Assessment of health-care seeking behaviour: The case of co-infection of TB and HIV/AIDS in Temeke, Tanzania

Background

Tanzania is number 14 of 22 countries classified by WHO as "high-burden countries" of TB, and like many other sub-Saharan countries, the TB epidemic is closely linked to the epidemic of HIV. Temeke district in Dar-Es-Salaam has carried out innovative approaches to reach WHO targets of case detection and cure rates in their TB-programme. They have also initiated well integrated TB and HIV approaches. Even if the health system offers both TB-medicines and anti-retroviral therapy (ART) free of charge, however, many TB patients diagnosed as HIV positive do not come for CD4-counting and collection of ART. In order to understand where the obstacles are for people in obtaining what is considered the best treatment, LHL and the counterparts in Temeke decided to initiate an external, anthropological assessment of the issue.

Purpose/objective

1) To assess to what extent peoples' health-care seeking behaviour and their causal explanations of disease influence TB case finding, diagnostic delay of TB and HIV, and low uptake of ART
2) To assess the potential for collaboration between traditional / religious healing and modern health care facilities in Temeke District.

Methodology

The study methods included household studies, life-career and illness narratives, interviews with individuals and groups on focused topics, participant observation of hospital- and clinic procedures and community sensitisation, and local documents and literature studies.

Key findings

1. Health networks in Temeke are relatively small and vulnerable. Support of a family member with disease is considered a 'family issue'. There is a plurality of complex and co-existing medical systems and cultures; Traditional African / Islamic medical practices, religious faith healing by various charismatic churches, government / modern biomedicine in private and public institutions. The systems are overlapping and the patients shuttle between systems. Many patients maintain their traditional beliefs, and interpret disease as punishment for sinful life styles.
2. Multiple consultations, examinations, laboratory tests, and repetitive, ineffective medication cause diagnostic delays of several months and place significant economic strain on the household's economy.
3. ART is available and can prolong life, but this does not make any difference among the "complicated" or "defaulter"-cases. People perceive that their body is too fragile to cope with ART in addition to the TB-medication, and believe that the two therapies together will overdose and overburden the body. They need proper nutrition to tolerate the medicines, and can not afford that.
4. Gender issues may negatively affect the "real" access to treatment for co-infected women.

Recommendations

1. Carry out an in-depth study of the 'family unit' in Temeke to assess who makes up the urban/modern extended family.
2. More efforts must be put into the formal / governmental health sector in order to reduce the diagnostic delay. Patient-doctor dialogue has room for significant improvement. The social worker's position and capacity in supporting the poorest patients should be looked into and possibly strengthened. The numerous forms the overburdened staff have to fill for each patient should be reduced.
3. The measuring of the CD4-level in the HIV positive patients should be undertaken whether the patient has agreed to initiate ART or not. The patients should receive proper information about ART as well as knowledge of a healthy diet. The strengthening of Mukikute patient organisation and involvement of former TB-patients should be strengthened gradually.
4. There is a potential for fruitful collaboration between modern and traditional medicine. It needs to take place between partners based on mutual respect, open-mindedness, and interest in learning and a sharing of knowledge, and should be based on a locally designed process.

Comments from the organisation

Findings and recommendations from the researcher are discussed with the counterparts during the data collection and analysis process and after publishing the report. The counterparts are already putting recommendations into action, for example through formalising the cooperation between traditional healers and the formal health system, and improving communication skills in its health personnel through courses in collaboration with LHL.