Bridging the gap: exploring the attitudes and beliefs of nurses and patients about coexisting traditional and biomedical healthcare systems in a rural setting in KwaZulu-Natal

The relationship between Indigenous and allopathic health practitioners in Africa and its implications for collaboration: a qualitative synthesis

BACKGROUND

There have been increasing calls for collaboration between Indigenous health practitioners (IHPs) and allopathic health practitioners (AHPs) in Africa. Despite this, very few successful systems exist to facilitate formal collaboration. Direct relationships between providers, and at a health systems level are crucial to successful collaboration, but the nature and extent of these relationships have yet to be adequately explored.

OBJECTIVE

To explore the relationship between IHPs and AHPs in Africa, and to discuss the implications of this for future collaboration.

METHODS

An interpretive qualitative synthesis approach, combining elements of thematic analysis, meta-ethnography, and grounded theory, was used to systematically bring together findings of qualitative studies addressing the topic of collaboration between Indigenous and allopathic health practitioners in Africa.

RESULTS

A total of 1,765 papers were initially identified, 1,748 were excluded after abstract, full text and duplicate screening. Five additional studies were identified through references. Thus, 22 papers were included in the final analysis. We found that the relationship between Indigenous and allopathic health practitioners is defined by a power struggle which gives rise to lack of mutual understanding, rivalry, distrust, and disrespect.

CONCLUSION

The power struggle which defines the relationship between IHPs and AHPs in Africa is a hindrance to their collaboration and as such could partly account for the limited success of efforts to foster collaboration to date. Future efforts to foster collaboration between IHPs and AHPs in Africa must aim to balance the power disparity between them if collaboration is to be successful. Since this would be a novel approach, decision-makers and organisations who trial this power balancing approach to facilitate collaboration should evaluate resultant policies and interventions to ascertain their feasibility and efficacy in fostering collaboration, and the lessons learnt should be shared.

The Croton megalobotrys Müll Arg. traditional medicine in HIV/AIDS management: Documentation of patient use, in vitro activation of latent HIV-1 provirus, and isolation of active phorbol esters

ETHNOPHARMACOLOGICAL RELEVANCE

Current HIV therapies do not act on latent cellular HIV reservoirs; hence they are not curative. While experimental latency reversal agents (LRAs) can promote HIV expression in these cells, thereby exposing them to immune recognition, existing LRAs exhibit limited clinical efficacy and high toxicity. We previously described a traditional 3-step medicinal plant regimen used for HIV/AIDS management in Northern Botswana that inhibits HIV replication in vitro. Here we describe use of one component of the regimen that additionally contains novel phorbol esters possessing HIV latency-reversal properties.

AIM OF THE STUDY

We sought to document experiences of traditional medicine users, assess the ability of traditional medicine components to reverse HIV latency in vitro, and identify pure compounds that conferred these activities.

MATERIALS AND METHODS

Experiences of two HIV-positive traditional medicine users (patients) were documented using qualitative interview techniques. Latency reversal activity was assessed using a cell-based model (J-Lat, clone 9.2). Crude plant extracts were fractionated by open column chromatography and reverse-phase HPLC. Compound structures were elucidated using NMR spectroscopy and mass spectrometry.

RESULTS

Patients using the 3-step regimen reported improved health over several years despite no reported use of standard HIV therapies. Crude extracts from Croton megalobotrys Müll Arg. ("Mukungulu"), the third component of the 3-step regimen, induced HIV expression in J-lat cells to levels comparable to the known LRA prostratin. Co-incubation with known LRAs and pharmacological inhibitors indicated that the active agent(s) in C. megalobotrys were likely to be protein kinase C (PKC) activator(s). Consistent with these results, two novel phorbol esters (Namushen 1 and 2) were isolated as abundant components of C. megalobotrys and were sufficient to confer HIV latency reversal in vitro.

CONCLUSION

We have identified novel LRAs of the phorbol ester class from a medicinal plant used in HIV/AIDS management. These data, combined with self-reported health effects and previously-described in vitro anti-HIV activities of this traditional 3-step regimen, support the utility of longitudinal observational studies of patients undergoing this regimen to quantify its effects on plasma viral loads and HIV reservoir size in vivo.

Insights into health care seeking behaviour for children in communities in KwaZulu-Natal, South Africa

Background

South African infant and child mortality remains high, with many deaths occurring outside the formal health services. Delayed health care seeking represents a large proportion of these deaths.

Aim

To generate knowledge about the role of, and influences on, caregivers with regard to decision-making about when and where to seek care for sick children.

Setting

Two communities in KwaZulu-Natal.

Methods

A qualitative, exploratory design employing participatory research techniques was used to undertake focus group discussions with community members.

Results

Health care seeking for a sick child was described as a complex process influenced by multiple carers using multiple providers. Decision-making about seeking health care for a sick child was not an individual effort, but was shared with others in the household and guided by how the symptoms were perceived, either a Western illness or African illness. A sick child could either be treated at home or be taken to a variety of places including clinics, private doctors, traditional healers, faith healers and hospitals. Traditional healers were associated with the treatment of illnesses perceived to be traditional. Few participants said that they would take their child back to the original health provider if the child remained ill, but would move from one provider to another until the child’s health improved.

Conclusion

The formal health system needs to ensure that sick children are identified and managed appropriately to reduce child deaths. Knowledge and understanding of health care seeking behaviour for sick children by carers is an important aspect. Interventions need to be designed with these contextual issues in mind.

Traditional, complementary and alternative medicine use by HIV patients a decade after public sector antiretroviral therapy roll out in South Africa: a cross sectional study

Background

The roll out of antiretroviral therapy in the South African public health sector in 2004 was preceded by the politicisation of HIV-infection which was used to promote traditional medicine for the management of HIV/AIDS. One decade has passed since; however, questions remain on the extent of the use of traditional, complementary and alternative medicine (TCAM) by HIV-infected patients. This study therefore aimed at investigating the prevalence of the use of African traditional medicine (ATM), complementary and alternative medicines (CAM) by adult patients in the eThekwini and UThukela Health Districts, South Africa.

Methods

A cross- sectional study was carried out at 8 public health sector antiretroviral clinics using interviewer-administered semi-structured questionnaires. These were completed from April to October 2014 by adult patients who had been on antiretroviral therapy (ART) for at least three months. Use of TCAM by patients was analysed by descriptive statistics using frequency and percentages with standard error. Where the associated relative error was equal or greater to 0.50, the percentage was rejected as unstable. A p-value <0.05 was estimated as statistically significant.

Results

The majority of the 1748 participants were Black Africans (1685/1748, 96.40 %, SE: 0.00045), followed by Coloured (39/1748, 2.23 %, SE: 0.02364), Indian (17/1748, 0.97 %, SE: 0.02377), and Whites (4/1748, 0.23 %, SE: 0.02324), p < 0.05. The prevalence of ATM use varied prior to (382/1748, 21.85 %) and after ART initiation (142/1748, 8.12 %), p <0.05, specifically by Black African females both before (14.41 %) and after uptake (5.49 %), p < 0.05. Overall, 35 Black Africans, one Coloured and one Indian (37/1748, 2.12 %) reported visiting CAM practitioners for their HIV condition and related symptoms post ART.

Conclusion

Despite a progressive implementation of a successful antiretroviral programme over the first decade of free antiretroviral therapy in the South African public health sector, the use of TCAM is still prevalent amongst a small percentage of HIV infected patients attending public healthcare sector antiretroviral clinics. Further research is needed to explore reasons for use and health benefits or risks experienced by the minority that uses both conventional antiretroviral therapy with TCAM.

Experiences of a Community-Based Lymphedema Management Program for Lymphatic Filariasis in Odisha State, India: An Analysis of Focus Group Discussions with Patients, Families, Community Members and Program Volunteers

Background

Globally 68 million people are infected with lymphatic filariasis (LF), 17 million of whom have lymphedema. This study explores the effects of a lymphedema management program in Odisha State, India on morbidity and psychosocial effects associated with lymphedema.

Methodology/Principal Findings

Focus groups were held with patients (eight groups, separated by gender), their family members (eight groups), community members (four groups) and program volunteers (four groups) who had participated in a lymphedema management program for the past three years. Significant social, physical, and economic difficulties were described by patients and family members, including marriageability, social stigma, and lost workdays. However, the positive impact of the lymphedema management program was also emphasized, and many family and community members indicated that community members were accepting of patients and had some improved understanding of the etiology of the disease. Program volunteers and community members stressed the role that the program had played in educating people, though interestingly, local explanations and treatments appear to coexist with knowledge of biomedical treatments and the mosquito vector.

Conclusions/Significance

Local and biomedical understandings of disease can co-exist and do not preclude individuals from participating in biomedical interventions, specifically lymphedema management for those with lymphatic filariasis. There is a continued need for gender-specific psychosocial support groups to address issues particular to men and women as well as a continued need for improved economic opportunities for LF-affected patients. There is an urgent need to scale up LF-related morbidity management programs to reduce the suffering of people affected by LF.

Around the world 68 million people are infected with lymphatic filariasis (LF), a mosquito-borne disease caused by filarial worms. The parasite can damage patients’ lymphatic systems causing pain, infections and swollen limbs, known as lymphedema or, in more advanced stages, elephantiasis. Lymphedema management programs can help patients to deal with the physical and emotional effects of lymphedema and elephantiasis. We held a total of 24 focus groups to discuss the experiences of people with lymphedema in Odisha State, India who participate in such a program. Discussions were held with patients, family members of patients, community members and program volunteers. Significant social, physical and economic difficulties were described by patients and family members, including marriage-related issues, social stigma, and lost workdays. However, the positive impacts of the lymphedema management program were also emphasized, and many family and community members indicated that community members were accepting of patients and had some improved understanding of the cause of the disease. People were able to hold both a ‘scientific’ and a ‘traditional’ understanding of LF at the same time. The financial hardships that people described highlight the need for improved economic opportunities for lymphedema-affected patients. Support programs based in the community also have clear social and emotional benefits. There is an urgent need to scale up LF management programs to reduce the suffering of people affected by LF.

Views and experiences of healthcare professionals towards the use of African traditional, complementary and alternative medicines among patients with HIV infection: the case of eThekwini health district, South Africa

BACKGROUND

Many patients with human immunodeficiency virus infection use traditional, complementary, and alternative medicines and other practices to combat the disease, with some also using prescribed antiretroviral therapy provided by the public health sector. This study aimed to establish the awareness of public sector biomedical health care providers on the use of traditional, complementary and alternative medicines by HIV-infected patients who also used highly active antiretroviral therapy, and to determine whether this was based on patients seen or cases being reported to them. Potential risks of interactions between the prescribed antiretroviral and non-prescribed medication therapies may pose safety and effectiveness issues in patients using both types of treatment.

METHODS

A descriptive cross-sectional study, using a researcher administered semi-structured questionnaire, was conducted from June to August 2013 at ten public sector antiretroviral clinics in five regional, three specialised and two district hospitals in eThekwini Health District, South Africa. Questionnaires were administered through face-to face interview to 120 eligible participants consisting of doctors, nurses, pharmacists and post-basic pharmacist assistants in HIV clinical practice. The results are presented as percent or proportion with standard error (SE), or as frequency.

RESULTS

Ninety-four respondents completed the questionnaire, yielding a response rate of 78.3 %. Almost half (48/94) were aware of patients using African traditional herbal medicines, over-the-counter supplements, unnamed complementary Ayurveda medicines and acupuncture. Twenty-three of the 94 respondents (24.4 %) said they had consulted patients who were using both antiretroviral therapy and certain types of non-prescribed medication in the previous three months.

CONCLUSIONS

Awareness among healthcare providers on patient use of traditional, complementary and alternative medicines was relatively high. Few respondents had seen patients who used mostly African traditional medicines, over-the counter supplements, and negligible complementary Ayurveda medicines and acupuncture, with caution being advised in the interpretation of the former. Further research is needed to investigate communication between healthcare providers and patients in this regard, and levels of acceptance of traditional, complementary and alternative medicines by biomedical health care workers in HIV public sector practice.