Retention and effectiveness of HIV/AIDS training of traditional healers in far western Nepal
Masamine Jimba (corresponding author), Krishna C. Poudel, Kalpana Poudel-Tandukar and Susumu Wakai, Department of International Community Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan. Tel.: +81 3 5841 3697; Fax: +81 3 5841 3422; E-mail: firstname.lastname@example.org; email@example.com; firstname.lastname@example.org; email@example.com
Anand B. Joshi, Department of Community Medicine & Family Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. E-mail: firstname.lastname@example.org
Mahesh Sharma, Resource Centre for Primary Health Care, Kathmandu, Nepal. E-mail: email@example.com
Objective To evaluate HIV/AIDS training for traditional healers (THs) in far western Nepal.
Methods We collected data using a structured questionnaire and assessed THs’ knowledge of HIV transmission, misconceptions and preventive measures immediately prior to the initial training conducted from June to December 1999, and then 9–12 months after the training in 2000. We also conducted six focus group discussions (FGD) and assessed THs’ performances after the training. We interviewed 12 key informants about their perceptions towards the trained THs.
Results THs significantly improved their knowledge of HIV transmission, misconceptions and preventive measures after the training. The FGD and key informant interview results showed that the trained THs provided culturally acceptable HIV/AIDS education to the local people, distributed condoms and played a role in reducing the HIV/AIDS-related stigma.
Conclusions THs have a potential to work as key players in HIV/AIDS programmes in Nepal.
Until the late 1980s, most HIV/AIDS prevention programmes were implemented based on the individual risk reduction approach (Anonymous 1996). Then in the 1990s and since 2000, socio-cultural factors surrounding the individual have been considered in designing HIV/AIDS prevention programmes (Anonymous 1996; UNAIDS 2000, 2002). As a result, traditional healers (THs) have been involved in culturally appropriate HIV/AIDS prevention programmes (Green 1994; Green et al. 1995; UNAIDS 2000, 2002). The WHO (1990) has also advocated the inclusion of THs in national HIV/AIDS programmes since the early 1990s.
Such programmes, which have been conducted primarily in Africa, have shown that THs are effective in caring for people living with HIV/AIDS (PLWHA) and preventing HIV infection (Green 1994; Green et al. 1995; King & Homsy 1997; UNAIDS 2000, 2002). But these programmes have not been fully evaluated. An intervention study that adopted pre- and post-test design showed an improvement in THs’ knowledge and attitudes on HIV/AIDS immediately after the training (Somse et al. 1998). Another study reported that HIV/AIDS training was effective in improving THs’ knowledge, attitudes and practices regarding HIV/AIDS 6 months after the training (Wellington et al. 1997). However, little is known about how well the THs retain their improved knowledge, attitudes, and practices over a longer period.
We conducted this study in Doti district, located approximately 450 km west of Kathmandu, in a hilly region of Nepal. Migration to and from India is common in Doti. Approximately 50% of the households in communities where migration is common have at least one migrant worker in India (Poudel et al. 2004a). Mumbai, Punjab and Chennai are their major destinations, where the HIV prevalence among female sex workers (FSWs) is very high. For example, 71% of the Mumbai FSWs were HIV positive in 1997 (Schwartlander et al. 2000).
In our next study in Doti in 2001, we found an HIV prevalence of 7.4% among male returned migrants and non-migrants in communities where the migrants tended to go to Mumbai (Poudel et al. 2003). Risky sexual behaviours among the migrants both in India and in their home villages in Nepal are common (Poudel et al. 2004b). Although talking openly about sexual issues and one's own sexually transmitted infections (STI) is taboo in the Nepalese culture (Hannum 1997; Pigg 2001; Poudel-Tandukar et al. 2003), THs are often consulted for the treatment of STIs in Nepal (Poudel-Tandukar et al. 2003). Therefore, we decided to involve Dhami-Jhankris (THs) in the ongoing HIV/AIDS programme of United Nations Development Programme (UNDP) entitled ‘Participatory Planning and Management of HIV/AIDS (NEP/97/003)’ in Doti. Our objectives were to measure the effectiveness of the HIV/AIDS training in changing THs’ knowledge of HIV transmission, misconceptions and prevention, and to assess the performance of THs after attending HIV/AIDS training in far western Nepal.
The study was conducted in 10 village development committees (VDCs: the lowest administrative unit in Nepal, each of which has 2000 to 5000 people) of Doti district where migration is common. Doti consists of 50 VDCs and one municipality, with a total population of 207 066 in 2001.
First, the district development committee (district-level government unit in Nepal) members identified 10 VDCs where migration is common. Several anecdotal episodes of PLWHA and AIDS deaths among the returned migrants were also reported in these VDCs. Then we sent a letter to the chairpersons of each VDC and asked them to recommend at least nine THs for the training. Criteria for selection were: the THs should be respected in the community, interested in participating in the HIV/AIDS training, able to walk at least a day to attend the training, and enthusiastic to work after the training. Once the appropriate THs had been identified, we invited them for a 2-day initial training course. Altogether, 81 THs voluntarily accepted the invitation and attended the training.
Training took place in two phases. First, we conducted the initial training for all the THs in four groups from June to December 1999. Then a 1-day follow-up class was organized 9–12 months after the initial training in 2000. Of 81 THs, 61 attended the follow-up class. We developed a curriculum after consulting with the THs: (i) HIV/AIDS: history, route of transmission, misconceptions/non-transmission, and preventive measures; (ii) STIs: diagnosis, importance of early treatment, and preventive measures; (iii) condom promotion; (iv) care and support of the PLWHA and THs’ role in it; and (v) role of THs in the prevention and control of HIV/STIs. In addition to these topics, a separate session was organized in each training to address the specific interests and queries of the THs.
Training evaluation was based on an interview survey and focus group discussions (FGDs). The interview survey was conducted immediately prior to the initial and follow-up training, from June to December 1999 and from June to September 2000 respectively. We interviewed participants using a questionnaire which consisted of demographic characteristics, knowledge, experience, and their interest in HIV/STIs. The questionnaire was pre-tested in the nearby area and necessary modifications were made according to the pre-test results.
We collected qualitative data by conducting six FGDs prior to the follow-up training. Each group consisted of eight to 13 THs. We designed the FGDs to address the central question of our study: after the initial training, how well did the THs perform in such areas as providing health education, distributing condoms, and reducing HIV/AIDS-related stigma?
Each FGD was conducted in the presence of a moderator and two to four reporters, who had acted as the trainers during the THs’ training. The first author served as the moderator, as he was familiar with the local area as a Nepalese officer of the UNDP. The THs were invited to join the discussions voluntarily. The confidentiality of their information was assured. In all FGDs, other people were not allowed to observe the discussions. As the FGDs were not tape-recorded, the reporters attempted to record the conversation during the FGDs. The moderator and the reporters then transcribed the conversation on the same day.
To triangulate the FGD results, we collected additional information by interviewing 12 key informants such as chairmen of VDCs (n = 3), local health workers (n = 2), members of local non-government organizations (NGOs) (n = 3) and local men (n = 4) as explained below. The VDC chairmen were recruited from three VDCs where the venues of the follow-up training were set up. We interviewed only two health workers from these VDCs, as we could not contact health workers of one. In the target VDCs, three local NGOs were involving with HIV/AIDS programme during the study period. We selected one member from each NGO. Finally, we visited the teashops near the follow-up training sites and selected four men who volunteered to participate in the study as key informants. In one site, we interviewed two men, as they were very interested in sharing their experiences.
The study procedures were reviewed and approved by the research committee of the Institute of Medicine, Tribhuvan University in Nepal.
Of 81 THs, we used data of 61 THs for analysis. We excluded 14 because they did not attend follow-up training, and another six THs as they were unable to attend the regular follow-up training due to a landslide. The quantitative data were analysed using SPSS 11.0 for windows. We performed the McNemar's test (Siegel & Castellan 1988) to compare the changes in the THs’ knowledge of HIV/AIDS between the initial and follow-up training.
For the FGD data, we first examined all the transcripts of the discussions and identified emergent themes that were the central focus of this study. Then we categorized the data under the appropriate headings. Finally, we compared and discussed the issues raised in the discussions. The key informants’ results were transcribed and cross-checked with the FGD data and used to support them.
Characteristics of the THs
Table 1 shows the socio-demographic characteristics of the 61 THs. The mean age of the THs was 49.9 years (SD ± 12.0). Nearly all (97%) were male, all were married and 56% were literate. The THs had practiced for a median of 15 years (Inter quartile range – IQR = 7.5–27.5 years). Regarding their healing practices, about three-fourths of the THs (46/61) said that they blew with tantra-mantra to treat their patients, while 34% (21/61) prescribed herbal medicines. Some mentioned that they also sacrificed animals (15%; 9/61) and prescribed modern medicines (5%; 3/61).
Table 1. Socio-demographic characteristics of the traditional healers (n = 61)
| 25–34||8 (13.1)|
| 35–44||11 (18.0)|
| 45–54||16 (26.2)|
| 55–64||17 (27.9)|
| >65||9 (14.8)|
| Male||59 (96.7)|
| Female||2 (3.3)|
| Ever married||61 (100.0)|
| Literate||34 (55.7)|
| Illiterate||27 (44.3)|
|Length of practice (years)|| |
| 2–9||19 (31.2)|
| 10–19||21 (34.4)|
| >20||21 (34.4)|
THs’ knowledge of HIV/AIDS
Of 61 THs, 49 (80.3%) had heard of Aidas– a local term for HIV/AIDS, at the time of the initial training. Their sources of information were: radio (62.3%; 38/49), health workers (21.3%; 13/49), leaflet, magazine, hoarding board (11.5%; 7/49), and friends or neighbours (6.6%; 4/49).
Table 2 shows significant changes in THs’ knowledge from the initial to the follow-up training on the transmission, misconceptions about, and prevention of HIV infection. THs who had never heard of HIV/AIDS at the initial training also improved their knowledge on HIV/AIDS by the follow-up training, although some of them still had some misconceptions on the routes of HIV transmission (Table 3).
Table 2. Changes in traditional healers’ knowledge and misconceptions of HIV/AIDS from the initial to follow-up training
|HIV can be transmitted by|
| Unprotected sex with infected person||35 (71.4)||44 (89.8)||0.035|
| Blood transfusion||26 (53.1)||49 (100.0)||<0.001|
| Using unsterilized surgical equipment||24 (49.0)||48 (98.0)||<0.001|
| Infected mother to her child||22 (44.9)||49 (100.0)||<0.001|
| Shaking hands with infected person||20 (40.8)||4 (8.2)||<0.001|
| Sleeping with infected person without having sex||28 (57.1)||5 (10.2)||<0.001|
| Inhaling smoke from the burning of a person who died from AIDS||25 (51.0)||9 (18.4)||<0.001|
|Condoms protect against HIV||35 (71.4)||45 (91.8)||0.013|
Table 3. Traditional healers’ knowledge and misconceptions on HIV/AIDS at follow-up (n = 12*)
|HIV can be transmitted by|
| Unprotected sex with infected person||11 (91.7)|
| Blood transfusion||11 (91.7)|
| Using unsterilized surgical equipment||12 (100.0)|
| Infected mother to child||12 (100.0)|
| Shaking hands with infected person||2 (16.7)|
| Sleeping with infected person without having sex||6 (50.0)|
| Inhaling smoke from the burning of a person who died from AIDS||5 (41.7)|
|Condoms protect against HIV||9 (75.0)|
THs’ interest in HIV/AIDS
At the initial training, 88% (54/61) of the THs mentioned that they were interested in giving HIV/AIDS and STI-related education or providing care and support to PLWHA. In the follow-up training, almost all of them (97%; 59/61) said that they were willing to give such education or support. The change in interest, however, was not statistically significant (P = 0.180).
Performance of THs
Box 1 depicts the THs’ performance after the initial training. Almost all the THs said that they taught the local people about HIV/AIDS and condoms. Some also claimed to teach fellow untrained THs. Some THs targeted returned migrants in their teaching, while others targeted their patients and other community members. The THs had their own explanations as to their choice of target groups for their HIV/AIDS education. Most THs said that the local people accepted their HIV/AIDS education. Some gave speeches on HIV/AIDS in the mass gathering of the local festivals. As a result, some women requested THs to teach their Mumbai-returned husbands. In the past, it had been difficult to talk about HIV/AIDS and condoms publicly, they said. In the questionnaire survey, 97% (59/61) of the THs mentioned that they gave health education to local people on HIV/AIDS and STI-related issues after their initial training.
Table Box 1 . Traditional healers' performances after the initial training
|a) Educating the local people on HIV/AIDS and condoms|
|Voices from THs|
|• … mainly I targeted returned migrants and young non-migrants in my ‘Aidas’ education …|
|• I taught about ‘Aidas’ to almost all of my patients. I also taught about it to old people and asked them to teach their sons or villagers who will go to India later.|
|• Before, it was shameful to talk about sex and condom … Now, we Dhami-Jhankris (THs) are talking about it … People listen to us … Training should be given to more Dhami-Jhankris so that there will be many Dhami-Jhankris to talk … Personally, I taught about ‘Aidas’ to some untrained Dhami-Jhankris…|
|• After the training, I always talk about ‘Aidas’, including in the teashop …|
|• My only son died of ‘Aidas.’… I am educating young men who plan to go to India and who return from there. I could not save my son but I will try to save the sons of many parents …|
|Voices from the key informants|
|• It was difficult to talk about sex in the village and it is still not easy …Dhami-Jhankris are respected persons … Therefore, we invited three trained Dhami-Jhankris to give speech on AIDS in the public programme. Later, some migrants’ wives also requested them to teach their Mumbai-returned husbands … They are also teaching other young people in the village – a chairperson of local NGO.|
|b) Distributing condoms|
|Voices from THs|
|• I distributed the entire condoms that I received in the initial training. Later, I had gone to local health institution and brought more. I had also finished them …|
|• Mainly I gave condom to the Mumbaiwala (Mumbai-returnees) …|
|• Many young men asked me for condom at the time of local festival … they said that they hesitated to go to health institutions for it …|
|• I gave condom to most of my patients. I also had taught them about its use. I suggested old people to give condom to their sons before they go to India … They accepted it …|
|Voices from the key informants|
|• Two trained Dhami-Jhankris came to me and asked for condoms. I gave approximately 50 condoms to each of them ….. – a local health worker.|
|• … one Dhami gave me 4 condoms … I said that I do not need them; but he asked me to give it to my sons or other young men before they go to India …– a local man.|
|c) Reducing HIV/AIDS-related stigma|
|Voices from THs|
|• It was very shameful to have ‘Aidas’. One young man who had ‘Aidas’ committed suicide in our village …|
|• ‘Aidas’ patients were like earlier Leprosy patients in the village. Before, I also hesitated to go to their house … Now, I am helping them …|
|• … villagers used to avoid the ‘Aidas’ patients and their family members … If someone visited their house, used to avoid any food or drink. However, after we started helping ‘Aidas’ patients at their homes, the local people are also visiting …|
|• … still there are some villagers who isolate ‘Aidas’ patients … I spent more time to teach such people …|
|• Before, one club organized an ‘Aidas’ programme at the time of local festival. We, three trained THs, gave speech saying we are happy to treat ‘Aidas’ patients at their home. We also requested the villagers to visit ‘Aidas’ patients … Many people were surprised … but gradually they started visiting ‘Aidas’ patients …|
|Voices from the key informants|
|• … one man who was tested HIV positive in Mumbai returned home … he could not live in the village due to stigma … he then went back to India and committed suicide …– a local NGO member.|
|• AIDS patients were like earlier Leprosy patients in the village. The village people also avoided the family members of AIDS patients. However, Dhami-Jhankris visited them and helped them. Then, gradually, more people are accepting them …Observing it, our VDC is also planning to train more Dhami-Jhankris, especially those who did not attend the previous training …– a VDC chairperson.|
All THs mentioned that they distributed condoms, which they had received at the initial training. Some had received more condoms from the local health institutions and distributed them as well. This was confirmed by key informants. According to the THs, the local people felt hesitant to visit health institutions, hence they requested condoms from the THs. Some THs explained how to use a condom to many people, including older people, at the time of distribution. They suggested that older people give condoms to their sons and other young people to use when they go to India.
The THs mentioned the prevailing stigma associated with HIV/AIDS in the study area. They said that the villagers used to avoid PLWHA and their families, and that the level of stigma was similar to that of leprosy in the past. They cited a case of suicide which resulted from stigma in the study area. Despite this, THs said that it was inappropriate to talk about HIV/AIDS, sex and condoms publicly in the local culture. In the past, THs had hesitated to visit suspected AIDS patients. However, several THs said that more people in the study area began to visit the suspected AIDS patients and their families after THs visited these patients and helped them. Some THs said that they gave speeches in the public meeting and mentioned that they were willing to see suspected AIDS patients and to treat them in their homes. The key informants also confirmed this point.
This study highlighted the importance of the THs’ involvement in the HIV/AIDS programme in rural Nepal in several ways. First, the THs significantly improved and retained their knowledge about transmission, misconceptions, and prevention of HIV/AIDS, even 1 year after the initial training. Secondly, they gave HIV/AIDS education to the community, who took it on board. Thirdly, they distributed condoms, and finally, THs played a role in reducing HIV/AIDS-related stigma in the community.
After gaining knowledge on HIV/AIDS, the THs began to use their new knowledge by educating their patients and other community members. This change was confirmed by the key informants. This is an important achievement, as talking about sex and condoms has been taboo in the Nepalese culture. In Nepal, THs are important resources of health care for many rural people (Stone 1992) and most people visit them first when they fall sick (Jimba et al. 2003). Therefore, as WHO (1990) stated, THs, as community opinion leaders, may be in a unique and influential position to change the local customs and traditions that facilitate the spread of HIV/AIDS. Thus, our results indicate that the involvement of THs in the HIV/AIDS programme helps community people to increase their acceptance of HIV/AIDS education.
The THs distributed condoms which they had received at the initial training, and some gave away additional condoms from the local health institutions. The local health workers also confirmed this. Condom use in Nepal is generally low (Ministry of Health [Nepal], New ERA & ORC Macro 2002). One of the reasons for it may be the lack of accessibility and availability of condoms. The number of THs in Nepal is much higher than the number of Female Community Health Volunteers (FCHVs) (400 000 to 800 000 THs vs. 48 549 FCHVs) (Shrestha & Lediard 1980; Ministry of Health 2002). Thus THs can distribute condoms more easily in rural Nepal.
Despite the social stigma towards PLWHA, the THs visited the PLWHA in their homes and provided support to them. Some of the THs also publicly announced that they are happy to treat suspected AIDS patients in their homes. They then requested that community members accept PLWHA as ordinary people, and to send them to the THs for support. Several key informants witnessed this. In urban Nepal, however, the medical doctors sometimes refused to treat or even to touch the PLWHA when their HIV status was known (Beine 2002). However, the THs provided their support to PLWHA by visiting their homes and encouraged the community people to accept them. These results indicate that the THs could be important resources in reducing the prevailing stigma associated with HIV/AIDS in the local area.
Our participant selection procedure was biased in that the VDCs recommended the most respected and active THs for the training. However, such a selection made sense in rural Nepal, where THs qualifications are non-standardized (Pigg 1995). Some THs passed their new knowledge to fellow untrained THs after they attended the initial training. It is less likely that other HIV/AIDS prevention activities, such as the HIV/AIDS campaign on ‘World AIDS Day’ or on ‘National Condom Day’ had a significant influence on the THs’ improved knowledge of HIV/AIDS. These prevention activities had been ongoing in the study area both before and after the initial training of THs.
In conclusion, THs improved and retained their knowledge of HIV/AIDS, even 1 year after their training. They also played an important role in giving culturally acceptable HIV/AIDS education, distributing condoms, and reducing HIV/AIDS-related stigma to the people in far western Nepal. Their contribution can be further strengthened by involving them in the future HIV/AIDS programmes.
This study was conducted as part of activities of a UNDP project entitled ‘Participatory Planning and Management of HIV/AIDS (NEP/97003)’. The authors thank the district and village level authorities, project staff members, trainers, THs, key informants and other community members who helped us to conduct this study. The views expressed in this paper are those of the authors and do not represent the official view of the UNDP/Nepal. During the study, Krishna Poudel, Kalpana Poudel-Tandukar and Mahesh Sharma were associated with the Participatory Planning and Management of HIV/AIDS Programme (NEP/97/003).