The interface between biomedical and traditional health practitioners in STI and HIV/ADIS care : A study on intersectoral collaboration in Zambia

Sammanfattning: The aim of this thesis is to explore potential opportunities for and obstacles to collaboration between biomedical and traditional health practitioners (BHPs and THPs) and to test a dialogue nurturing intervention in order to improve attitudes and increase collaborative activities pertinent for STIs and HIV/AIDS care in Zambia. The specific objectives were: to explore the local communities views on prerequisites (or preconditions) to collaboration between biomedical and traditional health providers with regards to STIs and HIV/AIDS care (I); to explore BHPs and THPs' experiences of and attitudes toward collaboration and to identify obstacles and potential opportunities for them to collaborate with regard to care for patients with STIs and HIV/AIDS (II); to explore biomedical and traditional health practitioners perceptions of good STIs and HIV/AIDS care and their opinions on weaknesses in the services they provide to patients with STIs and HIV/AIDS (III); to assess the changes in attitudes to and practices of collaboration among a set of BHPs and THPs following a participatory intervention in the Zambian city of Ndola, focusing on STIs and HIV/AIDS care (IV). The studies were conducted in Ndola and Kabwe, in Zambia. Both qualitative and quantitative methods were used. The study population consisted of community members, BHPs (nurses, midwives, physicians and laboratory and environmental health technicians) and THPs (herbalists, spiritualists, diviners and traditional birth attendants (TBAs)). Twenty one focus group discussions (I), semi-structured interviews with BHPs (n=152) and THPs (n=144) (II, III) and pre- and post-intervention KAP questionnaires with BHPs (n=19) and THPs (n=28) (IV) were used to collect the data. The community members underscored both the potential advantages of collaboration and the risks associated with failed collaboration. The prerequisites for collaboration included protection of traditional medicine and compensation of THPs, education of both groups of providers, preservation of some degree of secrecy in traditional medicine and adequate community involvement (I). Thirty seven BHPs (24%) and 19 THPs (13%) reported past collaboration with the other group. Most BHPs reported that they trained TBAs in conducting safer deliveries, whereas THPs mainly reported having been trained by BHPs on HIV/AIDS matters. Both groups believed that THPs had a role to play in the control of HIV/AIDS, including 126 BHPs (83%) and 136 THPs (97%). The suggested roles were mainly health education (including HIV prevention) and treatment of opportunistic infections and/or sexually transmitted infections. Sixty-one BHPs (40%) and 139 THPs (97%) expressed an interest in working together with the other sector (II). Substantial proportions of providers from both sectors perceived drugs availability (63% of BHPs and 70% of THPs) and welcoming attitude (73% of BHPs and 64% of THPs) as important aspects of good quality care. A majority of BHPs (87%) and THPs (80%) acknowledged deficiencies in their STIs and HIV/AIDS-related services. Both groups regarded training of providers, nutritional support and health education to patients as lacking. None of the THPs alluded to voluntary counselling and testing (VCT) or supportive/home-based care as aspects needing improvement (III). At pre intervention, BHPs expressed generally positive attitudes about collaboration. But additional improvements were observed afterwards, such as willingness to refer to THPs (68% before and 100% after); more BHPs agreed that THPs could provide counselling to patients with HIV (36% before, 71% after) and that collaboration was easy (36% before, 71% after). THPs were also positive to collaboration even before the intervention. After intervention, fewer said they would never visit a clinic (14% before, 3% after); fewer agreed with the statement that they would be annoyed if a patient visited a clinic before coming to them (21% before, 8% after). THPs self confidence in their role in HIV prevention increased after the intervention (39% before, 100% after). Cross-referrals and visits increased fairly after the intervention (IV). Lack of collaboration between BHPs and THPs may result in missed opportunities. Both groups seem willing to collaborate. Interventions enhancing dialogue between the two groups are feasible. A more participatory approach allowing for both groups learning together and from each other seems appropriate. More involvement by other community actors and leadership by district health authorities might be influential. Further research is called for to enhance evidence based collaboration before scaling up can be recommended.