Peltzer K, Mngqundaniso N, Petros G. A Controlled Study of an HIV/AIDS/STI/TB Intervention with Traditional Healers in KwaZulu-Natal, South Africa. AIDS Behav 2006 Nov;10(6):683-90.
To determine whether training traditional healers in KwaZulu-Natal, South Africa can reduce their risk practices and encourage them to provide appropriate information and referral for STI/HIV and TB care.
This was a quasi-experimental two-arm study conducted between January 2004 and March 2005. Traditional healers were allocated to either the intervention or control arm based on area of residence. Each study arm included traditional healers from one rural and one urban area.
Two rural and two urban areas in KwaZulu-Natal.
All traditional healers residing in the identified study areas were eligible; 233 (out of 234) participated, 160 in the intervention group and 73 in the control arm. There were some differences between groups: more healers in the intervention group were female (81% vs. 62% in the control) and from urban areas (41% vs. 23% in the control). Healers were classified as herbalists, diviners, or herbalist-diviners.
The traditional healer training model was developed by the National Health Department of South Africa, and included information on HIV/AIDS, STIs, family planning, TB, nutrition, mental illness, herbal medicine, the role of traditional health practitioners, cultural issues, counseling, history-taking, collaboration, and referral. Intervention group participants underwent a total of 3.5 days of training led by a professional nurse, a traditional healer, and two research staff, with a follow-up session two to three months later. They also received an educational manual, sterile razor blades, condoms, and gloves, which were supposed to be replenished as needed. Eighty-five percent of healers attended all training sessions. Control participants received an information booklet.
Primary outcomes included HIV/AIDS/STI and TB knowledge, HIV and STI management, HIV risk practices, attitudes towards biomedical health practitioners, and referral patterns. Participants completed an interviewer-administered semi-structured questionnaire at baseline and at seven to nine months post-intervention.
Of the 233 healers in the study, 155 (67%) completed the follow-up interview (no significant difference between arms). Those who dropped out were more likely to have been practicing for fewer years and to have fewer clients. The most commonly treated conditions were STIs; only 6% reported treating HIV/AIDS. At follow-up, those who received the intervention had higher levels of HIV/AIDS knowledge, improved STI management (such as partner referral and providing condoms), and were more likely to conduct risk-behavior assessments. However, there was no difference between groups in referral of clients to biomedical clinicians, knowledge of TB, or reduction in the HIV risk practices of traditional healers themselves (such as re-using blades for incisions and scarifications, not using gloves, reusing enema equipment). Although both groups stated that they were prepared and willing to refer clients to biomedical practitioners, only about half had done so in the previous three months and there was no difference between arms.
The authors concluded that traditional healers improved and retained their knowledge of HIV/AIDS and STIs. However, the intervention failed to adequately improve knowledge of TB or increase referral of patients to biomedical health care personnel. On the other hand, the authors note that because most healers are women, have strong community ties, and counsel their patients, they could play an important role in supporting women and acting as liaisons between the community and HIV/AIDS programs. The continuation of traditional practices that could result in HIV transmission may be difficult to change for cultural reasons, and might be more successfully addressed by regular supplies of sterile razor blades and gloves.
The quality of this quasi-experimental study was not graded. The quality of this study was limited by multiple factors, which were all mentioned by the authors: randomization was by geographic area rather than individual healer, resulting in significant baseline differences between groups; areas for inclusion in the trial were chosen by convenience; follow-up was poor (only 66%) and sample size was small. The long-term effects of the training are unknown, as only one follow-up assessment was conducted.
Collaborative HIV/AIDS, STI, and tuberculosis (TB) programs involving traditional healers have been initiated in a number of sub-Saharan African countries (1,2,3,4,5,6) with varying success. This study’s findings are similar to those that have previously reported significant improvement of HIV/AIDS knowledge among healers after training.(6)
The possibility of involving traditional healers in areas where they are well respected by the community and attend to clients at risk for HIV, STIs, and TB still needs to be explored. It appears that education programs can improve the healers' general knowledge and ability to counsel clients. However, better interventions need to be developed to change actual risk practices and encourage traditional healers to work with biomedical personnel. The largest group of traditional healers in the study was that of female diviners. Given the gendered nature of the HIV epidemic in South Africa and the need for strategies to enhance the ability of women to protect themselves, it is important to devise interventions that will enable these women to provide more support to other women in their communities.
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