Introducing visual participatory methods to develop local knowledge on HIV in rural South Africa

The authors would also like to acknowledge the field staff at the MRC/Wits Agincourt unit, particularly Ms Rirhandzu Debs and Dr Kerstin Edin from the Umeå Centre for Global Health Research, Umeå University, who facilitated data collection and made important contributions to the fieldwork.Peer reviewedPublisher PD

Pensions and Low Sodium Salt:A Qualitative Evaluation of a New Strategy for Managing Hypertension in Rural South Africa

BACKGROUND: This paper describes a pilot study to assess the feasibility of a novel intervention to improve the management of hypertension among older people in rural South Africa. Older South Africans have the highest rates of uncontrolled hypertension recorded for any country. Notably, South Africa has a widely-available old age grant (pension), which is delivered on a monthly basis to citizens living in rural villages.  METHODS: We assessed the feasibility of engaging with older people at the point of pension delivery in the Agincourt sub-district of Mpumalanga Province. This included providing information about hypertension, measuring blood pressure, referral to primary care services, and providing a monthly supply of low sodium salt. We recruited 20 people aged 60 and over to participate in the pilot intervention, which was conducted over three months in two villages. Towards the end of the intervention, we conducted focus groups with study participants and held a meeting with local stakeholders, including the district health office and the state social security agency.  RESULTS: The pilot study demonstrated (i) Sustained engagement with the original 20 participants. Of these, 19 continued to participate in the intervention during subsequent monthly pension days. (ii) A high level of acceptance of the low sodium salt product reflected in repeat usage and comments made in the focus groups. (iii) Strong support for the intervention and a willingness to collaborate with local stakeholders. (iv) A perception among participants that symptoms they associated with hypertension had abated. This is supported by blood pressure readings made over the three months of follow-up.  CONCLUSION: Though limited in scope, this pilot study provided evidence of the feasibility of the intervention and justification for it to be tested on a larger and more robust basis

Initiating a participatory action research process in the Agincourt health and socio–demographic surveillance site

Financial disclosure Funding: The research presented in this paper is funded by a Development Grant as part of the Health Systems Research Initiative from Department for International Development (DFID)/Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC) (MR/N005597/1). The fieldwork was completed with the Umeå Centre for Global Health Research, with support from FORTE: Swedish Council for Health, Working Life and Welfare (grant No. 2006–1512). The School of Public Health at the University of the Witwatersrand, the South African Medical Research Council, and the Wellcome Trust, UK support the MRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt HDSS (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z). OW is a recipient of an MSc Chevening Scholarship, the UK government's global scholarship programme, funded by the Foreign and Commonwealth Office (FCO) and partner organizations (Chevening Ref.: NGCV–2015–1194).Peer reviewedPublisher PD

Community perspectives on HIV, violence and health surveillance in rural South Africa : a participatory pilot study

Acknowledgements: The authors would like to acknowledge the study participants who contributed time and information and made significant contributions to the analysis, and the staff at the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Funding: The analysis presented in this paper is supported by Health Systems Research Initiative Development Grant from DFID/MRC/Wellcome Trust/ESRC (MR/N005597/1). The fieldwork was completed with the Umeå Centre for Global Health Research, with support from FORTE: Swedish Council for Health, Working Life and Welfare (grant No. 2006–1512). The Agincourt HDSS is supported by the School of Public Health, University of the Witwatersrand, South African Medical Research Council and the Wellcome Trust, UK (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z)Peer reviewedPublisher PD

Two decades of mortality change in rural northeast South Africa.

BACKGROUND: The MRC/Wits University Agincourt research centre, part of the INDEPTH Network, has documented mortality in a defined population in the rural northeast of South Africa for 20 years (1992-2011) using long-term health and socio-demographic surveillance. Detail on the unfolding, at times unpredicted, mortality pattern has been published. This experience is reviewed here and updated using more recent data. OBJECTIVE: To present a review and summary of mortality patterns across all age-sex groups in the Agincourt sub-district population for the period 1992-2011 as a comprehensive basis for public health action. DESIGN: Vital events in the Agincourt population have been updated in annual surveys undertaken since 1992. All deaths have been rigorously recorded and followed by verbal autopsy interviews. Responses to questions from these interviews have been processed retrospectively using the WHO 2012 verbal autopsy standard and the InterVA-4 model for assigning causes of death in a standardised manner. RESULTS: Between 1992 and 2011, a total of 12,209 deaths were registered over 1,436,195 person-years of follow-up, giving a crude mortality rate of 8.5 per 1,000 person-years. During the 20-year period, the population experienced a major HIV epidemic, which resulted in more than doubling of overall mortality for an extended period. Recent years show signs of declining mortality, but levels remain above the 1992 baseline recorded using the surveillance system. CONCLUSIONS: The Agincourt population has experienced a major mortality shock over the past two decades from which it will take time to recover. The basic epidemic patterns are consistent with generalised mortality patterns observed in South Africa as a whole, but the detailed individual surveillance behind these analyses allows finer-grained analyses of specific causes, age-related risks, and trends over time. These demonstrate the complex, somewhat unpredicted course of mortality transition over the years since the dawn of South Africa's democratic era in 1994

A Successful Failure: Missing the MDG4 Target for Under-Five Mortality in South Africa.

Reflecting on under-five mortality, Peter Byass and colleagues consider how some countries may fail to meet millennium development goal targets despite making considerable advances

Traditional healer treatment of HIV persists in the era of ART: a mixed methods study from rural South Africa

Abstract Background Human immunodeficiency virus (HIV) substantially contributes to the burden of disease and health care provision in sub-Saharan Africa, where traditional healers play a major role in care, due to both their accessibility and acceptability. In rural, northeastern South Africa, people living with HIV often ping-pong between traditional healers and allopathic providers. Methods We conducted 27 in-depth interviews and 133 surveys with a random sample of traditional healers living in Bushbuckridge, South Africa, where anti-retroviral therapy (ART) is publicly available, to learn: (1) healer perspectives about which HIV patients they choose to treat; (2) the type of treatment offered; (3) outcomes expected, and; (4) the cost of delivering treatment. Results Healers were mostly female (77%), older (median: 58.0 years; interquartile range [IQR]: 50–67), with low levels of formal education (median: 3.7 years; IQR: 3.2–4.2). Thirty-nine healers (30%) reported being able to cure HIV in an adult patients whose (CD4) count was >350cells/mm3. If an HIV-infected patient preferred traditional treatment, healers differentiated two categories of known HIV-infected patients, CD4+ cell counts <350 or ≥350 cells/mm3. Patients with low CD4 counts were routinely referred back to the health facility. Healers who reported offering/performing a traditional cure for HIV had practiced for less time (mean = 16.9 vs. 22.8 years; p = 0.03), treated more patients (mean 8.7 vs. 4.8 per month; p = 0.03), and had lower levels of education (mean = 2.8 vs. 4.1 years; p = 0.017) when compared to healers who reported not treating HIV-infected patients. Healers charged a median of 92 USD to treat patients with HIV. Conclusion Traditional healers referred suspected HIV-infected patients to standard allopathic care, yet continued to treat HIV-infected patients with higher CD4 counts. A greater emphasis on patient education and healer engagement is warranted

Mixed methods inquiry into traditional healers' treatment of mental, neurological and substance abuse disorders in rural South Africa

Background: Traditional healers are acceptable and highly accessible health practitioners throughout sub-Saharan Africa. Patients in South Africa often seek concurrent traditional and allopathic treatment leading to medical pluralism. Methods &amp; findings: We studied the cause of five traditional illnesses known locally as "Mavabyi ya nhloko" (sickness of the head), by conducting 27 in-depth interviews and 133 surveys with a randomly selected sample of traditional healers living and working in rural, northeastern South Africa. These interviews were carried out to identify treatment practices of mental, neurological, and substance abuse (MNS) disorders. Participating healers were primarily female (77%), older in age (median: 58.0 years; interquartile range [IQR]: 50-67), had very little formal education (median: 3.7 years; IQR: 3.2-4.2), and had practiced traditional medicine for many years (median: 17 years; IQR: 9.5-30). Healers reported having the ability to successfully treat: seizure disorders (47%), patients who have lost touch with reality (47%), paralysis on one side of the body (59%), and substance abuse (21%). Female healers reported a lower odds of treating seizure disorders (Odds Ratio (OR): 0.47), patients who had lost touch with reality (OR: 0.26; p-value&lt;0.05), paralysis of one side of the body (OR: 0.36), and substance abuse (OR: 0.36) versus males. Each additional year of education received was found to be associated with lower odds, ranging from 0.13-0.27, of treating these symptoms. Each additional patient seen by healers in the past week was associated with roughly 1.10 higher odds of treating seizure disorders, patients who have lost touch with reality, paralysis of one side of the body, and substance abuse. Healers charged a median of 500 South African Rand (similar to US$35) to treat substance abuse, 1000 Rand (similar to US$70) for seizure disorders or paralysis of one side of the body, and 1500 Rand (similar to US$105) for patients who have lost touch with reality. Conclusions: While not all healers elect to treat MNS disorders, many continue to do so, delaying allopathic health services to acutely ill patients

Pulmonary tuberculosis vs. Tindzhaka and Mafularha: A mixed methods inquiry of traditional healers' perceptions of tuberculosis in rural South Africa.

Although awareness of tuberculosis (TB) is high in South Africa, delays in TB testing or treatment persist. Even those with symptoms of TB often delay testing, with one study in Mpumalanga revealing a median allopathic care-seeking delay of four weeks. We sought to understand how traditional healers perceived TB symptoms among their patients, if they treated the disease, and what (if any) illnesses they defined as being traditional may have overlapping presentation with TB in South Africa. Nineteen traditional healers completed an in-depth interview (IDIs); 133 completed a quantitative survey about their treatment practices. IDIs focused on lung diseases treated, disease causation, treatment, and prognosis. Survey questions investigated diagnosis of lung ailments, including those treated by the allopathic health system and those by traditional healers. Traditional healers reported that they could differentiate between TB and traditional illnesses, like Tindzhaka and Mafularha, that presented with similar symptoms. Few (7.5%) believed they could treat TB, but the majority (72.9%) believed they could successfully treat Tindzhaka and Mafularha. Tindzhaka and Mafularha are interconnected illnesses that are reportedly caused by breaking social rules around death, sex and using the belongings of someone who recently passed away. Both, if not treated, are considered fatal. While we have no definitive data, traditional healers may be contributing to delays in the diagnosis and treatment for people with active TB by incorrectly diagnosing TB as Tindzhaka or Mafularha. Overcoming issues of trust and compensation, while respecting different forms of knowledge, are some of the challenges we face in successfully engaging with healers

Odds of treating some who has lost touch with reality (<i>Nhlanyi)</i>.

<p>Odds of treating some who has lost touch with reality (<i>Nhlanyi)</i>.</p