Factors Motivating Traditional Healer versus Biomedical Facility Use for Treatment of Pediatric Febrile Illness: Results from a Qualitative Study in Southwestern Uganda

Traditional healers' knowledge and infection control practices related to HIV in Bukavu City, Democratic Republic of the Congo

BACKGROUND

Patients with HIV consult traditional healers (THs). These THs can both delay care for people living with HIV (PLHIV) and transmit HIV through poor infection control practices. The main objective of this study was to evaluate knowledge and practices of THs regarding HIV in Bukavu.

METHODS

A cross-sectional study using quantitative approach was carried out among 71 THs in Bukavu City. The collected data included the following topics: personal and socio-demographic characteristics, HIV knowledge, and infection control practices. Descriptive statistics, independent-samples T-test or F-test, and multiple linear regression were used to analyze the data with a p-value < 0.05.

RESULTS

The THs' mean age was 49.2 ± 11.2 years, and the majority were aged 40 to < 60 years. Males constituted 88.7% of THs with a male-to-female ratio of 7.9. In general, 47.9% of study participants had poor knowledge about HIV/AIDS infection, 45.1% of them had fair knowledge, and only 7.0% had good knowledge. Overall, 43.7% of THs had poor infection control practices, 52.1% of THs had fair practices, and only 4.2% of participants had good practices. Results of multiple linear regression analysis revealed that none of the personal and demographic variables studied were significant predictors of their knowledge about HIV/AIDS (p > 0.05). In terms of practices, two variables were significant predictors of infection control practices: living in Ibanda and receiving training in taking care of HIV/AIDS.

CONCLUSION AND RECOMMENDATIONS

The study revealed that THs' knowledge about HIV infection was insufficient and that they had poor infection control practices. Formal standardized training on HIV infection should be organized for all THs so that they can always refer their patients to modern, reliable antiretroviral therapy (ART) clinics and reduce the risk of occupational exposure in their practices. Although PPE's assistance for THs is required in terms of protective measures, the province health authority must also oversee infection control procedures at THs' offices.

Factors influencing fever care-seeking for children under five years of age in The Gambia: a secondary analysis of 2019-20 DHS data

BACKGROUND

Malaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies.

METHODS

This cross-sectional analysis of The Gambia 2019-20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics.

RESULTS

Only 52.0% of mothers sought care from a trained healthcare provider for a child with fever-45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504-4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165-0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274-4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291-0.959).

CONCLUSIONS

Maintaining The Gambia's malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

Practices and attitudes of herbalists regarding informed consent in Uganda: A qualitative study

Background

Informed consent (IC) is a fundamental principle in medical ethics that upholds respect for patient autonomy. Although widely applied in healthcare, its feasibility and implementation in herbal medicine have been underexplored. This study therefore aimed to explore the practices and attitudes of herbalists regarding informed consent.

Methods

To achieve these objectives, a qualitative cross-sectional study was conducted from June to December 2020. Twenty-one in-depth interviews with herbalists and four key informant interviews with leaders of the different traditional medicine organizations were also conducted. The data were analyzed thematically using NVivo version 12 software.

Results

Sixteen of the twenty-one participants acquired oral herbal medicine knowledge from their relatives. Although a positive inclination toward obtaining IC was evident, the focus was on disclosing basic information. Discussions of alternative treatments and herbal specifics less frequent. Disease management decisions often involve shared responsibility within families or societies. Documented IC procedures are rare among herbalists, who deem consent forms unnecessary, although they recognize the potential benefits of IC in fostering trust and professionalism. Challenges hindering IC implementation included regulatory gaps, inadequate skills, and the absence of mechanisms to protect the intellectual property rights of herbal medicine.

Conclusion

This study illuminates how educational, cultural, familial, and regulatory factors influence herbalists' practices and attitudes toward informed consent.

Healthcare-seeking behaviours among mother's having under-five children with severe wasting in Dodoma and Mbeya regions of Tanzania-A qualitative study

Maternal healthcare-seeking behaviour affects the health and well-being of under-five children. Drawing from the concepts of the health belief model, this study seeks to understand the determinants of health-seeking behaviours among mothers or caregivers of under-five-year-old children having severe wasting in Tanzania. A qualitative study employing the ethnography method conducted 32 semi-structured and narrative interviews with healthcare workers, community health workers, traditional healers, religious and village leaders, and mothers or caregivers of children who had acute malnutrition. The analysis of transcripts was done by qualitative content analysis. Further, the thematic analysis was carried out by assigning data into relevant codes to generate categories based on study objectives. Severe wasting among under-five-year-old children was not observed as a serious disease by the majority of mothers or caregivers. The study established that the health systems parameters such as the availability of the community health workers or healthcare providers and the availability of medicines and supplies to the health facility impact on mothers' or caregivers' healthcare-seeking behaviours. The findings also show that long distances to the health facility, behavioural parameters such as lack of awareness, negative perception of the management of severe wasting at the health facility, superstitious beliefs, women's workload, household food insecurity, and gender issues have a significant role in seeking healthcare. The results reaffirm how a programme on integrated management of severe wasting in Tanzania should encompass sociocultural factors that negatively influence mothers or caregivers of children with acute malnutrition. The programme should focus on engaging community structures including traditional healers, religious and village leaders to address prevailing local beliefs and sociocultural factors.

Traditional health practitioners' training needs on biomedical knowledge and skills in a South African township

BACKGROUND

Traditional health practitioners (THPs) play an important role in communities by providing necessary health services for a variety of health problems. Possessing complementary biomedical knowledge and skills is vital in saving lives of patients. However, less is known about biomedical knowledge and skills among THPs.

AIM

This study aimed to explore and describe the training needs of THPs on biomedical knowledge and skills in urban townships in South Africa.

SETTING

The study was conducted in a township in the City of Tshwane Metropolitan Municipality of Gauteng province, South Africa.

METHODS

A qualitative, explorative, descriptive design with 18 THPs was employed through snowballing sampling. Data were collected through a lekgotla group discussion and thematic content analysis undertaken.

RESULTS

Themes that emanated include knowledge of the basic physiological functioning of the human body; biomedical knowledge and skills required for the assessment of patients; managing emergency health conditions and understanding diagnostic concepts used in traditional health practice versus biomedical systems.

CONCLUSION

Traditional health practitioners have demonstrated interest in being trained on certain skills used within the biomedical system to care for patients. Performing the necessary first-aid skills by THPs will assist patients in the communities while waiting for emergency services or referrals. Provision of training programmes for THPs on first aid interventions during emergencies is therefore recommended.Contribution: The study revealed that capacitating THPs with biomedical knowledge and skills can improve their ability to promote healthy living and prevent health problems in communities where access to resources is limited.

Uvula infections and traditional uvulectomy: Beliefs and practices in Luwero district, central Uganda

Uvulitis is the inflammation and swelling of the uvula, usually associated with infection of nearby structures. Uvulitis can be treated symptomatically, using medication or in some cases with uvulectomy, the uvula surgical removal or shortening. Traditional uvulectomy by traditional practitioners has been practiced in Africa for ages, associated with adverse outcomes. Although there is no empirical evidence for the association between adverse outcomes and traditional uvulectomy in Uganda, anecdotal findings showed incidents of uvula infections following uvulectomy in central Uganda. While these findings also indicate that traditional uvulectomy is common, the community understanding of uvulitis, the beliefs and practices are not well understood. This qualitative study sought to understand beliefs and practices using interviews with community health workers, traditional uvulectomy clients, and traditional surgeons, and focus group discussions with community members. Transcribed data were analysed in Atlas.ti 9 using thematic analysis steps. The findings show that uvula infection, locally known as "Akamiro" and the associated traditional uvulectomy are common in Luwero and beyond. "Akamiro" was described as larger than the normal, the size of a chicken heart or a big pimple, visible when a child cries, with unknown causes. Symptoms included persistent cough, diarrhoea, vomiting, loss of appetite, inability to swallow and ultimately weight loss, swollen stomach, saliva overflow, fever, breathing and speech difficulty. Diagnosis was confirmed after seeking care from health workers or in consultation with significant others and finally the traditional surgeon; in a hierarchical pattern. Uvulectomy was conducted by traditional surgeons, with surgery lasting a few minutes, in the morning or after sun-set. Tools used were razor blades, reeds, strings, wires, sickle knives and spoons. Payment was flexible; cash or in-kind. Surgeons had immense community trust, including community health workers. Interventions to support persons with uvula infections need to address the health system weaknesses, and health education.

Impact of beliefs on perception of newborn illness, caregiver behaviors, and care-seeking practices in Zambia's Southern province

Despite reductions in the number of under-five deaths since the release of the Sustainable Development Goals, the proportion of neonatal deaths among all under-five deaths has remained high. Neonatal health is linked to newborn care practices which are tied to distinct cultural perceptions of health and illness. We assessed how community beliefs in Zambia's Southern Province influence newborn care behaviors, perception of illness, and care-seeking practices, using qualitative data collected between February and April 2010. A total of 339 women participated in 36 focus group discussions (FGDs), with 9 FGDs conducted in each of the four study districts. In addition, 42 in-depth interviews (IDIs) were conducted with various key informants, with 11 IDIs conducted in Choma, 11 IDIs in Monze, 10 IDIs in Livingstone, and 10 IDIs in Mazabuka. The FGDs and IDIs indicate that beliefs among the Tonga people regarding postnatal illness prevention and management influence perceptions of newborn illness and care-seeking practices. Care seeking behaviors including when, why, and where parents seek newborn care are intimately tied to perception of disease among the Tonga people. These beliefs may stem from both indigenous and Western perspectives in Zambia's Southern Province. Findings are consistent with other analyses from Southern Province that highlighted the benefit of integrating local practices with Western biomedical care. Health systems models, led by policy makers and program designers, could aim to find synergies between community practices and formal health systems to support positive behavior change and satisfy multiple stakeholders.

Health itinerary-related survival of children under-five with severe malaria or bloodstream infection, DR Congo

BACKGROUND

Prompt appropriate treatment reduces mortality of severe febrile illness in sub-Saharan Africa. We studied the health itinerary of children under-five admitted to the hospital with severe febrile illness in a setting endemic for Plasmodium falciparum (Pf) malaria and invasive non-typhoidal Salmonella infections, identified delaying factors and assessed their associations with in-hospital death.

METHODOLOGY

Health itinerary data of this cohort study were collected during 6 months by interviewing caretakers of children (>28 days - <5 years) admitted with suspected bloodstream infection to Kisantu district hospital, DR Congo. The cohort was followed until discharge to assess in-hospital death.

PRINCIPAL FINDINGS

From 784 enrolled children, 36.1% were admitted >3 days after fever onset. This long health itinerary was more frequent in children with bacterial bloodstream infection (52.9% (63/119)) than in children with severe Pf malaria (31.0% (97/313)). Long health itinerary was associated with in-hospital death (OR = 2.1, p = 0.007) and two thirds of deaths occurred during the first 3 days of admission. Case fatality was higher in bloodstream infection (22.8% (26/114)) compared to severe Pf malaria (2.6%, 8/309). Bloodstream infections were mainly (74.8% (89/119)) caused by non-typhoidal Salmonella. Bloodstream infections occurred in 20/43 children who died in-hospital before possible enrolment and non-typhoidal Salmonella caused 16 out of these 20 bloodstream infections. Delaying factors associated with in-hospital death were consulting traditional, private and/or multiple providers, rural residence, prehospital intravenous therapy, and prehospital overnight stays. Use of antibiotics reserved for hospital use, intravenous therapy and prehospital overnight stays were most frequent in the private sector.

CONCLUSIONS

Long health itineraries delayed appropriate treatment of bloodstream infections in children under-five and were associated with increased in-hospital mortality. Non-typhoidal Salmonella were the main cause of bloodstream infection and had high case fatality.

TRIAL REGISTRATION

NCT04289688.

Improving the Management of Children with Fevers by Healers in Native Rural Areas in the South of Ecuador

BACKGROUND

Indigenous populations are represented among the poor and disadvantaged in rural areas. High rates of infectious diseases are observed in indigenous child populations, and fever as a general symptom is common.

OBJECTIVE

We aim to improve the skills of healers in rural indigenous areas in the South of Ecuador for managing children with fevers.

METHOD

We performed participatory action research (PAR) for this study with 65 healers.

RESULTS

The PAR focused on the following four phases: (1) 'observation,' eight focus groups were used. (2) 'planning' phase was developed, and with culturally reflective peer group sessions, a culturally adapted flowchart was constructed titled "Management of children with fever." In phase (3): 'action', the healers were trained to manage children with fever. Phase (4): 'evaluation', 50% of the healers used the flowchart.

CONCLUSIONS

Explicit recognition of the need for traditional healers and health professionals in indigenous communities to work together to improve health indicators such as infant mortality exists. Additionally, strengthening the transfer system in rural areas is based on knowledge and cooperation between the community and the biomedical system.

Traditional Medicine Beliefs and Practices among Caregivers of Children under Five Years-The Child Health and Mortality Prevention Surveillance (CHAMPS), Western Kenya: A qualitative study

BACKGROUND

Approximately 80% of the population residing in sub-Saharan Africa relies on Traditional Medicine (TM). However, literature on factors motivating the use of TM for children under the age of five in these settings is limited. Such information can guide policy formulation for integration of TM into mainstream health care services. This study aimed to describe the motivation on use of TM among caregivers of children residing in rural and urban communities in western Kenya.

METHODS

The socio-behavioral sciences (SBS) arm of the Child Health and Mortality Prevention Surveillance (CHAMPS) program in western Kenya, conducted a cross-sectional qualitative study in Manyatta-an urban informal settlement located in Kisumu town and Karemo-a rural setting in Siaya County. We performed 29 in-depth interviews, 5 focus group discussions and 11 semi-structured interviews with community representatives (n = 53), health workers (n = 17), and community leaders (n = 18). All the participants were purposively sampled. We performed thematic analysis using both inductive and deductive approaches. Data management was completed on Nvivo 11.0 software (QSR International, Melbourne, Australia).

RESULTS

Our findings reveal that some caregivers prefer TM to treat some childhood diseases. Use of TM was informed by illness beliefs about etiology of disease. We observed an appreciation from the study participants that malaria can effectively be treated by Conventional Medicine (CM) while TM was preferred to treat measles and diseases believed to be associated with supernatural etiology such as witchcraft, evil spirit or breaching cultural taboos. TM was also used in instances where CM failed to provide a diagnosis or when CM was 'slow'. TM in such cases was used as a last resort.

CONCLUSION

We observed varied beliefs that motivate caregivers' choice of TM use among children in western Kenya. It is therefore crucial to consider perceptions and socio-cultural beliefs about illnesses when formulating interventions that are geared towards child health.

Evaluation of the Polyphenolic Composition and Bioactivities of Three Native Cabo Verde Medicinal Plants

The use of medicinal plants in a variety of health conditions remains essential for the discovery of new treatments. The present study aimed to investigate the bioactive properties of three native plants from Cabo Verde Islands, namely Artemisia gorgonum Webb, Sideroxylon marginatum (Decne. ex Webb) Cout., and Tamarix senegalensis DC., contributing to the characterization of less-known medicinal plants and their potential benefits for human health. Known compounds, such as kaempferol, quercetin, caffeyolquinic, and apigenin derivatives, among others, were detected in the plant species under study. Overall, all species demonstrated good antioxidant capacity, especially the ethanolic extracts of A. gorgonum (EC50 = 0.149 mg/mL) in TBARS assay. Moreover, the ethanolic extracts of the studied plants showed cytotoxic properties against tumor cells, and again the A. gorgonum extract proved to be the most effective in inhibiting tumor growth, mainly in the CaCO₂ (GI50 = 17.3 μg/mL) and AGS (GI50 = 18.2 μg/mL) cell lines. Only the ethanolic extracts of T. senegalensis and S. marginatum demonstrated anti-inflammatory activity, albeit weak (EC50 = 35 and 43 μg/mL, respectively). The present study contributed to increased knowledge about the bioactive properties of these plants commonly used in traditional medicine, some of which was discussed for the first time, opening new perspectives for their use in a wider range of health conditions, especially in African countries, where access to modern health care is more limited.

Understanding the role of traditional healers in the HIV care cascade: Findings from a qualitative study among stakeholders in Mwanza, Tanzania

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.

How informal healthcare providers improve uptake of HIV testing: qualitative results from a randomized controlled trial

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.

Factors associated with HIV testing among traditional healers and their clients in rural Uganda: Results from a cross-sectional study

Uptake of HIV testing is suboptimal in Uganda, particularly in rural communities. Reaching UNAIDS 95-95-95 goals requires strategies to increase HIV testing among hard-to-reach populations. This cross-sectional study sought to characterize engagement with HIV testing among traditional healers and their clients in rural Uganda. We enrolled 175 traditional healers and 392 adult clients of healers in Mbarara District. The primary outcome for this study was having received an HIV test in the prior 12 months. Most clients (n = 236, 65.9%) had received an HIV test within 12 months, compared to less than half of healers (n = 75, 46.3%) who had not. In multivariate regression models, male clients of healers were half as likely to have tested in the past year, compared with female (adjusted odds ratios (AORs) = 0.43, 95% CI = 0.26-0.70). Increasing age negatively predicted testing within the past year (AOR = 0.95, 95% CI = 0.93-0.97) for clients. Among healers, more sexual partners predicted knowing ones serostatus (AOR = 1.6, 95% CI 1.03-2.48). Healers (AOR = 1.16, 95% CI 1.07-1.26) and clients (AOR = 1.28, 95% CI 1.13-1.34 for clients) with greater numbers of lifetime HIV tests were more likely to have tested in the past year. Traditional healers and their clients lag behind UNAIDS benchmarks and would benefit from programs to increase HIV testing uptake.

Care-seeking during fatal childhood illness in rural South Africa: a qualitative study

OBJECTIVES

This study aimed to better understand reasons why children in South Africa die at home, including caregivers' care-seeking experiences, decision-making, choice of treatment provider and barriers to accessing care during a child's final illness.

DESIGN

This qualitative study included semi-structured in-depth interviews and focus group discussions with caregivers of children who died below the age of 5 years. Data were thematically analysed, and key findings compared with the Pathways to Survival Framework-a model frequently used in the study of child mortality. An adapted model was developed.

SETTING

Two rural health and demographic surveillance system (HDSS) sites in South Africa-the Agincourt HDSS and the Africa Health Research Institute.

PARTICIPANTS

Thirty-eight caregivers of deceased children (29 participated in in-depth interviews and 9 were participants in two focus group discussions). Caregivers were purposively sampled to ensure maximum variation across place of death, child age at death, household socioeconomic status, maternal migration status and maternal HIV status.

FINDINGS

Although caregivers faced barriers in providing care to children (including insufficient knowledge and poor transport), almost all did seek care from the formal health system. Negative experiences in health facilities did not deter care-seeking, but most respondents still received poor quality care and were not given adequate safety-netting advice. Traditional healers were only consulted as a last resort when other approaches had failed.

CONCLUSION

Barriers to accessing healthcare disrupt the workings of previously accepted care-seeking models. The adapted model presented in this paper more realistically reflects care-seeking experiences and decision-making during severe childhood illness in rural South Africa and helps explain both the persistence of home deaths despite seeking healthcare, and the impact of a child's death on care-seeking in future childhood illness. This model can be used as the basis for developing interventions to reduce under-5 mortality.

Shortening "the Road" to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda

In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.

Exploring country-wide equitable government health care facility access in Uganda

Background

Rural access to health care remains a challenge in Sub-Saharan Africa due to urban bias, social determinants of health, and transportation-related barriers. Health systems in Sub-Saharan Africa often lack equity, leaving disproportionately less health center access for the poorest residents with the highest health care needs. Lack of health care equity in Sub-Saharan Africa has become of increasing concern as countries enter a period of simultaneous high infectious and non-communicable disease burdens, the second of which requires a robust primary care network due to a long continuum of care. Bicycle ownership has been proposed and promoted as one tool to reduce travel-related barriers to health-services among the poor.

Methods

An accessibility analysis was conducted to identify the proportion of Ugandans within one-hour travel time to government health centers using walking, bicycling, and driving scenarios. Statistically significant clusters of high and low travel time to health centers were calculated using spatial statistics. Random Forest analysis was used to explore the relationship between poverty, population density, health center access in minutes, and time saved in travel to health centers using a bicycle instead of walking. Linear Mixed-Effects Models were then used to validate the performance of the random forest models.

Results

The percentage of Ugandans within a one-hour walking distance of the nearest health center II is 71.73%, increasing to 90.57% through bicycles. Bicycles increased one-hour access to the nearest health center III from 53.05 to 80.57%, increasing access to the tiered integrated national laboratory system by 27.52 percentage points. Significant clusters of low health center access were associated with areas of high poverty and urbanicity. A strong direct relationship between travel time to health center and poverty exists at all health center levels. Strong disparities between urban and rural populations exist, with rural poor residents facing disproportionately long travel time to health center compared to wealthier urban residents.

Conclusions

The results of this study highlight how the most vulnerable Ugandans, who are the least likely to afford transportation, experience the highest prohibitive travel distances to health centers. Bicycles appear to be a “pro-poor” tool to increase health access equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01371-5.

Exploring communities' perceptions of the etiology of illnesses in newborns and young infants 0-59 days old in 4 counties in Kenya

BACKGROUND

Understanding communities' beliefs about the causes of illnesses in sick young infants (SYIs) is key to strengthening interventions and improving newborn health outcomes. This study explored communities' perception of the etiology of illnesses in SYIs 0-59 days old in four counties in Kenya.

METHODS

We used an exploratory qualitative study design. Data were collected between August and September 2018 and involved 23 in-depth interviews with female caregivers aged 15-24years; 25 focus group discussions with female caregivers aged 15-18 years, 19-24 years and 25-45 years; and 7 focus group discussions with fathers aged 18-34 years and 35 or more years. Participants were purposely sampled, only those with SYIs 0-59 days old were eligible to participate. Data were analyzed using inductive thematic analysis framework approach.

RESULTS

Female caregivers and fathers attributed illnesses in SYIs 0-59 days old to natural (biomedical) and supernatural causes which sometimes co-existed. There were commonalities in perceived natural causes of illness in SYIs across sites, age groups and gender. Perceived natural causes of illness in SYIs include unfavorable environmental and hygiene conditions, poor maternal and child nutrition, and healthcare practices. Perceived supernatural causes of illness in SYIs such as 'evil eyes' were common across the four counties while others were geographically unique such as the belief that owls cause illnesses.

CONCLUSION

Communities' understanding of the etiology of illnesses in SYIs in the study settings overlapped between natural and supernatural causes. There is need for child health programmes to take into consideration communities' beliefs and practices regarding disease and health to improve newborn health outcomes.