI and pooled the results using a random effects model. This study is registered with PROSPERO, number CRD42019117319. RESULTS The IHME data showed that there has been a gradual increase in morbidity and mortality due to asthma in African adults with a prevalence of 4%. Our search retrieved 5233 citations. We retained 20 studies that met our selection criteria. These were from 13 African countries published between 1967 and 2018. There were eight cross-sectional studies and twelve review articles. The average asthma prevalence in Africa was 6% from these studies. The prevalence of fungal sensitisation was relatively high (3-52%) in the asthmatic population with an average of 28% and a pooled estimate of 23.3%, mostly due to Aspergillus species. Prevalence of Allergic bronchopulmonary apsergillosis was estimated at 1.6-21.2%. Diagnosis of fungal allergy was mostly made by skin prick tests. There was no data on the use of medication to manage fungal asthma. None of the studies evaluated the association between fungal allergy and asthma severity. Data were lacking in children. CONCLUSION There is a high prevalence of fungal sensitization among Africans with asthma. Fungal asthma is a significant problem in Africa but there remains a paucity of data on the epidemiology and associated complications. There is urgent need for national epidemiological studies to estimate the actual burden of fungal asthma in Africa.
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Affiliation(s)
- Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Worodria
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Mulago National Referral Hospital, Kampala, Uganda
| | - Freddie Bwanga
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henry Kajumbula
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Stephen J. Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; NIHR Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Bruce J. Kirenga
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Mulago National Referral Hospital, Kampala, Uganda
| | - Robin Gore
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David W. Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Chang H, Hawley NL, Kalyesubula R, Siddharthan T, Checkley W, Knauf F, Rabin TL. Challenges to hypertension and diabetes management in rural Uganda: a qualitative study with patients, village health team members, and health care professionals. Int J Equity Health 2019; 18:38. [PMID: 30819193 PMCID: PMC6394065 DOI: 10.1186/s12939-019-0934-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/28/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The prevalence of hypertension and diabetes are expected to increase in sub-Saharan Africa over the next decade. Some studies have documented that lifestyle factors and lack of awareness are directly influencing the control of these diseases. Yet, few studies have attempted to understand the barriers to control of these conditions in rural settings. The main objective of this study was to understand the challenges to hypertension and diabetes care in rural Uganda. METHODS We conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals (HCPs), and 12 community health workers (known as village health team members [VHTs]) in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach. RESULTS The results replicated several findings from other settings, and identified some previously undocumented challenges including patients' knowledge gaps regarding the preventable aspects of HTN and DM, patients' mistrust in the Ugandan health care system rather than in individual HCPs, and skepticism from both HCPs and patients regarding a potential role for VHTs in HTN and DM management. CONCLUSIONS In order to improve hypertension and diabetes management in this setting, we recommend taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members.
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Affiliation(s)
- Haeyoon Chang
- Department of Epidemiology (Chronic Disease), Yale University School of Public Health, New Haven, CT USA
| | - Nicola L. Hawley
- Department of Epidemiology (Chronic Disease), Yale University School of Public Health, New Haven, CT USA
| | - Robert Kalyesubula
- African Community Center for Social Sustainability (ACCESS), Nakaseke, Uganda
- Department of Physiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA
- Center for Global Noncommunicable Disease Training and Research, Johns Hopkins University, Baltimore, MD USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA
- Center for Global Noncommunicable Disease Training and Research, Johns Hopkins University, Baltimore, MD USA
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Tracy L. Rabin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT USA
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
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Malamba-Lez D, Ngoy-Nkulu D, Steels P, Tshala-Katumbay D, Mullens W. Heart Failure Etiologies and Challenges to Care in the Developing World: An Observational Study in the Democratic Republic of Congo. J Card Fail 2018; 24:854-859. [PMID: 30359689 DOI: 10.1016/j.cardfail.2018.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 10/02/2018] [Accepted: 10/16/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Limited data are available regarding causes and outcomes of heart failure as well as organization of care in the developing world. METHODS AND RESULTS We included consecutive patients diagnosed with heart failure from November 2014 to September 2016 in a university and private hospital of Lubumbashi, Democratic Republic Congo. Baseline data, including echocardiography, were analyzed to determine factors associated with mortality. Cost of hospitalization as well as challenges for care regarding follow-up were determined. A total of 231 patients (56 ± 17 years, 47% men, left ventricular ejection fraction 29 ± 15%, 20% atrial fibrillation) were diagnosed, more during heart failure hospitalizations (69%) than as outpatients (31%). Main risk factors for heart failure included hypertension (59%), chronic kidney disease (51%), alcohol abuse (38%), and obesity (32%). Dilated cardiomyopathy was the most prevalent etiology (48%), with ischemic cardiomyopathy being present in only 4%. In-hospital mortality rate was 19% and associated with an estimated glomerular filtration rate of <60 mL·min-1·1.73 m-2 (P < .01) and atrial fibrillation (P = .02). One hundred six patients (46%) were lost to follow-up, which was mainly related to lack of organization of care, poverty, and poor health literacy. Of the remaining 95 subjects, another 33 (35%) died within 1 year after presentation. The average cost of care for a 10-day hospitalization was higher in a private than in a university hospital (885 vs 409 USD). CONCLUSIONS Patients admitted for heart failure in DRC have a high incidence of nonischemic cardiomyopathy and present late during their disease, with limited resources being available accounting for a high mortality rate and very high loss to follow-up.
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Affiliation(s)
- Didier Malamba-Lez
- Department of Internal Medicine, Faculty of Medicine, University of Lubumbashi, Democratic Republic of Congo; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
| | - Dophra Ngoy-Nkulu
- Department of Internal Medicine, Faculty of Medicine, University of Lubumbashi, Democratic Republic of Congo
| | - Paul Steels
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Désiré Tshala-Katumbay
- Department of Neurology and School of Public Health, Oregon Health & Science University, Portland OR, USA
| | - Wilfried Mullens
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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Tusuubira SK, Nakayinga R, Mwambi B, Odda J, Kiconco S, Komuhangi A. Knowledge, perception and practices towards sickle cell disease: a community survey among adults in Lubaga division, Kampala Uganda. BMC Public Health 2018; 18:561. [PMID: 29703184 PMCID: PMC5924488 DOI: 10.1186/s12889-018-5496-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/20/2018] [Indexed: 11/30/2022] Open
Abstract
Background Worldwide, the burden of Sickle Cell disease (SCD) has not been amply addressed. In Africa, Uganda has the 5th highest burden, a situation aggravated by limited and inaccessible formal social support structures to aid patients and families cope better with the psychosocial burden of SCD. In addition, this has been coupled with stigmatization and discrimination of people living with sickle cell disease causing isolation from family and society. Method This cross sectional study therefore set out to determine the attitudes, perception and level of awareness towards Sickle Cell disease in Ugandan communities. The study used an interviewer administered questionnaires to collect the data. Results Out of 110 people sampled; 91.2% of the respondents had ever heard of SCD with the highest proportion 38.7% hearing of SCD from friends and family. Close to half of the respondents 48% knew that SCD is inherited, however a large proportion 44.2% did not know the cause of SCD. However, 68.7% of the respondents said they cannot marry a person with SCD. Conclusion The study results indicate that more effort needs to be done to promote sickle cell awareness in Uganda communities with emphasis on the inclusion of sickle cell in health education campaigns.
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Affiliation(s)
- Sharifu K Tusuubira
- Uganda Sickle Cell Rescue Foundation, Plot 4/5 Hotel Close Wampewo Avenue, Clock Tower, P.O. Box 71887, Kampala, Uganda. .,Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda.
| | - Ritah Nakayinga
- Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda
| | - Bashir Mwambi
- Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda
| | - John Odda
- Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda
| | - Sylvia Kiconco
- Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda
| | - Alimah Komuhangi
- Clarke International University (formerly International Health Sciences University), St. Barnabas Road, Kisugu- Namuwongo, P.O.Box 7782, Kampala, Uganda
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Silver B, Ramaiya K, Andrew SB, Fredrick O, Bajaj S, Kalra S, Charlotte BM, Claudine K, Makhoba A. EADSG Guidelines: Insulin Therapy in Diabetes. Diabetes Ther 2018; 9:449-492. [PMID: 29508275 PMCID: PMC6104264 DOI: 10.1007/s13300-018-0384-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 01/25/2023] Open
Abstract
A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a combination of results with self-monitoring of blood glucose (SMBG) (B). Indications for exogenous insulin therapy in patients with type 2 diabetes mellitus (T2DM) include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy (B). In T2DM patients, with regards to achieving glycemic goals, insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol); and is essential for treatment in those with HbA1c ≥ 10% (≥ 86 mmol/mol), when diet, physical activity, and other antihyperglycemic agents have been optimally used (B). The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs) (B). If the desired glucose targets are not met, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime to control the expected postprandial raise in glucose. An insulin regimen should be adopted and individualized but should, to the extent possible, closely resemble a natural physiologic state and avoid, to the extent possible, wide fluctuating glucose levels (C). Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted in the patient's care plan. Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin (B). Metformin combined with insulin is associated with decreased weight gain, lower insulin dose, and less hypoglycemia when compared with insulin alone (C). Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of rebound hyperglycemia (D). Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia (B). The shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular (IM) injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them (A). Many patients in East Africa reuse syringes for various reasons, including financial. This is not recommended by the manufacturer and there is an association between needle reuse and lipohypertrophy. However, patients who reuse needles should not be subjected to alarming claims of excessive morbidity from this practice (A). Health care authorities and planners should be alerted to the risks associated with syringe or pen needles 6 mm or longer in children (A).
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Affiliation(s)
- Bahendeka Silver
- MKPGMS-Uganda Martyrs University | St. Francis Hospital, Nsambya, Kampala, Uganda.
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Chusi Street, Dar es Salaam, Tanzania
| | - Swai Babu Andrew
- Muhimbili University College of Health Sciences, United Nations Road, Dar es Salaam, Tanzania
| | - Otieno Fredrick
- Department of Clinical Medicine and Therapeutics School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, George Town, Allahabad, India
| | - Sanjay Kalra
- Bharti Research Institute of Diabetes and Endocrinology, Sector 12, PO Box 132001, Karnal, Haryana, India
| | - Bavuma M Charlotte
- University of Rwanda, College of Medicine and Health Science, Kigali University Teaching Hospital, Kigali, Rwanda
| | - Karigire Claudine
- Department of Internal Medicine, Rwanda Military Hospital, Kigali, Rwanda
| | - Anthony Makhoba
- MKPGMS-Uganda Martyrs University | St. Francis Hospital, Nsambya, Kampala, Uganda
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Galson SW, Staton CA, Karia F, Kilonzo K, Lunyera J, Patel UD, Hertz JT, Stanifer JW. Epidemiology of hypertension in Northern Tanzania: a community-based mixed-methods study. BMJ Open 2017; 7:e018829. [PMID: 29127232 PMCID: PMC5695455 DOI: 10.1136/bmjopen-2017-018829] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa is particularly vulnerable to the growing global burden of hypertension, but epidemiological studies are limited and barriers to optimal management are poorly understood. Therefore, we undertook a community-based mixed-methods study in Tanzania to investigate the epidemiology of hypertension and barriers to care. METHODS In Northern Tanzania, between December 2013 and June 2015, we conducted a mixed-methods study, including a cross-sectional household epidemiological survey and qualitative sessions of focus groups and in-depth interviews. For the survey, we assessed for hypertension, defined as a single blood pressure ≥160/100 mm Hg, a two-time average of ≥140/90 mm Hg or current use of antihypertensive medications. To investigate relationships with potential risk factors, we used adjusted generalised linear models. Uncontrolled hypertension was defined as a two-time average measurement of ≥160/100 mm Hg irrespective of treatment status. Hypertension awareness was defined as a self-reported disease history in a participant with confirmed hypertension. To explore barriers to care, we identified emerging themes using an inductive approach within the framework method. RESULTS We enrolled 481 adults (median age 45 years) from 346 households, including 123 men (25.6%) and 358 women (74.4%). Overall, the prevalence of hypertension was 28.0% (95% CI 19.4% to 38.7%), which was independently associated with age >60 years (prevalence risk ratio (PRR) 4.68; 95% CI 2.25 to 9.74) and alcohol use (PRR 1.72; 95% CI 1.15 to 2.58). Traditional medicine use was inversely associated with hypertension (PRR 0.37; 95% CI 0.26 to 0.54). Nearly half (48.3%) of the participants were aware of their disease, but almost all (95.3%) had uncontrolled hypertension. In the qualitative sessions, we identified barriers to optimal care, including poor point-of-care communication, poor understanding of hypertension and structural barriers such as long wait times and undertrained providers. CONCLUSIONS In Northern Tanzania, the burden of hypertensive disease is substantial, and optimal hypertension control is rare. Transdisciplinary strategies sensitive to local practices should be explored to facilitate early diagnosis and sustained care delivery.
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Affiliation(s)
- Sophie W Galson
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Catherine A Staton
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Global Neurosurgery and Neuroscience, Department of Neurosurgery, Duke Global Health Institute, Durham, North Carolina, USA
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Kajiru Kilonzo
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Uptal D Patel
- Department of Medicine, Duke Clinical Research Institute , Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - John W Stanifer
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, USA
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Abstract
ABSTRACTUganda's population is ageing, which comes with increased and varied burdens of disease and health-care needs. At the same time, gerontological care in Uganda remains neglected. This paper examines the factors that cause older Ugandans to delay health-care access. We conduct a thematic analysis of data drawn from nine focus groups held with rural Ugandans aged 60-plus. Our analysis highlights the factors that delay older persons’ access to health care and how these align with the Three-Delay Model, which was originally developed to assess and improve obstetric care in low-resource settings. Our participants report delays in deciding to seek care related to mobility and financial limitations, disease aetiology, severity and stigma (Delay I); reaching care because of poor roads and limited transportation options (Delay II); and receiving appropriate care because of ageism among health-care workers, and poorly staffed and under-supplied facilities (Delay III). We find these delays to care are interrelated and impacted by factors at the individual, community and health-system levels. We conclude by arguing for multi-pronged interventions that will address these delays, improve access to care and ultimately enhance older Ugandans’ health and wellbeing.
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Teixidor-Toneu I, Martin GJ, Puri RK, Ouhammou A, Hawkins JA. Treating infants with frigg: linking disease aetiologies, medicinal plant use and care-seeking behaviour in southern Morocco. JOURNAL OF ETHNOBIOLOGY AND ETHNOMEDICINE 2017; 13:4. [PMID: 28086924 PMCID: PMC5237284 DOI: 10.1186/s13002-016-0129-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/29/2016] [Indexed: 05/03/2023]
Abstract
BACKGROUND Although most Moroccans rely to some extent on traditional medicine, the practice of frigg to treat paediatric ailments by elderly women traditional healers known as ferraggat, has not yet been documented. We describe the role of these specialist healers, document the medicinal plants they use, and evaluate how and why their practice is changing. METHODS Ethnomedicinal and ethnobotanical data were collected using semi-structured interviews and observations of medical encounters. Information was collected from traditional healers, namely ferraggat, patients, herbalists and public health professionals. Patients' and healers' narratives about traditional medicine were analysed and medicinal plant lists were compiled from healers and herbalists. Plants used were collected, vouchered and deposited in herbaria. RESULTS Ferragat remain a key health resource to treat infant ailments in the rural High Atlas, because mothers believe only they can treat what are perceived to be illnesses with a supernatural cause. Ferragat possess baraka, or the gift of healing, and treat mainly three folk ailments, taqait, taumist and iqdi, which present symptoms similar to those of ear infections, tonsillitis and gastroenteritis. Seventy plant species were used to treat these ailments, but the emphasis on plants may be a recent substitute for treatments that used primarily wool and blood. This change in materia medica is a shift in the objects of cultural meaningfulness in response to the increasing influence of orthodox Islam and state-sponsored modernisation, including public healthcare and schooling. CONCLUSIONS Religious and other sociocultural changes are impacting the ways in which ferraggat practice. Treatments based on no-longer accepted symbolic elements have been readily abandoned and substituted by licit remedies, namely medicinal plants, which play a legitimisation role for the practice of frigg. However, beliefs in supernatural ailment aetiologies, as well as lack or difficult access to biomedical alternatives, still underlie the need for specialist traditional healers.
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Affiliation(s)
- Irene Teixidor-Toneu
- Section of Ecology and Evolutionary Biology (EEB), Harborne Building, School of Biological Sciences, University of Reading, Whiteknights, Reading, RG6 6AS UK
| | | | - Rajindra K. Puri
- Centre for Biocultural Diversity, School of Anthropology and Conservation, University of Kent, Canterbury, Kent CT2 7NR UK
| | - Ahmed Ouhammou
- Department of Biology, Laboratory of Ecology and Environment, Regional Herbarium MARK, Faculty of Sciences Semlalia, Cadi Ayyad University, PO Box 2390, Marrakech, 40001 Morocco
| | - Julie A. Hawkins
- Section of Ecology and Evolutionary Biology (EEB), Harborne Building, School of Biological Sciences, University of Reading, Whiteknights, Reading, RG6 6AS UK
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