Religious and Medical Pluralism Among Traditional Healers in Johannesburg, South Africa.

Religion and spirituality are powerful social forces in contemporary South Africa. Traditional Health Practitioners (THPs) are commonly consulted for both spiritual and medical ailments as a first line of care. Many studies have assessed African traditional health seeking behaviors but few have examined beliefs, practices, and behaviors of THPs themselves. This study sought to explore spiritual worldviews among South African THPs. Semi-structured in-depth interviews were conducted with 18 THPs in Johannesburg, South Africa between January and May, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 12 software and thematically analyzed. The majority of THPs interviewed indicated that initiation as a THP was almost always preceded by a sickness accompanied by dreams/visions that represented an "ancestral calling" to become a healer. Most THPs also trained as both sangomas-who healed according to traditional beliefs-and prophets-who healed according to Christian beliefs. This reflects a syncretic relationship between traditional African beliefs and Christianity. However, not all churches are accepting of traditional beliefs and subsequently these THPs are members only at non-Pentecostal AIC churches who blend both African and Christian practices. Similar to these forms of religious pluralism melding Christianity and traditional beliefs, many THPs also often practice medical pluralism, mixing Western treatments with traditional practices/medicines. THPs are able to adapt elements of Western and African beliefs into healing practices that span multiple religious and medical fields. Thus, collaborative and decentralized healthcare services may be highly acceptable among such a pluralistic community.

Maladi Nanm, Maladi Zonbi, & Maladi Lalin: A qualitative study of cultural concepts of distress in northern Haiti.

Cultural Concepts of Distress (CCDs) are culturally constructed diagnostic categories that exist within a specific society or culture. While several studies have assessed CCDs around the world, few studies have examined them in Haiti. This qualitative study examines manifestations of anxiety and depression via "sent spirits" in the form of maladi nanm ("Soul disorder") and maladi zonbi ("Zombie disorder"), and bipolar disorder in the form of maladi lalin ("Moon disorder"). Examples of CCDs were recorded as part of a study which interviewed 96 outpatients at the first mental health center in northern Haiti. Using qualitative methods, the authors identified three specific CCDs as reported by mental health patients. Maladi nanm and maladi zonbi represent alternative explanatory models of anxiety and depression in which the sufferer views mental illness as stemming from a sent spirit, or spirit which is intentionally sent supernaturally with the intent to cause harm. Maladi lalin is experienced by patients with bipolar disorder who associate cycles of mania and depression as in-sync with the phases of the moon. Understanding culture-bound forms of mental distress in settings such as Haiti is essential to developing accurate psychometrics for measuring mental health, as well as ensuring culturally appropriate and effective diagnosis and treatment.

Determinants of mental illness and care seeking behaviours in Northern Haiti: an assessment of demographic, social, and religio-cultural factors among patients at the first mental health clinic in the region.

Populations in countries such as Haiti demonstrate a high level of need for mental health care despite a lack of services and trained professionals. In addition to the dearth of biomedical services, local belief systems and explanatory models contribute to a majority of the population relying on traditional medicine as their first option for care. Using a mixed-methods approach, we aim to characterise mental illness at the first mental health clinic in the region - Sant Sante Mantal Mòn Pele (SSMMP) - by interviewing 96 patients with a demographic questionnaire as well as Anxiety, Depression, and Functionality Scales. Multivariate logistic and linear regression models were conducted examining the impact of demographic variables on whether patients believed their illness was caused by sent spirits or previously visited a Vodou priest for treatment, as well as Depression, Anxiety, and Functionality Scale scores. Factors associated with mental illness in this sample included sex, number of traumatic events, physical health status, and number of sessions attended at SSMMP. Factors which impacted traditional beliefs or practices related to mental illness included sex, age, and income.

Perceptions of causes and treatment of mental illness among traditional health practitioners in Johannesburg, South Africa.

Mental disorders are among the most poorly treated illnesses in sub-Saharan Africa. It is estimated that 70%-80% of South Africans consult traditional health practitioners for the treatment of psychological ailments. As traditional health practitioners maintain a strong role in assessing and treating patients with mental illness in this context, this study contributes to the burgeoning research literature on the topic. Semi-structured in-depth interviews were conducted with 18 traditional health practitioners in Johannesburg, South Africa, between January and May 2022. Interviews were transcribed and translated into English. The data were managed using NVivo 12 software and thematically analysed. Traditional health practitioners interviewed generally perceived mental illness to be of supernatural causation, either as a result of bewitchment, a calling for patients to become THPs themselves, due to displeased ancestors, or due to natural causes. Traditional health practitioners identified eight primary treatments that they use for treating mental illness. Among these were throwing of bones (tinhlolo) to start communicating with ancestors, steaming (ukufutha) to start a cleansing process, sneezing (umbhemiso) to forcefully dispel the spirit causing the illness, induced vomiting (phalaza), and the administration of laxatives (mahlabekufeni) to remove the spirits poisoning the body as well as animal sacrifice to purge spirits and communicate with ancestors. This is all followed by cutting (ukucaba), which is the final part of the treatment and ensures that the evil spirit cannot return. Due to the ubiquity of traditional health practitioner usage for mental illness in sub-Saharan Africa, it is essential to understand what conceptions traditional health practitioners have of the aetiology of these disorders as well as their modalities for administering treatment.

Adverse childhood experiences, traumatic events, and mental health among adults at two outpatient psychiatric facilities in Johannesburg, South Africa: a cross-sectional analysis.

BACKGROUND: Adverse childhood experiences and adult trauma, including sexual abuse, physical abuse, neglect, and interpersonal violence, are highly prevalent in low-resource settings and associated with adverse psychological outcomes. However, there is limited focus on the impact of ACEs and trauma on mental health in sub-Saharan Africa. Therefore, this study examines the impact of traumatic events and ACEs on depression, anxiety, and stress scores among outpatients receiving psychiatric care at two public mental health treatment facilities in Johannesburg, South Africa. METHODS: A sample of 309 participants were recruited between January and June 2022 at Helen Joseph Hospital and Alexandra 18th Avenue Clinic. Participants completed screening measures for mental health outcomes, including the 9-item Patient Health Questionnaire (PHQ-9), the 7-item General Anxiety Disorder scale (GAD-7) and the 10-item Perceived Stress Scale. We fitted modified Poisson and linear regression models to estimate the impact of ACEs and adult experiences of trauma on depression, anxiety, and stress scale scores. RESULTS: 47.57% (n = 147) of participants screened positive for anxiety, 44.66% (n = 138) for depression, and 17% (n = 54) for severe stress. More females screened positive for anxiety (65.31%), depression (65.94%), and stress (77.78%). Each ACE was associated with a 12% increased risk of depression, a 10% increased risk of anxiety, and a 17% increased risk of stress. In separately estimated models, each additional traumatic event during adulthood was associated with a 16% increased risk for depression, an 8% increased risk of anxiety, and a 26% increased risk of stress. Across all models, being male and self-reported physical health were consistently associated with a reduced risk for depression, anxiety, and stress. CONCLUSIONS: ACEs and experiences of traumatic events as adults were associated with significantly increased risks of anxiety, depression, and severe stress. Given high exposure to ACEs and trauma and the associated impact on the mental health of individuals, families, and communities, there is a need to strengthen and scale innovative combination interventions that address multiple stressors impacting people in low-resource settings.

Pathways to care among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa.

BACKGROUND: A patient's pathway to care is often characterized by a sequence of actions taken to remedy ill-health. Research exploring the help-seeking behavior of individuals with mental health problems in sub-Saharan Africa is relatively limited. This study assessed the perceptions and experiences of mental illness and treatment among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa. METHODS: 309 interviewer administered surveys were conducted between January and July 2022. We used a logistic regression model to examine factors associated with receiving treatment for mental illnesses from traditional healers. Semi-structured interviews were conducted with 18 participants during the same period. Interviews were transcribed and translated into English. Data were managed using NVivo 11 software and thematically analyzed. FINDINGS: Results showed that 144 (47%) patients sought mental health care from traditional healers. Higher anxiety symptoms, number of people in the household, believing that traditional medicine can cure mental illnesses, and township living were associated with seeking mental healthcare from traditional healers. Qualitative analysis indicated that participants often believed that mental illness was due to bewitchment and consulted with multiple traditional healers, thus spending large amounts of money for treatment and ultimately delaying access to biomedical care. CONCLUSION: Collaborative approaches between traditional healers and biomedical professionals show promise in terms of allowing for improved identification and treatment of individuals with mental disorders.

Perceptions of HIV and Mental Illness as "Western" or "Traditional" Illnesses: A Cross-Sectional Study from Limpopo Province, South Africa.

Although Western biomedical treatment has dramatically increased across sub-Saharan African health systems, traditional medicine as a form of healing and beliefs in supernatural powers as explanations for disease remain prevalent. Research in this region has identified HIV in particular as a disease located within both the traditional African and Western medical paradigms, whilst mental illness is ascribed to primarily supernatural causes. Within this context, this study sought to understand and explore the perceptions of HIV and mental illness among a population of rural women in Limpopo, South Africa. 82 in-depth interviews were conducted between January and December, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 11 software and thematically analyzed. The majority of participants identified HIV as a Western illness requiring biomedical treatment with causation largely attributed to biological mechanisms. A traditional form of HIV only cured using traditional treatments was also denoted. Unlike for HIV, the majority of respondents felt that there was no biological or behavioral cause for mental illness but rather the illness was conceptualized supernaturally thus likely impacting patient care pathways. Further research to study HIV and mental health perceptions among a larger sample in different regions of sub-Saharan Africa is warranted.

Examining the Etiology and Treatment of Mental Illness Among Vodou Priests in Northern Haiti.

This study assesses the perspectives and experiences of Vodou priests (ougan) in the treatment of mental illness in northern Haiti. Our goal is to explore the etiology and popular nosologies of mental illness in the context of Haitian Vodou, through understandings of illness and misfortune which are often viewed as a result of sent spirits-or spirits sent supernaturally by others with the intent to cause harm. Using a qualitative approach, this study conducted semi-structured in-depth interviews with 20 ougan living near the city of Cap-Haïtien. Interviews highlight a sample of healers with little formal training who maintain beliefs and practices that differ significantly from current biomedical models. Ougan treat mental illness through a variety of means including prayer and conjuring of spirits, leaves for teas and baths, as well as combinations of perfumes, rum, human remains, and other powdered concoctions that are either imbibed or rubbed on the skin. The primary purpose of these treatments is to expel the spirit causing harm, yet they can often result in additional harm to the patient. Findings suggest that while ougan are willing to collaborate with biomedical practitioners, significant barriers remain preventing cooperation between these two groups.

Localizing syndemics: A comparative study of hunger, stigma, suffering, and crime exposure in three Haitian communities.

Theoretically, disease syndemics are hyper-localized in the forms they take, but little empirical data show how localization manifests. We present a comparison across three sites in Haiti, from data collected in June-august 2017 testing for localizations of risks across three communities: rural farming, border town, and in a high gang-activity urban zone. First, we modeled survey responses collected from heads of 4055 geographically-sampled households via linear regression, considering additive and interaction effects of food insecurity, crime exposure, and discrimination on depression and anxiety levels. Exposure to food insecurity, crime exposure, and discrimination were each associated with more depression and anxiety symptoms. For those living in the urban zone, there was weak evidence of possible interactional risks between the three vulnerabilities, suggesting little meaningful localized syndemic patterning. Second, we conducted thematic and word-based semantic network analysis to identify if people themselves cognitively connected vulnerabilities of hunger/poverty, crime, and suffering/discrimination using 7321 text blocks from 95 semi-structured interviews/focus groups. Network visualization suggested people commonly connect these domains. While the patterns were localized, crime concerns were central to all networks. The domain connections expressed through people's own words were more complexly inter-related than was evident from the modeled survey data, and suggested counter-intuitive influences. The quantitative approach to modeling syndemic interactions suggests no apparent practical benefits to layering or combining local anticrime, anti-hunger, and anti-discrimination programming. However, the qualitative network analysis suggests that programming could none-the-less leverage the perceived connections across domains for more meaningful and effective interventions. For the broader study of syndemics, incorporating novel qualitative approaches clarifies that constituent processes are not just potentially localizing suffering, but are also extremely important in how people cognitively understand and organize their everyday lives.

Shaping the future of healthcare: building back better.

The Covid-19 pandemic has not only highlighted societal inequalities but also shown how a resilient health service is essential for protecting citizens. The NHS was founded in 1948 to provide universal healthcare but has been under sustained attack for the past thirty years. As a seven-year-old patient with osteomyelitis, the NHS almost certainly saved my life. Seventy years later I reflect on the humanising and civilising aspects of the NHS, the need for doctors to be advocates and custodians, as well as clinicians working in the best interests of their individual patients; and the requirement for the medical profession to understand the social determinants of ill health and how these can be ameliorated. The reward for engaging in this struggle: a healthier world in the widest sense and greater satisfaction for all those working in the prevention and treatment of ill health.

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Seizure activity and anion gap metabolic acidosis secondary to adverse effect of nalidixic acid-a case report.

Nalidixic acid is a commonly prescribed treatment for suspected dysentery in Middle Eastern populations. We describe a case of convulsions resulting from a single dose of nalidixic acid in a previously healthy two-month-old child in Northern Iraq who was being treated for a diarrhoeal illness. The child presented to us with new onset seizures, irritability, and acidaemia. Nalidixic acid was thought to be responsible after the exclusion of other potential causes of seizures. Symptoms resolved by treatment with intravenous (IV) diazepam, and cessation of nalidixic acid, and the child recovered fully and was discharged home neurologically intact after two days of observation. In regions where it is commonly prescribed, such as Northern Iraq, nalidixic acid should be considered as a cause of convulsions in any seizing child who has been exposed to the drug. Furthermore, quinolones such as nalidixic acid are contraindicated in children < 3 months of age.

High-contrast integral field spectrograph (HCIFS): multi-spectral wavefront control and reduced-dimensional system identification.

Any high-contrast imaging instrument in a future large space-based telescope will include an integral field spectrograph (IFS) for measuring broadband starlight residuals and characterizing the exoplanet's atmospheric spectrum. In this paper, we report the development of a high-contrast integral field spectrograph (HCIFS) at Princeton University and demonstrate its application in multi-spectral wavefront control. Moreover, we propose and experimentally validate a new reduced-dimensional system identification algorithm for an IFS imaging system, which improves the system's wavefront control speed, contrast and computational and data storage efficiency.

Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis.

BACKGROUND: Total ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA. AIM: This analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA. PATIENTS AND METHODS: A multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively. RESULTS: Mean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51-49.69, p<0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084-0.173), all cause revision was 0.185 (95%CI: 0.131-0.256), unplanned reoperation was 0.288 (95%CI: 0.204-0.390) and all infection was 0.033 (95%CI: 0.021-0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118-0.325), all cause revision was 0.305 (95%CI: 0.191-0.448), unplanned reoperation was 0.422 (95%CI: 0.260-0.603) and all infection was 0.029 (95%CI: 0.013-0.066). CONCLUSION: Despite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.

Droplet Combinations: A Scalable Microfluidic Platform for Biochemical Assays.

Droplet-based microfluidics holds enormous potential for transforming high-throughput drug screening. Miniaturization through droplets in combination with automation contributes to reduce reagent use and analysis time as well as minimizing or eliminating labor-intensive steps leading to associated reductions in cost. In this paper, we demonstrate the potential of automated and cost-effective microfluidic droplet-generating technology in the context of an enzymatic activity assay for screening collagenase inhibitors. Experimental results show reproducible and accurate creation and mixing of droplet combinations resulting in biochemical data comparable to data produced by an industry standard instrument. This microfluidic platform that can generate and combine multiple droplets represents a promising tool for high-throughput drug screening.

Using Integrated Environmental Modeling to Assess Sources of Microbial Contamination in Mixed-Use Watersheds.

Microbial fate and transport in watersheds should include a microbial source apportionment analysis that estimates the importance of each source, relative to each other and in combination, by capturing their impacts spatially and temporally under various scenarios. A loosely configured software infrastructure was used in microbial source-to-receptor modeling by focusing on animal- and human-impacted mixed-use watersheds. Components include data collection software, a microbial source module that determines loading rates from different sources, a watershed model, an inverse model for calibrating flows and microbial densities, tabular and graphical viewers, software to convert output to different formats, and a model for calculating risk from pathogen exposure. The system automates, as much as possible, the manual process of accessing and retrieving data and completes input data files of the models. The workflow considers land-applied manure from domestic animals on undeveloped areas; direct shedding (excretion) on undeveloped lands by domestic animals and wildlife; pastureland, cropland, forest, and urban or engineered areas; sources that directly release to streams from leaking septic systems; and shedding by domestic animals directly to streams. The infrastructure also considers point sources from regulated discharges. An application is presented on a real-world watershed and helps answer questions such as: What are the major microbial sources? What practices contribute to contamination at the receptor location? What land-use types influence contamination at the receptor location? and Under what conditions do these sources manifest themselves? This research aims to improve our understanding of processes related to pathogen and indicator dynamics in mixed-use watershed systems.

Capturing Microbial Sources Distributed in a Mixed-use Watershed within an Integrated Environmental Modeling Workflow.

Many watershed models simulate overland and instream microbial fate and transport, but few provide loading rates on land surfaces and point sources to the waterbody network. This paper describes the underlying equations for microbial loading rates associated with 1) land-applied manure on undeveloped areas from domestic animals; 2) direct shedding (excretion) on undeveloped lands by domestic animals and wildlife; 3) urban or engineered areas; and 4) point sources that directly discharge to streams from septic systems and shedding by domestic animals. A microbial source module, which houses these formulations, is part of a workflow containing multiple models and databases that form a loosely configured modeling infrastructure which supports watershed-scale microbial source-to-receptor modeling by focusing on animal- and human-impacted catchments. A hypothetical application - accessing, retrieving, and using real-world data - demonstrates how the infrastructure can automate many of the manual steps associated with a standard watershed assessment, culminating in calibrated flow and microbial densities at the watershed's pour point.

Mobile device application for monitoring cyanobacteria harmful algal blooms using Sentinel-3 satellite Ocean and Land Colour Instruments.

Cyanobacterial harmful algal blooms (cyanoHAB) cause human and ecological health problems in lakes worldwide. The timely distribution of satellite-derived cyanoHAB data is necessary for adaptive water quality management and for targeted deployment of water quality monitoring resources. Software platforms that permit timely, useful, and cost-effective delivery of information from satellites are required to help managers respond to cyanoHABs. The Cyanobacteria Assessment Network (CyAN) mobile device application (app) uses data from the European Space Agency Copernicus Sentinel-3 satellite Ocean and Land Colour Instrument (OLCI) in near realtime to make initial water quality assessments and quickly alert managers to potential problems and emerging threats related to cyanobacteria. App functionality and satellite data were validated with 25 state health advisories issued in 2017. The CyAN app provides water quality managers with a user-friendly platform that reduces the complexities associated with accessing satellite data to allow fast, efficient, initial assessments across lakes.