Health-care seeking behaviour and the use of traditional medicine among persons with type 2 diabetes in south-western Uganda: a study of focus group interviews

Pathways to care for psychosis in rural Uganda: Mixed-methods study of individuals with psychosis, family members, and local leaders

Background

Low- and middle-income countries (LMICs) bear a disproportionate burden of mental illness, with limited access to biomedical care. This study examined pathways to care for psychosis in rural Uganda, exploring factors influencing treatment choices.

Methods

We conducted a mixed-methods study in Buyende District, Uganda, involving 67 in-depth interviews and 4 focus group discussions (data collection continued until thematic saturation was reached) with individuals with psychotic disorders, family members, and local leaders. Structured questionnaires were administered to 41 individuals with psychotic disorders.

Results

Three main themes emerged: (1) Positive attitudes towards biomedical providers, (2) Barriers to accessing biomedical care (3) Perceived etiologies of mental illness that influenced care-seeking behaviors. While 81% of participants eventually accessed biomedical care, the median time to first biomedical contact was 52 days, compared to 7 days for any care modality.

Conclusions

Despite a preference for biomedical care, structural barriers and diverse illness perceptions led many to seek pluralistic care pathways. Enhancing access to biomedical services and integrating traditional and faith healers could improve mental health outcomes in rural Uganda.

Factors associated with severity and anatomical distribution of diabetic foot ulcer in a tertiary care hospital in Bangladesh: A cross-sectional study

Diabetic foot ulcers are characterized by disturbances in the epidermis and/or a portion of the dermis in patients with the disease. With over a million amputations performed annually, it has also emerged as one of the primary causes of lower limb amputation globally. To better understand the severity and anatomical distribution of ulcerated areas in patients with type II diabetes mellitus, this study aimed to identify the factors associated with diabetic foot ulcers (DFUs). This descriptive cross-sectional study was conducted at M Abdur Rahim Medical College Hospital in Dinajpur, Bangladesh, from July to September 2023. The study population was selected using a purposive sampling technique based on the patients' availability during their usual and regular treatment at MARMCH. Using a Bangla questionnaire data was obtained to evaluate the DFUs, in addition to measuring blood pressure and assessing the affected area's neurological function. The severity of the ulcer is calculated by using the Wagner grading system. Data was analyzed by using STATS v15 and chi-square was applied. A total of 113 DFU patients took part in this study. The mean age in years was 56 ± 12 (SD + mean) and the male proportion was greater (61.9%). Most of them (93.91%) were negligent about foot care and suffered from severe DFU (86.37%). The majority of respondents (57.94%) had a right foot ulcer, of which 94.50% had severe ulcers. Almost all ulcers were severe (86.14%) and measured <5 cm in diameter (69.71%). The results highlight the tremendous burden of DFUs, which can have serious consequences and substantial mental and economic effects on patients' healthcare systems.

Household economic burden of type-2 diabetes and hypertension comorbidity care in urban-poor Ghana: a mixed methods study

BACKGROUND

Non-communicable diseases (NCDs) predispose households to exorbitant healthcare expenditures in health systems where there is no access to effective financial protection for healthcare. This study assessed the economic burden associated with the rising burden of type-2 diabetes (T2D) and hypertension comorbidity management, and its implications for healthcare seeking in urban Accra.

METHODS

A convergent parallel mixed-methods study design was used. Quantitative sociodemographic and cost data were collected through survey from a random community-based sample of 120 adults aged 25 years and older and living with comorbid T2D and hypertension in Ga Mashie, Accra, Ghana in November and December 2022. The monthly economic cost of T2D and hypertension comorbidity care was estimated using a descriptive cost-of-illness analysis technique from the perspective of patients. Thirteen focus group discussions (FGDs) were conducted among community members with and without comorbid T2D and hypertension. The FGDs were analysed using deductive and inductive thematic approaches. Findings from the survey and qualitative study were integrated in the discussion.

RESULTS

Out of a total of 120 respondents who self-reported comorbid T2D and hypertension, 23 (19.2%) provided complete healthcare cost data. The direct cost of managing T2D and hypertension comorbidity constituted almost 94% of the monthly economic cost of care, and the median direct cost of care was US$19.30 (IQR:10.55-118.88). Almost a quarter of the respondents pay for their healthcare through co-payment and insurance jointly, and 42.9% pay out-of-pocket (OOP). Patients with lower socioeconomic status incurred a higher direct cost burden compared to those in the higher socioeconomic bracket. The implications of the high economic burden resulting from self-funding of healthcare were found from the qualitative study to be: 1) poor access to quality healthcare; (2) poor medication adherence; (3) aggravated direct non-medical and indirect cost; and (4) psychosocial support to help cope with the cost burden.

CONCLUSION

The economic burden associated with healthcare in instances of comorbid T2D and hypertension can significantly impact household budget and cause financial difficulty or impoverishment. Policies targeted at effectively managing NCDs should focus on strengthening a comprehensive and reliable National Health Insurance Scheme coverage for care of chronic conditions.

Use of herbal medicines for the management of type 2 diabetes: A systematic review of qualitative studies

BACKGROUND

Many people with Type 2 Diabetes Mellitus (T2DM) use herbal medicines, some of which can improve glycaemic control. Providing evidence-based advice on herbal medicines could be an effective intervention to improve control of diabetes, if it is designed to address key needs and concerns of T2DM patients.

AIM

To understand the views and experiences of patients and health professionals on herbal treatments for self-management of T2DM.

METHOD

MEDLINE, EMBASE, CINAHL, SOCIOFILE and Google Scholar were searched for qualitative studies in T2DM patients about their views on herbal medicines. Included papers were analysed using thematic synthesis.

RESULTS

Thirty-one papers (about 30 studies) were included: 20 from low-and-middle income countries, 10 from high income countries, and 1 internet-based study. Almost all studies from high income countries focussed on ethnic minorities. Many people with T2DM wanted a "cure", and often took advice from friends and family, but also traditional healers and mass media. However, they were reluctant to discuss herbal medicines with health professionals, whom they perceived as "closed-minded". They based their treatment decisions on personal experience (from "trial-and-error"), availability, cost and convenience of both herbal and conventional medicines. Most health professionals were reluctant to discuss herbal medicines, or recommended against their use, because of lack of knowledge and concerns about their quality, efficacy and potential interactions.

CONCLUSION

Evidence-based information could help to overcome the current lack of communication about herbal medicines between people with T2DM and health professionals.

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.

Qualitative study of pathways to care among adults with diabetes in rural Guatemala

OBJECTIVE

The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala.

DESIGN

A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors.

RESULTS

Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors.

CONCLUSIONS

This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.

Penicillin V prophylaxis uptake among children living with sickle cell disease in a specialist sickle cell clinic in Ghana: A cross-sectional study

Background and Aims

Penicillin V prophylaxis protects children living with sickle cell disease (SCD) from bacteria infections especially Streptococcus pneumonia. However, the uptake of penicillin V prophylaxis is difficult to assess and often poor among SCD patients. Therefore, this study sought to investigate oral penicillin V prophylaxis adherence among SCD children using urine assay and self-reported methods and the associated factors.

Methods

The study employed an analytical cross-sectional design in the assessment of penicillin V prophylaxis adherence using both urine assay and self-reported methods. Multiple logistic regression analysis was used to determine the factors associated with penicillin V prophylaxis adherence. A p value < 0.05 was considered statistically significant.

Results

Among the 421 SCD patients recruited, penicillin V prophylaxis adherence was observed to be 30.0% and 68.0% for the objective and subjective methods of assessment, respectively. For the objective method of assessment, being cared for by grandparents increased the odds of penicillin V adherence (adjusted odds ratio [aOR] = 3.68, confidence interval [CI] = 1.03-13.15). However, SCD patients within the ages of 10-14 years (aOR = 0.36, CI = 0.17-0.80), >14 years (aOR = 0.17, CI = 0.05-0.61), SCD patient cared for by married caregivers/parents (aOR = 0.32, CI = 0.14-0.72), SCD patient cared for by divorced caregivers/parents (aOR = 0.23, CI = 0.07-0.75), SCD patients taking homemade (herbal) preparations for the treatment of SCD (aOR = 0.42, CI = 0.21-0.83), and inappropriate intake of penicillin V prophylaxis (aOR = 0.27, CI = 0.11-0.67) reduced the odds of penicillin V adherence. For the subjective method of assessment, taking homemade preparation (herbal) for the treatment of SCD (aOR = 0.52, CI = 0.30-0.89) and inappropriate intake of penicillin V (aOR = 0.32, CI = 0.17-0.60) reduced the odds of penicillin V adherence.

Conclusion

This study reports a relatively low adherence rate of penicillin V prophylaxis among children living with SCD. Educating and counseling both SCD patients and/or caregivers on the need to be adherent to penicillin V prophylaxis could prevent complications that may arise from nonadherence.

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.

Health-Seeking Behaviors in Mozambique: A Mini-Study of Ethnonursing

In settings where traditional medicine is a crucial part of the healthcare system, providing culturally competent healthcare services is vital to improving patient satisfaction and health outcomes. Therefore, this study sought to gain insight into how cultural beliefs influence health-seeking behaviors (HSBs) among Mozambicans. Participant observation and in-depth interviews (IDIs) were undertaken using the ethnonursing method to investigate beliefs and views that Mozambicans (living in Pemba City) often take into account to meet their health needs. Data were analyzed in accordance with Leininger’s ethnonursing guidelines. Twenty-seven IDIs were carried out with 12 informants from the Makonde and Makuwa tribes. The choice of health service was influenced by perceptions of health and illness through a spiritual lens, belief in supernatural forces, dissatisfaction with and dislike of the public medical system on grounds of having received poor-quality treatment, perceived poor communication skills of health professionals, and trust in the indigenous medical system. This study confirmed the need for health professionals to carefully take cultural influences into consideration when providing care for their patients. We recommend an educational intervention that emphasizes communication skills training for healthcare workers to ensure successful physician/nurse–patient relationships.

Using Intersectionality to Identify Gendered Barriers to Health-Seeking for Febrile Illness in Agro-Pastoralist Settings in Tanzania

BACKGROUND

Research has shown that gender is a significant determinant of health-seeking behavior around the world. Gender power relations and lay etiologies of illness can influence the distribution of household resources, including for healthcare. In some rural settings in Africa, gender intersects with multiple forms of health inequities, from proximal socio-cultural factors to more "upstream" or distal health system determinants which can amplify barriers to health-seeking for specific groups in specific contexts.

AIM

We used an intersectionality approach to determine how women in particular, experience gendered barriers to accessing healthcare among Maa and non-Maa speaking agro-pastoralists in northern Tanzania. We also explored lay etiologies of febrile illness, perceptions of health providers and rural health-seeking behavior in order to identify the most common barriers to accessing healthcare in these settings.

METHODS

Mixed method ethnographic approaches were used to collect data between 2016 and 2018 from four Maa-speaking and two Swahili-speaking agro-pastoralist villages in northern Tanzania. Maa-speaking villages were based in Naiti, Monduli district while non-Maa speaking villages were selected from Msitu in Babati district. Data on health seeking behaviors was collected through semi-structured questionnaires, in-depth interviews, focus group discussions, and home and facility-based participant observation.

FINDINGS

The results primarily focus on the qualitative outcomes of both studies. We found that febrile illness was locally categorized across a spectrum of severity ranging from normal and expected illness to serious illness that required hospital treatment. Remedial actions taken to treat febrile illness included attending local health facilities, obtaining medicines from drug sellers and use of herbal remedies. We found barriers to health-seeking played out at different scales, from the health system, community (inter-household decision making) and household (intra-household decision making). Gender-based barriers at the household had a profound effect on health-seeking. Younger married women delayed seeking healthcare the most, as they often had to negotiate health-seeking with husbands and extended family members, including co-wives and mothers-in-law who make the majority of health-related decisions.

CONCLUSION

An intersectional approach enabled us to gain a nuanced understanding of determinants of health-seeking behavior beyond the commonly assumed barriers such lack of public health infrastructure. We propose tapping into the potential of senior older women involved in local therapy-management groups, to explore gender-transformative approaches to health-seeking, including tackling gender-based barriers at the community level. While these social factors are important, ultimately, improving the public health infrastructure in these settings is a first step toward addressing structural determinants of treatment-seeking.

Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments’ priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Attitude Towards Traditional Eye Medicine and Associated Factors Among Adult Ophthalmic Patients Attending University of Gondar Comprehensive Specialized Hospital-Tertiary Eye Care and Training Center, Northwest Ethiopia

BACKGROUND

Traditional eye medicine is a form of biologically based therapies, practices, or partially processed organic or inorganic agents that can be applied to the eye and lead to a blinding complication. Attitude towards those medicines plays a pertinent role in the practice of those traditional eye medicines.

OBJECTIVE

To determine attitude towards traditional eye medicine and associated factors among adult ophthalmic patients attending University of Gondar Comprehensive Specialized Hospital-Tertiary Eye Care and Training Center, Northwest Ethiopia, 2020.

METHODS

A hospital-based cross-sectional study was conducted on 417 newly presenting adult ophthalmic patients who were selected by using a systematic random sampling method from June 22 to August 11, 2020. The data from the interview-based structured questionnaire were entered into Epi Info 7 and analyzed by SPSS 20. Frequency and cross-tabulations were used for descriptive analysis. Association between variables was analyzed using binary logistic regression through the enter method with a 95% confidence interval.

RESULTS

A total of 417 subjects with a 98.8% response rate have participated in the study. Of the total study subjects, 60.7% (253) (95% CI: 19-26%) had a positive attitude towards traditional eye medicine. Residing in a rural area (AOR=6.46 (95% CI: 2.89-14.45)), positive family history of traditional eye medicine use (AOR=8.01 (95% CI: 4.17-15.37)) and availability of traditional healer (AOR=19.43 (95% CI: 12.06-31.64)) were significantly associated with a positive attitude towards traditional eye medicine.

CONCLUSION AND RECOMMENDATION

Most adult ophthalmic patients had a positive attitude towards traditional eye medicine. Residing in a rural, availability of a traditional healer, and positive family history of traditional eye medicine use had a significant positive association with a positive attitude. Educating the traditional healers on safe practices is crucial in reducing the burden.

Use of herbal medicine by caregivers in the management of children with sickle cell disease in Mulago National Referral Hospital - Uganda

Introduction

Sickle Cell Disease (SCD) is the leading genetic disease in sub-Saharan Africa and therefore remains a global public health threat. Use of complementary and alternative medicines (CAM) most especially herbal medicine (HM) in chronic diseases such as sickle cell disease has widely been reported in Africa where advanced technologies are greatly lacking. Despite a large presence of the sickle cell disease in Uganda, the extent to which herbal medicines are used in management of children with sickle cell disease has not been documented. This study purposed to determine the prevalence of herbal medicine (HM) use and associated factors among caregivers of children with SCD at Mulago National Referral Hospital.

Methods

a total of 384 child caretakers were interviewed in a descriptive cross-sectional quantitative study conducted at the Mulago Sickle cell clinic in March 2019. Enrolment was done consecutively and a structured interviewer administered questionnaire administered to collect data from the caretakers which was managed using SPSS version 23. Multivariate logistic regression was used to identify the factors associated with herbal medicine (HM) use. Factors with p-value <0.05 were regarded significant.

Results

the rate of herbal use was 77.6% (298 of 384 caregivers). At multivariate analysis, the odds of a caregiver who agreed that; HM cures symptoms faster than conventional medicine (CM) were 3 times those who disagreed with this statement (AOR =3.439, 95% CI: 1.447 - 8.176). The odds that a caregiver who agreed that HM has fewer side effects than CM were almost 4 times those that disagreed with this statement (AOR = 3.528, 95% CI: 1.917 -6.494). The odds that a caregiver who agreed that marketing HM through televisions adverts encourages HM use were 4 times those who disagreed with this statement (AOR = 4.185, 95% CI: 2.036 -8.603).

Conclusion

this study reports a high prevalence of HM use among caregivers of children with SCD at Mulago Hospital, in Uganda. The practice is significantly influenced by caretakers´ perception that HM cures symptoms faster than CM, has fewer side effects and that telemarketing has greatly facilitated its use over CM. More effort is therefore needed to encourage clinic attendances and CM use and limit the unfounded TV adverts on HM. There is also need for studies to identify the common HM used so that their efficacy and safety are well studied.

Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda

Background

Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings.

Objective

We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.

Methods

Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes.

Results

Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities.

Conclusion

Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.

Qualitative exploration into reasons for delay in seeking medical help with diabetic foot problems

Purpose

Delay in reporting foot symptoms in patients with diabetes to health-care professionals is said to be responsible for limb amputation. While reasons for these delays have been investigated elsewhere, they are not well documented in Nigeria. This study explored the causes of delayed presentation in a Nigerian sample of patients with diabetic foot ulcers.

Method

The study followed an explorative qualitative design in which the lived experience of eight participants with diabetes were explored. The participants completed in-depth interviews which were digitally audio-recorded and transcribed verbatim. Data were analysed thematically using deductive reasoning.

Results

The study identified four themes which included knowledge and awareness of foot challenges, risk perception, health seeking triggers and behaviours and competing priority as the factors responsible for delay in presentation of diabetic foot complications.

Conclusions

Limited knowledge and awareness and negative health seeking behaviours including self-management and consultation of traditionalists were the major reasons for delays.

Potential factors that influence usage of complementary and alternative medicine worldwide: a systematic review

OBJECTIVES

To determine similarities and differences in the reasons for using or not using complementary and alternative medicine (CAM) amongst general and condition-specific populations, and amongst populations in each region of the globe.

METHODS

A literature search was performed on Pubmed, ScienceDirect and EMBASE.

KEYWORDS

'herbal medicine' OR 'herbal and dietary supplement' OR 'complementary and alternative medicine' AND 'reason' OR 'attitude'. Quantitative or qualitative original articles in English, published between 2003 and 2018 were reviewed. Conference proceedings, pilot studies, protocols, letters, and reviews were excluded. Papers were appraised using valid tools and a 'risk of bias' assessment was also performed. Thematic analysis was conducted. Reasons were coded in each paper, then codes were grouped into categories. If several categories reported similar reasons, these were combined into a theme. Themes were then analysed using χ2 tests to identify the main factors related to reasons for CAM usage.

RESULTS

231 publications were included. Reasons for CAM use amongst general and condition-specific populations were similar. The top three reasons for CAM use were: (1) having an expectation of benefits of CAM (84% of publications), (2) dissatisfaction with conventional medicine (37%) and (3) the perceived safety of CAM (37%). Internal health locus of control as an influencing factor was more likely to be reported in Western populations, whereas the social networks was a common factor amongst Asian populations (p < 0.05). Affordability, easy access to CAM and tradition were significant factors amongst African populations (p < 0.05). Negative attitudes towards CAM and satisfaction with conventional medicine (CM) were the main reasons for non-use (p < 0.05).

CONCLUSIONS

Dissatisfaction with CM and positive attitudes toward CAM, motivate people to use CAM. In contrast, satisfaction with CM and negative attitudes towards CAM are the main reasons for non-use.

Utilization of traditional medicine in primary health care in low- and middle-income countries: a systematic review

This paper reports the findings from the first systematic review of the utilization of traditional medicine (TM) in primary health care (PHC) in low- and middle-income countries (LMICs). PHC is an important component of health care and essential for achieving universal health coverage (UHC). For countries where there is a gap in PHC, TM plays a vital role. It is widely used and has the potential to increase the coverage of PHC and UHC. Hence in situations where TM is recognized in a considerable magnitude, there are scarce evidence and minimal regulation on it and TM practitioners (TMPs). This study aims to identify the current situation in the utilization of TM in PHC or UHC in LMICs. A systematic review and thematic synthesis of qualitative and quantitative studies have been conducted. A total of 56 articles met the criteria and were included in the review. In all, 14 analytic themes have been developed including the current use of TM in PHC, higher accessibility of TM, medical pluralism, national health system, national health policy and national health insurance to include TM, including TMPs in the referral system, utilizing TMPs as community health workers, the needs of scientific research on TM and the need for training both TMPs and conventional medical staffs for better collaboration. The study concluded that it is necessary to further focus on TM in the macro level on strengthening the referral system by including TM to establish a comprehensive service delivery network under UHC and in the micro level to focus on training the TMPs and conventional medicine health workers on both areas to attain more in-depth understanding of each other, which can lead to better collaboration and quality patient care.

Healthcare services utilisation among patients with hypertension and diabetes in rural Ghana

BACKGROUND

Non-communicable diseases (NCDs) remain a global burden and is projected to increase due to aging, rapid urbanization and unhealthy lifestyles. The study was conducted to determine the prevalence of hypertension and diabetes in rural districts in the Ashanti region of Ghana and to determine factors that influence utilization of health care services.

SETTING

Offinso North, Amansie West, Ahafo Ano South, and Asante Akim South.

METHODS

A population based prospective cross-sectional study comprising of adults aged 18 years and above was carried out from January 2016 to March 2016. A multistage sampling method was employed to select four rural districts in the Ashanti region of Ghana. A structured questionnaire was used to collect primary data from respondents.

RESULTS

A total of 684 participants were recruited in the study. The prevalence of hypertension and diabetes was found to be 16.23% and 5.41% respectively. The prevalence of diabetes and hypertension comorbidity was 1.61%. The public hospital was the most preferred choice of facility (52.56%) for patients with NCDs.Educational level significantly decreased the likelihood of seeking healthcare in OTCMS and Health Centre to Hospitals (RRR = 0.1, 95% CI = 0.011-0.917, p = 0.042) and (RRR = 0.4, 95% CI = 0.198-0.679, p = 0.001) respectively.

CONCLUSION

The prevalence of self -reported hypertension and diabetes observed in this study was relatively lower for hypertension and higher for diabetes as compared to other studies in Ghana. The public hospital is the most preferred choice of health facilities for patients with hypertension and diabetes in the rural districts.

Comparison of Structured Nutrition Therapy for Ramadan with Standard Care in Type 2 Diabetes Patients

(1) Background: Structured nutrition therapy (NT) is essential for the management of type 2 diabetes (T2D), but the optimal delivery during Ramadan fasting remains unclear. The present study aimed to evaluate the effect of structured NT program versus standard care in patients with T2D during Ramadan. (2) Methods: The present study was an 8-week, parallel, non-randomized study with patients' preference design involving 64 patients with T2D. The participants were asked to choose their preferred group, i.e., structured NT (Structured Ramadan NT, sRNT) or standard care (SC). The participants in the sRNT group received a Ramadan-focused nutrition plan, including a diabetes-specific formula throughout the study, whereas the patients in the SC group received standard nutrition care. Study outcomes included clinical outcomes and quality of life (QoL). Data was analyzed using two-way repeated-measures ANOVA and linear mixed-effects model. (3) Results: More than half of the participants (n = 38, 63%) chose sRNT as their preferred group. Both groups had comparable baseline characteristics. After 8-weeks of the respective intervention, participants in the sRNT group had lower levels of fasting plasma glucose (-0.9 ± 0.3 mmol/L vs. 0.2 ± 0.3 mmol/L, p < 0.05), triglycerides (-0.21 ± 0.08 mmol/L vs. 0.20 ± 0.17 mmol/L, p < 0.05), and self-monitoring glucose at pre-dawn (6.9 mmol/L vs. 7.8 mmol/L, p < 0.05) and pre-bedtime (7.6 mmol/L vs. 8.6 mmol/L, p < 0.05) than participants in the SC group. Although not different between groups, HbA1c levels decreased significantly in the sRNT (-0.72 ± 0.16%, p < 0.001) but not in the SC group (-0.35 ± 0.24%, p = 0.155). QoL and satisfaction scores improved significantly in sRNT group, but not in SC group. (4) Conclusions: The structured NT regimen for Ramadan is a feasible and beneficial program for T2D patients observing Ramadan fasting as it showed an improvement in clinical outcomes and QoL.

Hypoglycemic and Toxic Effect of Morus mesozygia Leaf Extract on the Liver and Kidneys of Alloxan-Induced Hyperglycemic Wistar Rats

Purpose

We investigated the hypoglycemic and toxic effect of Morus mesozygia leaf extract on the liver and kidneys of alloxan-induced hyperglycemic wistar rats.

Method

Phytochemical analysis was done. Diabetes was induced by the use of alloxan monohydrate in six groups of rats, i.e., 200 mg/kg, 400 mg/kg, 800 mg/kg, glibenclamide, normal saline, and normal control group. Blood glucose was measured at the time of inoculation, then at 1, 2, 3, and 4 hours after. After 14 days, rats were killed under anesthesia; blood collected for measurement of total protein, albumin, TAGs, cholesterol, AST, ALT, urea, and creatinine; and whole tissue of liver and kidneys used for histological studies.

Results

The extract possessed antidiabetic effects between 400 mg/kg and 800 mg/kg doses, which we attributed to the presence of flavonoids, tannins, terpenoids, and amino acids. There was a drop in total protein and albumin with no statistical significance (P ≥ 0.05). The changes in levels of ALT, TAGs, cholesterol, AST, creatinine, and urea were not statistically different from the standard diabetic drug. The extract was protective against histological damage as there were no significant lesions suggestive of toxicities in the liver and kidneys at doses below 800 mg/kg.

Conclusion

We established credible evidence that Morus mesozygia leaf extract has hypoglycemic effects between 400 mg/kg and 800 mg/kg and that it is safe on the liver and kidneys of wistar rats at doses less than 800 mg/kg.

Understanding Interpersonal Influences on the Use of Formal Health Services among a Population of Iranian Women in Reproductive Age: A Qualitative Study

BACKGROUND

One of the most important factors contributing to using formal health care services by women is people who are involved in the social network around them.

AIM

This study aimed to understand the interpersonal influences on the use of formal health services among Iranian women of reproductive age.

METHODS

This study is a deductive content analysis approach based on the Health Promotion Model. Twenty-two semi-structured interviews were done with women of reproductive age and health care staffs in Qom, Iran. Transcripts were analysed by a deductive content analysis approach based on the Health Promotion Model (HPM).

RESULTS

Three main categories and eight subcategories were drawn consisting of (1) social support with 4 subcategories including "Family support and influence", "support of religious people", "support of health care providers" and "negative social support"; (2) social pressure and expectations with 2 subcategories including "feeling pressure due to role-playing" and "society's expectations regarding women's health", and (3) healthy role models with 2 subcategories including "family role models" and "modeling friends and peers in taking action for treatment".

CONCLUSION

A positive interpersonal influence in women acts as a strong incentive to seek health care when they are suffering from a disease, and prevents the chronicity of the disease by timely treatment.

Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study

Background

How people respond to febrile illness is critical to malaria prevention, control, and ultimately elimination. This article explores factors affecting treatment-seeking behaviour for febrile illnesses in a remote area of Lao PDR.

Methods

Household heads or their representatives (n = 281) were interviewed using a structured questionnaire. A total of twelve focus group discussions (FGDs) each with eight to ten participants were conducted in four villages. In addition, observations were recorded as field notes (n = 130) and were used to collect information on the local context, including the treatment seeking behaviour and the health services.

Results

Almost three-quarters (201/281) of respondents reported fever in past two months. Most (92%, 185/201) sought treatment of which 80% (149/185) sought treatment at a health centre. Geographic proximity to a health centre (AOR = 6.5; CI = 1.74–24.25; for those < 3.5 km versus those > 3.6 km) and previous experience of attending a health centre (AOR = 4.7; CI = 1.2–19.1) were strong predictors of visiting a health centre for febrile symptoms. During FGDs, respondents described seeking treatment from traditional healers and at health centre for mild to moderate illnesses. Respondents also explained how if symptoms, including fever, were severe or persisted after receiving treatment elsewhere, they sought assistance at health centres. Access to local health centres/hospitals was often constrained by a lack of transportation and an ability to meet the direct and indirect costs of a visit.

Conclusion

In Nong District, a rural area bordering Vietnam, people seek care from health centres offering allopathic medicine and from spiritual healers. Decisions about where and when to attend health care depended on their economic status, mobility (distance to the health centre, road conditions, availability of transport), symptoms severity and illness recognition. Current and future malaria control/elimination programmes could benefit from greater collaboration with the locally accessible sources of treatments, such as health volunteers and traditional healers.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

BACKGROUND

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

METHODS

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

RESULTS

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

CONCLUSION

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient-provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Pathways to diabetic care at hospitals in rural Eastern Uganda: a cross sectional study

Background

Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals.

Methods

Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another.

Results

Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals’ diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another.

Conclusions

Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

Health professionals' knowledge and attitudes to healthcare-seeking practices and complementary alternative medicine usage in Ugandans with diabetes: a cross-sectional survey

INTRODUCTION

Healthcare-seeking behaviour among persons with diabetes has been investigated to a limited extent, and not from professionals' perspective. The aim of the study was to describe healthcare professionals' knowledge, attitudes and practice concerning healthcare-seeking behaviour and the use of complementary and alternative medicine among persons with diabetes.

METHODS

A cross-sectional, self-administered questionnaire was conducted in western Uganda. Nurses, midwives or nurse assistants 72.2%, physicians 12% and clinical officers 10% volunteered to participate in the study with a total 108 (93% response rate) response rate. Descriptive statistics were used to analyse data with frequencies, percentages and summarized in tables.

RESULTS

Most of the healthcare providers perceived more uneducated people to be at risk of developing complications related to diabetes (66.7%) and that most of the patients with diabetes were not knowledgeable about signs and symptoms of diabetes before being diagnosed (75.9%). The main reasons inducing persons with diabetes to seek care outside the health care sector were reported to be seeking a cure for the condition, influence from the popular sector, the accessibility of the place and signs of complications of diabetes related to poor glycaemic control. Healthcare providers had relatively positive attitudes towards using complementary and alternative medicine.

CONCLUSION

Insufficient knowledge about diabetes, compromised healthcare-seeking practices including drug procurement for diabetes seem to be barriers to diabetes management. Patients were thus reported to be burdened with co-morbidities of complications of diabetes related to poor glycaemic control.

Selection of Treatment Strategies among Patients with Type 2 Diabetes Mellitus in Malaysia: A Grounded Theory Approach

BACKGROUND

Diabetes Mellitus is a multifaceted chronic illness and its life-long treatment process requires patients to continuously engage with the healthcare system. The understanding of how patients manoeuvre through the healthcare system for treatment is crucial in assisting them to optimise their disease management. This study aims to explore issues determining patients' treatment strategies and the process of patients manoeuvring through the current healthcare system in selecting their choice of treatment for T2DM.

METHODS

The Grounded Theory methodology was used. Twelve patients with Type 2 Diabetes Mellitus, nine family members and five healthcare providers from the primary care clinics were interviewed using a semi-structured interview guide. Three focus group discussions were conducted among thirteen healthcare providers from public primary care clinics. Both purposive and theoretical samplings were used for data collection. The interviews were audio-taped and transcribed verbatim, followed by line-by-line coding and constant comparison to identify the categories and core category.

RESULTS

The concept of "experimentation" was observed in patients' help-seeking behaviour. The "experimentation" process required triggers, followed by information seeking related to treatment characteristics from trusted family members, friends and healthcare providers to enable decisions to be made on the choice of treatment modalities. The whole process was dynamic and iterative through interaction with the healthcare system. The decision-making process in choosing the types of treatment was complex with an element of trial-and-error. The anchor of this process was the desire to fulfil the patient's expected outcome.

CONCLUSION

Patients with Type 2 Diabetes Mellitus continuously used "experimentation" in their treatment strategies and help-seeking process. The "experimentation" process was experiential, with continuous evaluation, information seeking and decision-making tinged with the element of trial-and-error. The theoretical model generated from this study is abstract, is believed to have a broad applicability to other diseases, may be applied at varying stages of disease development and is non-context specific.