Assessment of the Diversity of Medico-Magic Knowledge on Four Herbaceous Species in Benin.

BACKGROUND: Ethnobotanical knowledge on four herbaceous species, Acmella uliginosa (Sw.) Cass., Momordica charantia L., Phyllanthus amarus Schumach. & Thonn., and Scoparia dulcis L., in Benin was investigated. METHODS: Herbal medicine traders in six different markets were interviewed using a semi-structured questionnaire. The linear regression test was performed to check for the influence of respondent's age on ethnobotanical uses they hold. Relative frequency citation, fidelity level, use value, and Rahman similarity index were calculated to assess the diversity of medico-magic knowledge. The Informant Consensus Factor is not applicable in this study since we are dealing neither with the diversity of medicinal plants used by a community of people nor with a great number of plant species used for medicinal purposes, nor the diversity of plant species used in the treatment of a specific or group of ailments. RESULTS: The respondent's age did not influence the ethnobotanical uses they hold on the species. All thirty-six informants surveyed traded Phyllanthus amarus Schumach. & Thonn., Momordica charantia L., and Scoparia dulcis L., and the majority traded Acmella uliginosa (Sw.) Cass. The respondent's age does not influence the diversity of ethnobotanical uses they hold on the study species. Purchase in traders' own markets was the predominant source of Phyllanthus amarus Schumach. & Thonn., Momordica charantia L., and Scoparia dulcis L. while Acmella uliginosa (Sw.) Cass. was mostly purchased in other more distant markets. A noticeable proportion of traders also collect Phyllanthus amarus Schumach. & Thonn. and Momordica charantia L. from wild populations. Phyllanthus amarus Schumach. & Thonn. was the species most demanded by customers followed by Momordica charantia L. Traders confirmed the scarcity of all species in recent years and climate change and destruction of natural habitats for logging were the most cited causes. The entire plant of Phyllanthus amarus Schumach. & Thonn. was used mainly to treat malaria, diabetes, and constipation, and decoction with oral administration was the most frequent preparation for malaria treatment. To treat diabetes, informants mixed Phyllanthus amarus Schumach. & Thonn. with Momordica charantia L. used as a decoction with oral administration. Momordica charantia L. was also used to treat measles and chicken pox. Acmella uliginosa (Sw.) Cass. and Scoparia dulcis L. were mostly used for their spiritual use for luck, predominantly by chewing fresh leaves or flowers, and by bathing with the ground plant mixed with soap, respectively. Overall, Momordica charantia L. had the greatest use value followed by Phyllanthus amarus Schumach. & Thonn. The majority of traders do not plant the species. CONCLUSIONS: The harvesting and trade of the species threaten their natural populations and urgent tools, including in situ and ex situ conservation, are needed to ensure their long-term sustainable exploitation.

Epilepsy in Morocco: Realities, pitfalls and prospects.

The World Health Organization (WHO) estimates that about 50 million people of all ages have epilepsy and nearly 85% of whom live in low- and middle-income (LMICs) countries. In Morocco, epilepsy is one of the major neurological health conditions, with an estimated prevalence of 1.1%. The management of patients is difficult due to multiple factors. The lack of neurologists whose number is currently 180, the uneven distribution of neurologists who are concentrated in large cities, 43% of whom are in Rabat and Casablanca alone; the low involvement of general practitioners in the management of epilepsy; the frequent consultation of traditional healers; and the low coverage of social security all contribute to the treatment gap. The management of epilepsy has advanced considerably since the early nineties. Several factors contributed to this progress: the increasing number of neurologists compared to previous years, the creation of well-equipped new academic centers, and small units of general neurology, in addition to the disuse of several antiepileptic drugs. However, much work remains to be done against the use of many forms of traditional practices and the low involvement of general practitioners in the management of epilepsy. This is the first study on epilepsy conducted in Morocco.

Factors that promote and sustain the use of traditional, complementary and integrative medicine services at LEKMA hospital, Ghana, 2017: an observational study.

BACKGROUND: About 70% of Ghanaians depend on traditional, complementary and integrative medicine (TCIM) practices for primary healthcare needs. It was therefore integrated into mainstream healthcare delivery system by the Ministry of Health in September 2012. LEKMA hospital was one of the institutions for piloting TCIM services. We assessed factors that promote the usage and sustainability of TCIM services within the formal healthcare system. METHODS: We conducted a cross-sectional study from April-June 2017 at the LEKMA hospital, Accra, Ghana. Patients and managers of TCIM clinic were interviewed. Data was collected through qualitative and quantitative approaches. We defined usage of TCIM as its current use, and sustainability as structures in place to run TCIM services. For assessing usage, a five-point Likert scale was used to assess five domain areas via exit interviews. Managers were assessed on the sustainability of TCIM services through in-depth interviews. Likert scales responses were analysed quantitatively using descriptive tertile statistics. Thematic analysis was used for qualitative analysis. RESULTS: Overall, 72.7% (40/55) of the clients showed a high preference for TCIM usage and 80.0% (4/5) of the managers valued it as partially sustainable. Eighty per cent (44/55) of patients indicated that the location of TCIM services and availability of visible directional signs influenced the good usage; 84% (46/55) of the patients agreed that the usage of TCIM was influenced by their perceived effectiveness. Managers indicated that human resources for providing services was a challenge and TCIM integration into the operations of the hospital needed to be improved. CONCLUSION: We observed a high preference for usage of TCIM among users at LEKMA hospital. The general belief in the potency, perceived effectiveness, location and availability of TCIM services are key determinants of the high preference for usage of TCIM. Provision of TCIM services in its current form is partially sustainable from the managers' perspective. We recommend that the Ministry of Health ensures the availability of staff and create awareness of TCIM services among the general populace.

Conceptual model for pluralistic healthcare behaviour: results from a qualitative study in southwestern Uganda.

INTRODUCTION: Medical pluralism, or concurrent utilisation of multiple therapeutic modalities, is common in various international contexts, and has been characterised as a factor contributing to poor health outcomes in low-resource settings. Traditional healers are ubiquitous providers in most regions, including the study site of southwestern Uganda. Where both informal and formal healthcare services are both available, patients do not engage with both options equally. It is not well understood why patients choose to engage with one healthcare modality over the other. The goal of this study was to explain therapeutic itineraries and create a conceptual framework of pluralistic health behaviour. METHODS: In-depth interviews were conducted from September 2017 to February 2018 with patients seeking care at traditional healers (n=30) and at an outpatient medicine clinic (n=30) in Mbarara, Uganda; the study is nested within a longitudinal project examining HIV testing engagement among traditional healer-using communities. Inclusion criteria included age ≥18 years, and ability to provide informed consent. Participants were recruited from practices representing the range of healer specialties. Following an inductive approach, interview transcripts were reviewed and coded to identify conceptual categories explaining healthcare utilisation. RESULTS: We identified three broad categories relevant to healthcare utilisation: (1) traditional healers treat patients with 'care'; (2) biomedicine uses 'modern' technologies and (3) peer 'testimony' influences healthcare engagement. These categories describe variables at the healthcare provider, healthcare system and peer levels that interrelate to motivate individual engagement in pluralistic health resources. CONCLUSIONS: Patients perceive clear advantages and disadvantages to biomedical and traditional care in medically pluralistic settings. We identified factors at the healthcare provider, healthcare system and peer levels which influence patients' therapeutic itineraries. Our findings provide a basis to improve health outcomes in medically pluralistic settings, and underscore the importance of recognising traditional healers as important stakeholders in community health.

Factors Influencing Seeking and Reaching Care in Patients With Peritonitis in Rwanda.

BACKGROUND: Peritonitis is an emergency which frequently requires surgical intervention. The aim of this study was to describe factors influencing seeking and reaching care for patients with peritonitis presenting to a tertiary referral hospital in Rwanda. METHODS: This was a cross-sectional study of patients with peritonitis admitted to University Teaching Hospital of Kigali. Data were collected on demographics, prehospital course, and in-hospital management. Delays were classified according to the Three Delays Model as delays in seeking or reaching care. Chi square test and logistic regression were used to determine associations between delayed presentation and various factors. RESULTS: Over a 9-month period, 54 patients with peritonitis were admitted. Twenty (37%) patients attended only primary school and 15 (28%) never went to school. A large number (n = 26, 48%) of patients were unemployed and most (n = 45, 83%) used a community-based health insurance. For most patients (n = 44, 81%), the monthly income was less than 10,000 Rwandan francs (RWF) (11.90 U.S. Dollars [USD]). Most (n = 51, 94%) patients presented to the referral hospital with more than 24 h of symptoms. More than half (n = 31, 60%) of patients had more than 4 d of symptoms on presentation. Most (n = 37, 69%) patients consulted a traditional healer before presentation at the health care system. Consultation with a traditional healer was associated with delayed presentation at the referral hospital (P < 0.001). Most (n = 29, 53%) patients traveled more than 2 h to reach a health facility and this was associated with delayed presentation (P = 0.019). The cost of transportation ranged between 5000 and 1000 RWF (5.95-11.90 USD) for most patients and was not associated with delayed presentation (P = 0.449). CONCLUSIONS: In this study, most patients with peritonitis present in a delayed fashion to the referral hospital. Factors associated with seeking and reaching care included sociodemographic characteristics, health-seeking behaviors, cost of care, and travel time. These findings highlight factors associated with delays in seeking and reaching care for patients with peritonitis.

Exploring factors influencing integration of traditional and medical male circumcision methods at Ingquza Hill Local Municipality, Eastern Cape: A socio-ecological perspective.

BACKGROUND:  Medical male circumcision (MMC) and traditional male circumcision (TMC) are reportedly having negative and positive outcomes in the Eastern Cape province. Researchers show contradictory remedies; some advocate for abolishment of TMC and others call for the integration of both methods. AIM:  This study aimed to explore factors influencing the integration of TMC and MMC at different socio-ecological levels. SETTING:  The study was conducted at Ingquza Hill Local Municipality in the Eastern Cape province. METHODS:  An explorative qualitative study design, using in-depth interviews (IDIs) and focus group discussions (FGDs), was employed in this study. Purposive sampling was used to select the participants. A framework analysis approach was used to analyse the data, and the themes were developed in line with the socio-ecological model. RESULTS:  Four main themes emerged from the data as important in influencing the integration of TMC and MMC methods. These included: (1) individual factors, related to circumcision age eligibility and post-circumcision behaviour; (2) microsystem factors, related to alcohol and drug abuse, peer pressure, abuse of initiates, and family influence; (3) exosystem factors, related to financial gains associated with circumcision and the role of community forums; and (4) macrosystem factors, related to stigma and discrimination, and male youth dominance in circumcision practices. CONCLUSION:  Male circumcision in this area is influenced by complex factors at multiple social levels. Interventions directed at all of these levels are urgently needed to facilitate integration of the TMC and MMC methods.

Modern or traditional health care? Understanding the role of insurance in health-seeking behaviours among older Ghanaians.

AIM: This paper examined the association between wealth and health insurance status and the use of traditional medicine (TM) among older persons in Ghana. BACKGROUND: There have been considerable efforts by sub-Saharan African countries to improve access to primary health care services, partly through the implementation of risk-pooling community or national health insurance schemes. The use of TM, which is often not covered under these insurance schemes, remains common in many countries, including Ghana. Understanding how health insurance and wealth influence the use of TM, or otherwise, is essential to the development of equitable health care policies. METHODS: The study used data from the first wave of the World Health Organisation's Study of Global Ageing and Adult Health conducted in Ghana in 2008. Descriptive statistics and negative loglog regression models were fitted to the data to examine the influence of insurance and wealth status on the use of TM, controlling for theoretically relevant factors. FINDINGS: Seniors who had health insurance coverage were also 17% less likely to frequently seek treatment from a TM healer relative to the uninsured. For older persons in the poorest income quintile, the odds of frequently seeking treatment from TM increased by 61% when compared to those in the richest quintile. This figure was 46%, 62% and 40% for older persons in poorer, middle and richer income quintiles, respectively, compared to their counterparts in the richest income quintile. CONCLUSION: The findings indicate that TM was primarily used by the poor and persons who were not enrolled in the National Health Insurance Scheme. TM continues to be a vital health care resource for the poor and uninsured older adults in Ghana.

Priority mental, neurological and substance use disorders in rural Kenya: Traditional health practitioners' and primary health care workers' perspectives.

BACKGROUND: Over 75% of people with mental neurological and substance use disorders (MNSD) live in low and middle-income countries with limited access to specialized care. The World Health Organization's Mental Health Gap Action Program (mhGAP) aims to address the human resource gap but it requires contextualization. AIMS: We conducted a qualitative study in rural coastal Kenya to explore the local terms, perceived causes and management modalities of priority MNSD listed in the mhGAP, to inform implementation in this setting. METHODS: We conducted 8 focus group discussions with primary health care providers and traditional health practitioners and used the framework method to conduct thematic analysis. We identified local terms, perceived causes and treatment options for MNSD. We also explored possibilities for collaboration between the traditional health practitioners and primary health care providers. RESULTS: We found local terms for depression, psychoses, epilepsy, disorders due to substance use and self-harm/ suicide but none for dementia. Child and adolescent mental and behavioral problems were not regarded as MNSD but consequences of poor parenting. Self-harm/suicide was recognized in the context of other MNSD. Causes of MNSD were broadly either biological or supernatural. Treatment options were dependent on perceived cause of illness. Most traditional health practitioners were willing to collaborate with primary health care providers mainly through referring cases. Primary health care providers were unwilling to collaborate with traditional health practitioners because they perceived them to contribute to worsening of patients' prognoses. CONCLUSIONS: Local terms and management modalities are available for some priority MNSD in this setting. Community level case detection and referral may be hindered by lack of collaboration between traditional health practitioners and primary health care providers. There is need for training on the recognition and management of all priority MNSD.

The experience of carers of children with cerebral palsy living in rural areas of Ghana who have received no rehabilitation services: A qualitative study.

AIM: This study aims to explore the experiences of carers of children with cerebral palsy living in rural areas of Ghana who have received no rehabilitation services. BACKGROUND: Cerebral palsy is the most common chronic disability from childhood, which needs lifelong rehabilitation. Most of the population living in rural communities in Ghana have virtually no form of rehabilitation services for their chronic disabling conditions. Caring for children with disability are known to be challenging especially when coupled with environmental challenges in rural communities. RESULTS: Purposive and snowball techniques were used to recruit 12 carers, age 22 to 68 years, of children with cerebral palsy aged 7 to 15 years. Two main themes, developing personal beliefs to support the caregiving role and the demands that shape the experience of caring, emerged from six subthemes and 25 theme clusters of the narratives of the carers. The essential structure of the phenomenon demonstrated the complex interaction of personal and environmental factors in harmony with the actual demands to influence the experiences of participants positively or negatively. Positively, carers achieved coping, committed to caring, hoped for the future, and accepted the condition. However, negatively, carers described the triggering factors of feeling of despair and sorrow as frustration and lack of understanding of the condition, felt stigmatized, and perceived the child was going through pain and suffering. CONCLUSIONS: Carers derived strength from their religious and spiritual beliefs to balance the demands of caregiving. Findings could be used as basis for developing interventions to support carers and inform new strategies for rehabilitation service and sensitization of community members about inclusion of children with disabilities.

Health care providers' knowledge, attitude and perceived stigma regarding tuberculosis in a pastoralist community in Ethiopia: a cross-sectional study.

BACKGROUND: Tuberculosis (TB) remains the prime killer disease among infectious diseases. TB control depends on early case detection and treatment in a directly observed treatment short course (DOTS) programme. The success of DOTS depends on the ability of the health care system to identify and properly manage TB cases. The present study aims to assess healthcare provider (HCP) knowledge, attitude and perceived stigma regarding TB and perception about traditional healers. METHODS: A descriptive cross sectional study was conducted among 108 HCPs using a semi-structured, self-administered questionnaire from September 2014 to January 2015. The study district has a high TB burden area with one district hospital, 4 health centres, and 18 health posts. All health facilities and HCPs available during the study period in the district were included in the study. Statistical software for social science (SPSS) version 22 and STATA version 14 were used to enter and analyse data, respectively. RESULTS: The majority (64%) of the HCPs had poor overall knowledge regarding TB, and 67.6 and 57.6% had poor knowledge regarding TB diagnosis and nature of the disease, respectively. Moreover, most 66.7 and 55.6% of the HCPs had an unfavourable attitude towards TB and TB control systems, respectively. Slightly under half (49.1%) of the HCPs had a favourable attitude towards TB patients, and the majority (88.9%) had low perceived stigma. The majority (87.0%) of the HCPs indicated the importance of community involvement in TB control activity. Moreover, most (60.2%) of the HCPs showed willingness to collaborate with traditional healers (THs) on TB control activity. CONCLUSIONS: Healthcare workers' knowledge gap and unfavourable attitude towards TB control systems reported in this study may cause poor TB care delivery. HCPs' perception of the importance of community involvement in TB control and willingness to collaborate with THs on TB management could be an opportunity to strengthen the World Health Organization's (WHO's) component of End TB strategy through community engagement. Training and workshops could be used to address the knowledge gap and the unfavourable attitude regarding TB among HCPs.