How beliefs in traditional healers impact on the use of allopathic medicine: In the case of indigenous snakebite in Eswatini.

Snakebite is a major public health problem in Eswatini and serious envenomations can be responsible for considerable morbidity and mortality if not treated correctly. Antivenom should be administered in hospital in case of adverse reactions and any delays due to distance, transport, costs, antivenom availability and cultural beliefs can be critical. Myths and superstition surround snakes, with illness from snakebite considered a supernatural phenomenon best treated by traditional medicine since healers can explore causes through communication with the ancestors. Traditional consultations can cause significant delays and the remedies may cause further complications. Four rural focus group discussions were held in varying geographical regions to establish why people may choose traditional medicine following snakebite. The study revealed four themes, with no apparent gender bias. These were 'beliefs and traditions', 'logistical issues', 'lack of knowledge' and 'parallel systems'. All snakes are feared, regardless of geographical variations in species distribution. Deep-seated cultural beliefs were the most important reason for choosing traditional medicine, the success of which is largely attributed to the 'placebo effect' and positive expectations. Collaboration and integration of the allopathic and traditional systems assisted by the regulation of healers and their methods could improve future treatment success. The plight of victims could be further improved with more education, lower costs and improved allopathic facilities.

Exploring the Potential of Participatory Theatre to Reduce Stigma and Promote Health Equity for Lesbian, Gay, Bisexual, and Transgender (LGBT) People in Swaziland and Lesotho.

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

Emotional abuse of girls in Swaziland: prevalence, perpetrators, risk and protective factors and health outcomes.

BACKGROUND: Research on emotional child abuse in sub-Saharan Africa is scarce. Few studies thus far have examined prevalence, risk and protective factors for emotional child abuse or the associations between emotional abuse and girls' health. METHODS: A nationally representative two-stage, cluster-sampled, household survey of females aged 13-24 years (n = 1244) on childhood abuse victimisation was conducted. Participants completed interviewer-assisted questionnaires. Associations between emotional abuse and putative risk, and protective factors and health outcomes were analyzed using separate logistic regression models accounting for sampling design. Marginal effects of cumulative risk factors for emotional abuse victimisation were examined. RESULTS: Lifetime prevalence of emotional abuse was 28.5% with 58.3% of these girls reporting many abusive incidents. The most common perpetrators were female (27.8%) and male (16.7%) relatives and, more rarely, biological parents. Risk factors associated with emotional abuse were frequent caregiver changes (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.03-1.970, poverty (OR 1.51, 95% CI 1.12-2.03), and physical abuse (OR 1.98, 95% CI 1.45-2.71) and sexual abuse (OR 2.22, 95% CI 1.57-3.10) victimisation. Being close to one's mother was a protective factor (OR 0.88, 95% CI 0.80-0.97). Risk for emotional abuse increased from 13% with no risk factors present to 58.4% -with all four risk factors present. Health outcomes associated with emotional child abuse were suicidal ideation (OR 1.85, 95% CI 1.30-2.63) and feeling depressed (OR 1.89, 95% CI 1.31-2.71). CONCLUSIONS: Girls in Swaziland experience high levels of emotional abuse victimisation. Emotional abuse is associated with economic disadvantage, family factors, other types of abuse victimisation and poor mental health. Therefore, a holistic approach to prevention is needed, incorporating poverty reduction and programmes to improve parent-child relationships, reduce the use of harsh criticism, and change parenting social norms.

Does integration of HIV and SRH services achieve economies of scale and scope in practice? A cost function analysis of the Integra Initiative.

OBJECTIVE: Policy-makers have long argued about the potential efficiency gains and cost savings from integrating HIV and sexual reproductive health (SRH) services, particularly in resource-constrained settings with generalised HIV epidemics. However, until now, little empirical evidence exists on whether the hypothesised efficiency gains associated with such integration can be achieved in practice. METHODS: We estimated a quadratic cost function using data obtained from 40 health facilities, over a 2-year-period, in Kenya and Swaziland. The quadratic specification enables us to determine the existence of economies of scale and scope. FINDINGS: The empirical results reveal that at the current output levels, only HIV counselling and testing services are characterised by service-specific economies of scale. However, no overall economies of scale exist as all outputs are increased. The results also indicate cost complementarities between cervical cancer screening and HIV care; post-natal care and HIV care and family planning and sexually transmitted infection treatment combinations only. CONCLUSIONS: The results from this analysis reveal that contrary to expectation, efficiency gains from the integration of HIV and SRH services, if any, are likely to be modest. Efficiency gains are likely to be most achievable in settings that are currently delivering HIV and SRH services at a low scale with high levels of fixed costs. The presence of cost complementarities for only three service combinations implies that careful consideration of setting-specific clinical practices and the extent to which they can be combined should be made when deciding which services to integrate. TRIAL REGISTRATION NUMBER: NCT01694862.

Need, demand and missed opportunities for integrated reproductive health-HIV care in Kenya and Swaziland: evidence from household surveys.

OBJECTIVE: Little is known about the need and demand for integrated reproductive health and HIV services at the population level. DESIGN: Descriptive data analysis of household surveys collected by the Integra Initiative. METHODS: Household surveys were conducted among 18-49-year-olds in Kenya (N = 1752) and Swaziland (N = 779) in 2009. Data on fertility intentions, contraceptive use, sexual behaviours and HIV testing were used to determine unmet needs. Demand for integrated services was defined as wanting reproductive health services with HIV/sexually transmitted infection (STI) services within one visit. RESULTS: At the population level, family planning needs (90%) were higher than HIV/STI prevention needs: 53% (women) and 75% (men). Fewer had unmet family planning needs through non-use of contraceptives: 17% (women) and 27% (men); versus unmet HIV/STI prevention needs through inconsistent condom use: 48 and 26% of women; 51 and 32% of men in Kenya and Swaziland, respectively. Dual need was higher for men: 64% (Kenya) and 73% (Swaziland) versus women (48%) with more unmet in Kenya (43%) compared to Swaziland (25%). Missed opportunities for integrated service provision were high among women: 49 and 57% with unmet family planning needs; and 55 and 32% with unmet HIV/STI prevention needs in Kenya and Swaziland, respectively, used services, but did not receive the needed service. Most men with unmet needs were non-service users. Approximately a quarter of women wanted and received integrated reproductive health-HIV/STI services in both countries. CONCLUSIONS: Demand creation at the community level and provider-initiated integrated service provision are needed, using different strategies for men and women, to address substantial family planning and HIV/STI prevention needs.

The relationship between service integration and client satisfaction: a mixed methods case study within HIV services in a high prevalence setting in Africa.

Integration of HIV with other primary health services, including sexual and reproductive health (SRH) care, is being widely promoted in sub-Saharan Africa. However, evidence on its benefits is equivocal, and some studies indicate client preferences for stand-alone HIV services. A comparative case study investigated the relationship between integration and client satisfaction across different models of care in Swaziland: two clinics integrated with SRH services, and two stand-alone HIV clinics. An exit survey (n=602) measured satisfaction across model using logistic regression. In-depth interviews (n=22), repeated three times, explored satisfaction and how it was influenced by integration or not. Satisfaction was highest at the fully stand-alone clinic; in multivariable models, clients there were more satisfied than partially integrated and partially stand-alone sites (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.25-0.81; and aOR 0.53, 95% CI 0.31-0.90, respectively); there was no difference between the fully integrated and fully stand-alone sites. Qualitative analysis suggested that satisfaction was constituted by eleven dimensions of care, including access to HIV medication, interpersonal care, efficiency, and confidentiality. Some dimensions were positively influenced by integration, while others were positively influenced by stand-alone care; some were not influenced by integration at all. Assumptions on the inherent value of integrated care were challenged in this high HIV prevalence setting, where stand-alone HIV care could be equally if not more satisfying to many clients. Those aiming to scale-up access to HIV care in this region may need to consider providing a variety of treatment models for clients with different health care needs.

Integrating intensified case finding of tuberculosis into HIV care: an evaluation from rural Swaziland.

BACKGROUND: Swaziland has the highest HIV prevalence in the world and the highest estimated tuberculosis incidence rate in the world. An estimated 80% of TB patients are also infected with HIV. TB detection through intensified case finding (ICF) has yet to become a routine aspect of integrated tuberculosis and HIV care. The purpose of this study was to evaluate implementation of ICF for TB into routine integrated tuberculosis and HIV care at 16 community clinics and one district hospital in Swaziland. METHODS: Nurses and lay counsellors conducted ICF using a TB screening tool and patient pathway at all HIV service entry points in clinics and the hospital. The patient pathway had three-stages; screening, sputum smear diagnosis and TB treatment initiation. Outcomes and losses to follow up were monitored at each stage. Patient demographics, access, and service feasibility and effectiveness were compared at hospital and clinic sites. RESULTS: 1467 HIV patients at clinics and the hospital were screened over a 3 month period. Large losses to follow up occurred prior to the sputum diagnosis stage; only 47% (n = 172) of TB suspects provided a specimen. 28 cases of smear positive TB were diagnosed and 24 commenced treatment. People screened at clinics were significantly more likely to be female, older, and from rural or geographically remote areas (p < 0.001). There was no significant difference between the hospital and clinics sites in the proportion of all participants screened who were smear positive (x2 = 1.909; p = 0.16). The number needed to screen to detect one sputum positive TB case was 34 at clinics and 63 at the district hospital. CONCLUSIONS: ICF was operationally feasible and became established as a routine aspect of tuberculosis and HIV integrated care. ICF in community clinics was potentially more accessible to an underserved, rural population and was as effective as the hospital service in detecting smear positive TB.

The relationship between infant feeding practices and diarrhoeal infections.

To determine the relationship between infant feeding practices and diarrhoeal infections, a descriptive survey was conducted on infants aged between 6 and 12 months of age. A guided interview was conducted with 105 mothers of infants who attended the health facilities of Mbabane, Swaziland. The results showed that breast feeding was routinely practised by the majority of mothers, although exclusive breast feeding was very low. Supplementary feeds in the form of formula or solids were introduced by the majority of respondents within the first 3 months of life. Infants who were given colostrum and breast milk had fewer diarrhoeal attacks. Other factors, for example education and cultural factors, influenced the feeding practices and number of diarrhoeal attacks. It is recommended that breast feeding should be promoted as an important intervention in the control of diarrhoea.