A role for traditional doctors in health promotion: experience from a trial of HIV prevention in Botswana

Introduction

Traditional medicine in Africa had never dealt with HIV infection before the 1980s but, in response to frantic demand not addressed by Western medicine, traditional practitioners rapidly introduced an array of neo-traditional supportive therapies (1). Highly publicised perverse practices promoted by some traditional healers, including the infamous virgin myth (2), positioned traditional doctors as a liability in HIV prevention. This was not helped by the folkloric musings of poorly advised South African national leaders (3). The subsequent negative focus on traditional medicine alongside dramatic pharmaceutical advances means traditional doctors have been largely ignored in HIV prevention, especially in primary HIV prevention, although some authors have suggested they could be trained to encourage their clients to use condoms and be faithful to reduce HIV risks (4–6). Others have focused on the possibility of involving traditional doctors in the provision of anti-retroviral therapy for people with HIV (7).

Despite prevention efforts, there are still some 12,000 new infections every year among the 2 million residents of Botswana, mostly among young women. For these young women, knowledge is not the problem so much as the disabling interpersonal power gradient between them and the older men with whom they trade sexual favours for survival and modern material goods. They are not able to implement choices to protect themselves against HIV (8,9). They need a change in their structural position – their self-confidence and voice – next to those who will infect them. The Inter-Ministerial National Structural Intervention Trial (INSTRUCT) (ISRCTN54878784) tries to incline government structural support programmes towards the most vulnerable young women to reduce their choice disability and thus their HIV risk. Part of the INSTRUCT intervention is the creation of an enabling environment for young women as they start to make prevention choices, using an audio-drama called Beyond Victims and Villains (BVV).

The audio-drama shares the findings from a large survey of school pupils in South Africa, updated with survey evidence from adults and children in Botswana, to spur discussions about gender, gender violence, and HIV risk. In each episode, the actors (playing a radio show host, a fieldworker, and a senior researcher) discuss evidence about one of eight topics: understanding sexual violence; culture of sexual violence; not all men rape; when victims become villains; cool teens and cold reality; sexual violence and HIV risk; transactional sex; choice disability. The episodes cover gender roles, gender violence and how this is all linked to HIV risk.

In each session with a BVV group, the group listens to the episode and then the facilitator leads a semi-structured discussion where participants consider the evidence and look for local solutions. In order to hold discussions about the BVV audio-drama widely within communities, we trained several categories of BVV facilitators: health education assistants (HEAs) from each government clinic in the trial districts, guidance teachers in government primary and secondary schools, and men in the communities interested in reducing gender violence and HIV. A chance meeting in one district between the coordinator of the district traditional doctors’ association and an INSTRUCT researcher led to a new initiative involving traditional doctors in HIV prevention as part of the trial intervention. The coordinator pointed out that traditional doctors are ideally placed to convene men’s groups, a major target of the BVV audio-drama and, with training, they could extend the community exposure to the BVV materials.

Methods

In 2016, we trained 147 traditional doctors (100 of them men) in four districts in the use of the BVV audio-drama. The traditional doctors’ associations in the districts, together with the government health promotion departments, identified and invited traditional doctors they believed would be interested in taking part in the BVV initiative. The training covered the same knowledge and skills as we earlier provided to HEAs and teachers. In their training, traditional doctors identified strongly with the BVV topics. They mentioned, for example, that some young women offered them sex in payment for treatment. They confirmed that many people come to them to seek help for family violence. Some of them revealed their own experiences of abuse.

The training provided an opportunity for sometimes heated self-reflection about gender roles and gender violence. Some male participants initially rejected the idea that a woman has the right to refuse sex, especially with a long-standing partner. Some initially said that hitting a woman was justifiable if she had done something to deserve it. Discussion among the participating traditional doctors helped to generate a positive consensus about these issues.

All the trained traditional doctors agreed to run BVV sessions in their communities. We provided them with MP3 players, the eight BVV episodes on micro-SD cards, and facilitators’ manuals.

In 2017, we attempted to contact the trained traditional doctors in two of the four districts where we had run training sessions. We contacted 43 (29 men) of the 87 trained traditional doctors (56 men) and asked them about their experience with running BVV sessions.

The work reported here is part of the Inter-ministerial National Structural Intervention (INSTRUCT) trial, approved by the Health Research and Development Committee, Ministry of Health, Botswana, 8 August 2013, HRDC protocol number 00724, PPME 13/18/1.

Results

The majority (32/43) of the traditional doctors had established and were running up to four BVV groups. On their own initiative, many of them had built professional linkages with other HIV prevention players in their communities. Many were working with the local BVV-trained health education assistant to run BVV groups. Sometimes the groups took place in the government clinic; the clinic staff and traditional doctors were quite comfortable with this. Some worked in concert with the guidance teachers: the teachers covered BVV with the pupils in the school, while the traditional doctor covered BVV with their parents in the community.

The traditional doctors reported running a variety of groups, including men-only groups and groups with mixed sexes and different ages. Many had opted to run mixed sex and mixed age groups, an unusual approach in HIV prevention education. They argued the mixed groups ensured common understanding between the men and women in the community. Some mentioned that openly discussing the sensitive topics included in the BVV sessions was helping to solve other problems in their communities; people became more open to talk about difficult issues.

Running the groups was not without challenges. Although the traditional doctors could easily recruit men, some men were impatient and would leave sessions early, claiming they needed to go and ‘look after their cattle’. The traditional doctors, as private practitioners running small businesses, sometimes struggled to find time for the sessions. Some needed to travel for their work, reducing their availability for running BVV groups.

The overall experience of the traditional doctors was positive. They reported some male participants of the groups had told them they now realised the way they treated their partners amounted to abuse. Some noticed young women participants were taking control of their own lives, no longer frequenting local bars to meet older men. They felt that discussion to arrive at solutions was a better way to achieve change than simply telling people what to do. Discussion, they said, is the traditional way to solve problems in Botswana.

Discussion

Our experience in Botswana confirms that rural residents hold traditional doctors in high esteem, and this can be valuable in integrated HIV prevention programmes.

Perhaps because of their local standing, some traditional doctors pushed boundaries that other programmes might steer shy of. Men have always been extremely difficult to recruit and to retain for sit-down education sessions; the traditional doctors seem to have had few problems recruiting and maintaining their groups. As opinion leaders in their communities, traditional doctors talking about gender violence made it easier for others to do so. On their own initiative, traditional doctors devised ways to work together with HEAs – a rare point of contact between western and traditional medicine.

Our follow-up only reached 43 of the 87 trained traditional doctors in the two districts on which we followed up. None of the traditional doctors declined follow-up, but it was difficult to reach some of them, especially in rural communities, as they are quite mobile and not always present in their villages.

We believe this is the first report of involving traditional doctors in primary prevention of gender violence and HIV. Perhaps for the first time since the HIV epidemic took hold in Botswana, traditional doctors feel engaged and positive about their role in HIV prevention. In the words of one traditional doctor who runs several BVV groups, ‘If we had had these BVV materials in the 1980s, we would not have had the HIV epidemic we have now’.