The relationship between cultural beliefs and treatment-seeking behaviour in Papua New Guinea: implications for the incorporation of traditional medicine into the health system

Health indicators in Papua New Guinea (PNG) are poor by virtually any standards and have declined over the last 2 decades. As in other developing countries that find it impossible to achieve ‘health for all’ through western medical services alone, the idea of developing an integrated health system, one that incorporates traditional medicine, has been proposed as a way of addressing poor health status. The idea of developing an integrated health system in PNG is not new but only recently has it translated into action with tangible results including a draft ‘National Policy on Traditional Medicine for Papua New Guinea’. Over many years researchers have bemoaned the paucity of information on cultural beliefs and treatment practices that could make the incorporation of traditional medicine into the health system, along the lines proposed in the National Policy, better informed. To date this information gap has not been filled.The thesis includes a review of literature on traditional medicine around PNG and the results of a case study conducted by indigenous research assistants among the Nasioi speakers of Central Bougainville. An international perspective is brought to bear through a critique of theoretical models of integration and a review of practical experiences in other countries that have tried to develop various types of integrated health systems. Information from each of these sources is considered in an endeavour to address the urgent need for information to inform the implementation of the National Policy on Traditional Medicine for Papua New Guinea.All available studies on traditional medicine in PNG were included in the literature review. Despite PNG's vast cultural diversity it became evident that some common elements exist between different cultural groups.The case study used a focused ethnographic approach to examine treatment-seeking responses to illness and associated beliefs and decision-making criteria in relation to traditional and modern medicine. It also investigated the organization of traditional health services, attitudes towards an integrated health system and the potential for practitioners to collaborate with one another. The case study made it possible to focus on pertinent issues that had not been covered in earlier studies. The case study suggests that in areas where the organization of and attitudes toward traditional medicine resemble those in the Nasioi area there may be great potential for a health system that incorporates traditional medicine to deliver health benefits to communities. The case study also serves as an example of research that could be replicated or adapted by provinces that need more information about their own situation before embarking on the process of incorporating traditional medicine into the local health system.The process by which integration might proceed in PNG is considered in the context of integration experiences in other countries. Although ideologically attractive, total integration is not realistic for PNG at this stage. The informality and lack of documentation on traditional medicine as well as the lack of resources to support the development of an integrated health system mean that PNG’s own version of an incorporated or collaborative model of integration is more appropriate.It should be noted that in this thesis the term ‘integrated health system’ is used to cover the full range of varying degrees of integration of traditional with modern medicine and should not be taken to imply only a fully integrated system. Similarly, the terms ‘integration’ and ‘incorporation’ are normally used to refer to the process and not the outcome.Even an incorporated health system may not be a viable proposition in all parts of PNG. Where it is feasible, incorporation would need to be progressed in a carefully considered and planned manner with a realistic and long-term approach. The process would require coordination at national level and the flexibility for provinces to participate according to their own prevailing circumstances and capacity. Incorporation should proceed slowly and will require government support including the allocation of resources. It may be possible to pilot and thus fine-tune PNG’s integration model in a few places, such as the Nasioi area, before expanding to multiple provinces.The potential benefits of an incorporated health system include strengthening of primary health care, better access to services, more affordable services, cultural relevance, a holistic approach, preservation of traditional knowledge, increased autonomy and possibly cost savings. An incorporated health system is worth pursuing because, if carefully planned and implemented, it does have the potential to improve health status in a country where health indicators desperately need to be elevated

Designing Disability Services in South Asia: Understanding the Role that Disability Organizations Play in Transforming a Rights-based Approach to Disability

Since the advent of the Disability Rights Movement in the 1960's and 1970's, practitioners and scholars have sought ways of conceptualizing disability and understanding the strategies employed in its management. The push for a rights-based approach to disability first begun in North America and Europe has become globalized, influencing the discourse, strategies, and day-to-day activities of international policy-making bodies, non-governmental organizations working on disability, and individuals with disabilities worldwide. Scholarship within disability studies has fixed attention on a small range of models for explaining the meanings and experience of disability. However, the adequacy of these models in describing the relationship between international institutions, disability organizations, and individuals with disabilities has not been examined. Similarly, scholars have not examined the influence these different theoretical models have on the everyday work of organizations working with individuals with disabilities. This paper explores the way in which two organizations in South Asia have framed and defined organizational goals and a "rights based" approach to disability. It employs ethnographic data from preliminary field projects in Kathmandu, Nepal and Delhi, India to examine the underlying theoretical models of disability that each organization operationalizes through its programming. Analysis of each organization's values, programming, and disability discourse suggests that organizations are differently defining disability rights, leading to heterogeneity in the types of services available to people with disabilities. I suggest that this heterogeneity in available services across organizations, as well as within a single organization is the product of organizations employing different theoretical understandings of the meaning of disability. However, programming opportunities available to an individual with a disability not only stem from different theoretical models of disability, but also forge new hybrid models of disability that incorporate multiple theoretical constructs in order to address the challenges facing individuals with disability. This suggests that disability organizations are actively engaged in defining and transforming disability policy and discourse at the local level and beyond. The paper concludes with a discussion of the implications these findings have on how we understand and study disability, as well as design and implement services for individuals with disabilities

TB STIGMA – MEASUREMENT GUIDANCE

TB is the most deadly infectious disease in the world, and stigma continues to play a significant role in worsening the epidemic. Stigma and discrimination not only stop people from seeking care but also make it more difficult for those on treatment to continue, both of which make the disease more difficult to treat in the long-term and mean those infected are more likely to transmit the disease to those around them. TB Stigma – Measurement Guidance is a manual to help generate enough information about stigma issues to design and monitor and evaluate efforts to reduce TB stigma. It can help in planning TB stigma baseline measurements and monitoring trends to capture the outcomes of TB stigma reduction efforts. This manual is designed for health workers, professional or management staff, people who advocate for those with TB, and all who need to understand and respond to TB stigma

The effectiveness of foot orthoses as a treatment for plantar ulceration in leprosy : a study of the efficacy, acceptability, appropriateness and implantation of a podiatric regimen

This was a holistic study. Four themes were investigated to demonstrate the effectiveness of orthotic intervention for plantar ulceration affecting leprosy impaired subjects in India. 1. Efficacy Efficacy was demonstrated, primarily, through analysis of data pertaining to a controlled trial. Thirty-seven subjects, presenting with leprosy impairments including anaesthesia and plantar ulceration, were fitted with orthoses and allocated to an experimental group. Thirty-four similar subjects, were not offered orthoses and were allocated to a control group. After 8 months 52% of the ulcers presented by Experimental group and 12% of the ulcers presented by the Control group had healed. The rationale supporting the prescription of orthoses was investigated using the EMED system. It was demonstrated that intervention with orthoses resulted in significantly lower sub pedal peak pressures than intervention with leprosy sandals. 2. Implementation and Sustain ability Ulcer assessment data from March 1994 to January 1995 were used to compare the effects of orthoses supplied by the investigator with orthoses supplied by an Indian technician. The service, evaluated on the strength of these findings, was considered to have been successfully implemented. The analysis of data, collected from January 1995 to December 1995, was used to explain why the service was not sustained at an acceptable level. 3. Acceptability Interview data were analysed to describe the attitudes of the subjects to the intervention (n = 46). Indications from the analysis were that neither ulcer status (healed or unresolved) nor group allocation (Experimental or Control) affected attitudes towards the intervention. A general indication was that the intervention was favourably endorsed. 4. Appropriateness Using the Delphi technique (n = 10), a consensus on indicators of "appropriate" impairment control measures was sought. Differences of opinion were not resolved, but group priorities were ranked and a polled response was recorded. The results of the study were similar to the criteria suggested by the Delphi contributors

Disease and Illness in Medieval Ireland

This thesis explores various aspects of the medical system, and illness/disease for the medieval period (5th-12th centuries) in Ireland. On examining three archival source-types (hagiographical material, annals, medico-legal law texts), it became clear that there were different perspectives on health and healing for this period. Two distinguishing models came to light, a „Christian (religious) explanatory model‟ and a „Naturalistic Model‟. The former model centered mainly on the hagiographical material and elements related to Christian doctrine; however, aspects of this model were found in the annals also. The latter model was to be found in the annals and medico-legal law texts; both sources provided naturalistic aspects in relation to cause, cure/treatment and the legalities of illness and injury. The anthropological literature acted as a valuable interpretative tool when addressing these models and the processes of healing which took place. For example, the hagiographical material contained much religious symbolism in relation to illness causation and healing; the annals displayed symptomatic, prophylactic and naturalistic elements related to cause of illness; the medico-legal texts contained naturalistic aspects also; however, they came from a different perspective, they centred on the legalities of the medical system and took an empirical approach to cure. This thesis aims to convey how these two models, which were composed of three perspectives, when combined provided a picture of the health care system in medieval Ireland. These sources individually outline a range of illnesses, injuries and plagues; they also demonstrate the existence of healers. The anthropological literature has enabled this system to be placed in a particular cultural context; it has allowed us to see a medical system which was composed of different parts, yet function and act as one system. A second and no less important element of this thesis is the connection that is conveyed between the medical system and other institutions in society; the medical system acted as a window into the entire order of society

Tuberculosis

Asserts that despite progress in controlling tuberculosis (TB), the decline in incidence has been disappointing, pointing to the need for new strategies and more effective tools. HIV/AIDS is one factor that challenges effective control of TB, especially in Southern African countries. Three key elements are needed to achieve effective TB control and to meet the Sustainable Development Goals: (1) early and accurate diagnosis and drug-sensitivity testing, (2) patient access to and completion of effective treatment, and (3) prevention of progression from latent infection to disease. Prevention requires vaccination and screening of individual at high risk as well as interventions such as air disinfection and the use of masks and respirators in hospitals and other congregate settings. Recommendations stress the need to strengthen health systems in high-burden countries by emphasizing community-based care over hospital care; to improve information systems to ensure patient adherence and manage medication supply chains; and to invest in research to develop the necessary interventions. Fundamentally, current global TB control strategies must undergo revision and receive significant research funding

The impact of Neglected Tropical Diseases, and their associated stigma, on people’s basic capabilities

Neglected Tropical Diseases (NTDs) are a group of diseases prevalent in developing countries. It has been estimated that collectively they may account for a health burden, in terms of years of life lost to disability, close to that of malaria, tuberculosis or HIV/AIDS. Stigma, in part, accounts for this high disease burden. However there is little literature on why NTDs are highly stigmatised, how the infected individual and their family are affected by stigma, and how this may manifest as either an entry into poverty or a deepening of poverty; in terms of both economics and capabilities. This thesis combines the capabilities approach, as theorised and developed by Amartya Sen and Martha Nussbaum (1993), and NTDs in order to assess NTDs’ impact on poverty in terms of reducing people’s ability to choose a life that is valuable to them. A conceptual framework has been devised, linking health, poverty and capabilities, in which to place NTDs. Using the capabilities approach as a basis for analyzing NTDs is useful, as it is a well-established paradigm, which inspired the creation of the UN’s Human Development Index (HDI). Therefore combining the high profile paradigm of the capabilities approach with the lower profile NTDs may help to raise NTDs’ profile, as well as creating a way in which to assess their impact on poverty that does not concentrate on monetary losses or mortality rates alone. It is hoped that this new direction will reveal major gaps in the current literature and initiate new research directions

From Isolation to Inclusion: Embracing Local Perspectives in Examining the Treatment Model of Care for Aboriginal Persons Affected by Tuberculosis or Leprosy in the Kimberley Region, North Western Australia

In the remote Kimberley region of North Western Australia, tuberculosis (TB) and leprosy continue to affect a small number of Aboriginal people, despite historical efforts to eliminate either disease. Treatment, predominantly antibiotic therapy, is a principal therapeutic intervention used to cure TB and leprosy and halt infection transmission. Decisions made around treatment therefore impact not only the individual person affected, but also their families and communities. The well-worn models of Directly Observed Therapy (DOT) and case management are used nationally to assist treatment continuity and completion. Neither model has been substantiated for cultural appropriateness nor for meeting the specific needs of Aboriginal people. Given the important role of treatment, this thesis uses decolonial theory to critically examine how culturally secure and person-centred care practice could be better incorporated into the current treatment model of care used in the Kimberley region for Aboriginal persons affected by TB or leprosy. To achieve this, qualitative methods were employed to explore the lived experience of Aboriginal persons affected by either disease, as well as community members and Health Care Workers involved in care. In addition, archival research of historical documents relating to treatment was conducted. The findings of this research revealed deeper narratives about medication safety concerns, the importance of family history knowledge for early treatment intervention, and challenges relating to integrating TB and leprosy management into primary health care due to competing priorities of more prevalent chronic diseases. Health care relationships were found to play a key role in optimising treatment. However, gaps and inconsistences were identified within these relationships in the areas of two-way trust, communicating importance and consequences of treatment, providing feedback, shared treatment decision-making, and the provision of culturally respectful support. Family relationships and connection to culture were also significant for psychosocial support. Understanding the history of TB and leprosy treatment specific to the region was found to be an integral part of understanding contemporary treatment models and in identifying ongoing colonising within the way health care services for the treatment of TB and leprosy are delivered. Using these findings, a novel treatment model of care is presented. This offers theoretical and practical strategies to re-think and apply culturally responsive approaches to optimising treatment for Aboriginal persons affected by TB or leprosy. This has the potential benefit of improved wellbeing and elimination of disease for current and future generations