Interventions for educating traditional healers about STD and HIV medicine

Abstract

Background

For the treatment of HIV/AIDS, individuals may consult traditional healers because they possess a shared sociocultural background, meet the needs and expectations of the patients, and pay special attention to social and spiritual matters. Various intervention strategies have been adopted to educate traditional healers in various aspects of Western medicine, with a particular focus on HIV/AIDS.

Objectives

To evaluate the effectiveness of interventions for educating traditional healers in the fundamentals of sexually transmitted infection (STI) and HIV medicine.

Search methods

We searched the Cochrane Register of Controlled Trials, Pubmed, Embase, Gatway and AIDSearch from the period of 1980 to 2008. We also handsearched the reference lists of the retrieved articles, located conference proceedings of international conferences related to AIDS 
 studies and contacted key personnel and organizations working in HIV/AIDS intervention programs in developing countries.

Selection criteria

All intervention studies using a controlled design that have evaluated the effect of educational interventions on any one of the outcome measures specified were included.

Data collection and analysis

Two reviewers independently assessed the eligibility of potentially relevant studies and extracted data from and assessed study quality of included studies. A meta‐analysis of study outcomes was not possible given the small number of included studies and the heterogeneity in methodological designs and outcome measures.

Main results

We included two studies (one RCT and one CBA study) in this review (n = 311). Both of these studies indicated that a training workshop increased the knowledge about HIV/AIDS of traditional healers. With regards to behaviour change, Peltzer 2006 detected a significant difference in traditional healers' reports of managing their patients; however, there was no evidence of a reduction of HIV/STI risk behaviours and referral practices, as assessed by self‐report. The study by Poudyal 2003 did not assess this outcome.

Authors' conclusions

Two studies met the inclusion criteria for this review. Although these studies reported some positive outcomes, the few studies and methodological heterogeneity limits the conclusions that can be drawn about the effectiveness of HIV training programs aimed at traditional healers. More rigorous studies (i.e. those employing rigorous randomisation procedures, reliable outcome measures and larger sample sizes) are needed to provide better evidence of the impact of HIV training programs aimed at traditional healers.

Plain language summary

Interventions for educating traditional healers about STD and HIV medicine

There is a strong argument for the importance of collaborating with traditional healers in the management of STIs such as HIV/AIDS. Political and health care systems have failed adequately to cope with the pandemic, and engaging every available resource is therefore crucial. One such potential resource is treatment by traditional healers. Certain traditional healer practices, however, could contribute to the spread of HIV/AIDS. Training and educational programmes have been developed as a possible way to improve traditional healer practices.

This review found four studies that evaluated the effectiveness of HIV/AIDS training programs aimed at traditional healers; information about two of these studies is not yet available. Both of these studies found that workshops improved traditional healer knowledge about HIV/AIDS. However, an assessment of behaviour change in one study found that a training program improved traditional healer behaviour in terms of managing patients, but not in reducing risky behaviours and referral practices.

Although the studies evaluated reported some positive outcomes, they were not of high quality. It is therefore difficult to be certain about the efficacy of interventions for educating traditional healers in the fundamentals of STI and HIV medicine.

Background

The HIV and AIDS epidemic is a global catastrophe, with a particular burden in the developing world. In 2006, it was estimated that approximately 39.5 million people were living with HIV, 4.3 million were recently infected and 2.9 million people died from the devastating epidemic (UNAIDS 2006). Developed countries have not remained untouched by this epidemic; however, countries such as Africa, Asia, and Latin America lead the world in number of people living with HIV infection. Of the 39.5 million people living with HIV worldwide in 2006, for example, more than 63% were from sub‐Saharan Africa.

Although some progress has been made in addressing the HIV epidemic through prevention programs and improved access to treatment, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) advocate that countries look towards the potential contribution of local resources and knowledge (such as traditional medicine) as a way of meeting the challenges in developing cost‐effective treatment and prevention programs. (WHO‐UNICEF 1978). Due to the shortage of health care professionals in many parts of the world, organized and well‐trained traditional healers have the potential to be a significant information, treatment and referral resource.

There is no precise terminology depicting the various types of traditional healers across all countries, languages or cultural groups. As an example, in South Africa the types of healers include the Inyanga and the Isangoma (Edwards 1986; Freeman 1992). The Inyanga (predominantly male) specialize in the production of herbal medicines. The Isangoma (predominantly female) are believed to be specialists in divination within the supernatural context which gives them the ability to divine the cause of illness and misfortune (Ngubane 1977). There is, however, debate about whether faith healers are under the umbrella of traditional healer, as they integrate Christian ritual and traditional practices and belong to one of the Independent African churches (Edwards 1983).

Individuals may consult traditional healers for the treatment of sexually transmitted infections (STIs) because they offer great cultural and conceptual familiarity by meeting the needs and expectations of the patients and by paying attention to social and spiritual matters (King 1997). In a community survey conducted in rural South Africa, for example, 36% of the respondents who reported having an STI in the past 12 months had consulted with a traditional healer for treatment (Peltzer 2006). Although few studies have been conducted which accurately determine the extent of use of traditional healers, a growing body of small studies indicates that use may be as high as 70% of the general populations in some countries.

There is a strong argument for the importance of collaborating with traditional healers in the management of STIs such as HIV/AIDS (Mills 2006). Political and health care systems have failed adequately to cope with the pandemic, and engaging every available resource is therefore crucial. One such potential resource is treatment by traditional healers; however, certain traditional healer practices could contribute to the spread of HIV/AIDS.

A few studies have investigated traditional practices and have identified numerous HIV risk practices among traditional healers. As one example, a study conducted in Botswana reported that when healers performed "bloodletting" on a patient, they would use their own mouth to suck the blood (Chipfakacha, 1997); similarly, a study conducted in Nigeria found that 77% of patients had received treatment from a traditional healer who used unsterilized blades. The patients reported that the healers would use their unprotected fingers to rub the herbal medicine into their bleeding wounds (Peters 2004).

Traditional healers have been involved in a number of HIV and AIDS prevention programs (Green 1994; Green 1995; UNAIDS 2000; UNAIDS 2002). The WHO (1990) advocated the inclusion of traditional healers in national HIV and AIDS programmes since the early 1990s. Since then, a number of programs, conducted primarily in Africa, have shown that traditional healers have the potential to be a valuable resource in caring for people living with HIV and AIDS and in preventing HIV infection (Green 1994; Green 1995; King 1997; UNAIDS 2000; UNAIDS 2002). An intervention study that adopted a pre‐ and post‐test design demonstrated an improvement in traditional healers' knowledge and attitudes towards HIV and AIDS immediately after the training (Somse 1998).

In summary, various intervention strategies have been adopted to educate traditional healers in the fundamentals of STI and HIV medicine. To our knowledge, however, no systematic review has thus far attempted to determine whether interventions to educate traditional healers in HIV and STI medicine result in an increase in knowledge. We propose conducting such a review using the methodology of the Cochrane Collaboration.

Objectives

To evaluate the efficacy of interventions for educating traditional healers in the fundamentals of STI and HIV medicine.

Methods

Criteria for considering studies for this review

Types of studies

All intervention studies using a controlled design, such as randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), that have evaluated the effect of interventions on any one of the outcome measures specified were included. Publication is not necessarily related to study quality and, indeed, publication may imply certain biases (Dickersin 1992; Song 2000); therefore, unpublished abstracts and reports were also considered. Trial reports in all languages were included.

Types of participants

All traditional healers (including native, aboriginal and indigenous healers) practicing in the developing and developed world were included regardless of whether they were still in training or were members of an organizational body (e.g., the Traditional Healers Organization).

Types of interventions

The review focused only on interventions aimed at educating traditional healers in STI and HIV medicine. Comparisons were conducted between educational interventions versus no intervention. Both short‐term and long‐term interventions were included, where available.

Types of outcome measures

Primary Outcomes 
 a) Increase in knowledge about STI and HIV medicine. This included knowledge surrounding HIV transmission routes, prevention methods, and antiretroviral therapy (ART).

Secondary Outcomes

Change in behaviour including: 
 a) Reduction in HIV risk practices (e.g., performing scarifications or incisions with unsterilized blades, performing enemas with reused equipment 
 b) Referring patients for HIV testing 
 c) Distributing condoms to community members 
 d) Providing advice and counselling on safe sex practices 
 e) Referring patients to Western medicine

Search methods for identification of studies

We formulated a comprehensive and exhaustive search strategy in an attempt to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress).

E lectronic searches

1) PubMed was searched on 4 April 2008 using the search strategy documented in Table 1.

1. Search Strategy for Pubmed.

Number	Search Terms
#1	HIVInfections[MeSH]ORHIV[MeSH]ORhiv[tw]ORhiv‐1*[tw]ORhiv‐2*[tw]ORhiv1[tw]ORhiv2[tw]OR hiv infect*[tw] OR human immunodeficiency virus[tw] OR human immunedeficiency virus[tw] OR human immuno‐deficiency virus[tw] OR human immune‐deficiency virus[tw] OR ((human immun*) AND (deficiency virus[tw])) OR acquired immunodeficiency syndrome[tw] OR acquired immunedeficiency syndrome[tw] OR acquired immuno‐deficiency syndrome[tw] OR acquired immune‐deficiency syndrome[tw] OR ((acquired immun*) AND (deficiency syndrome[tw]))
#2	sexually transmitted diseseases, viral[mh:exp] OR sexually transmitted diseases, bacterial [mh:exp] OR (sexually transmitted disease) OR (sexually transmitted diseases) OR (sexually transmitted infection) OR (sexually transmitted infections) OR (genital ulcer) OR (genital ulcer disease) OR (genital ulcer diseases) OR (genital ulcers) OR (veneral disease) OR (veneral diseases) OR (venereal infections) OR (venereal infection)
#3	#1 OR #2
#4	randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR random allocation [mh] OR double‐blind method [mh] OR single‐blind method [mh] OR clinical trial [pt] OR clinical trials [mh] OR ("clinical trial" [tw]) OR ((singl* [tw] OR doubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw])) OR ( placebos [mh] OR placebo* [tw] OR random* [tw] OR research design [mh:noexp] OR (comparative study) OR (comparative studies) OR (evaluation studies) OR (evaluation study) OR follow‐up studies [mh] OR prospective studies [mh] OR control* [tw] OR prospectiv* [tw] OR volunteer* [tw]) NOT (animals [mh] NOT human [mh])
#5	medicine, traditional [mh:exp] OR Native Healer OR Native Healers OR Aboriginal healer or Aboriginal Healers or Indigenous Healer or Indigenous Healers or traditional healer OR traditional Healers
#6	Search #3 AND #4 AND #5 Limits: Publication Date from 1980 to 2008/04/04

2) EMBASE on line was searched on 9 April 2008. See Table 2 or search strategy.

2. Search Strategy for Embase.

Number	Search Terms
#1	('humanimmunodeficiencyvirusinfection'/expOR'humanimmunodeficiencyvirusinfection')OR('human immunodeficiency virus infection'/exp OR 'human immunodeficiency virus infection')) OR (('human immunodeficiency virus infection'/exp OR 'human immunodeficiency virus infection') OR ('human immunodeficiency virus infection'/exp OR 'human immunodeficiency virus infection'))) OR (((('human immunodeficiency virus'/exp OR 'human immunodeficiency virus') OR ('human immunodeficiency virus'/exp OR 'human immunodeficiency virus')) OR (('human immunodeficiency virus'/exp OR 'human immunodeficiency virus') OR ('human immunodeficiency virus'/exp OR 'human immunodeficiency virus')))) OR (((('b cell lymphoma'/exp OR 'b cell lymphoma') OR ('b cell lymphoma'/exp OR 'b cell lymphoma')) OR (('b cell lymphoma'/exp OR 'b cell lymphoma') OR ('b cell lymphoma'/exp OR 'b cell lymphoma')))) OR (hiv:ti OR hiv:ab) OR ('hiv‐1':ti OR 'hiv‐1':ab) OR ('hiv‐2':ti OR 'hiv‐2':ab) OR ('human immunodeficiency virus':ti OR 'human immunodeficiency virus':ab) OR ('human immunedeficiency virus':ti OR 'human immunedeficiency virus':ab) OR ('human immune‐deficiency virus':ti OR 'human immune‐deficiency virus':ab) OR ('human immuno‐deficiency virus':ti OR 'human immuno‐deficiency virus':ab) OR ('acquired immunodeficiency syndrome':ti OR 'acquired immunodeficiency syndrome':ab) OR ('acquired immuno‐deficiency syndrome':ti OR 'acquired immuno‐deficiency syndrome':ab) OR ('acquired immune‐deficiency syndrome':ti OR 'acquired immune‐deficiency syndrome':ab) OR ('acquired immunedeficiency syndrome':ti OR 'acquired immunedeficiency syndrome':ab) AND [1980‐2008]/py
#2	'viral sexually transmitted diseases' OR 'bacterial sexually transmitted diseases'OR (('sexually transmitted disease'/exp OR 'sexually transmitted disease') OR ('sexually transmitted disease'/exp OR 'sexually transmitted disease')) OR (('sexually transmitted diseases'/exp OR 'sexually transmitted diseases') OR ('sexually transmitted diseases'/exp OR 'sexually transmitted diseases')) OR 'sexually transmitted infection'OR 'sexually transmitted infections'OR (('genital ulcer'/exp OR 'genital ulcer') OR ('genital ulcer'/exp OR 'genital ulcer')) OR 'genital ulcer disease' OR 'genital ulcer diseases' OR 'genital ulcers' OR (('venereal disease'/exp OR 'venereal disease') OR ('venereal disease'/exp OR 'venereal disease')) OR 'venereal diseases' OR 'venereal infections' OR (('venereal infection'/exp OR 'venereal infection') OR ('venereal infection'/exp OR 'venereal infection')) AND [1980‐2008]/py
#3	#1 OR #2
#4	((random*:ti OR random*:ab) OR (factorial*:ti OR factorial*:ab) OR (cross?over*:ti OR cross?over*:ab OR crossover*:ti OR crossover*:ab) OR (placebo*:ti OR placebo*:ab) OR ((doubl*:ti AND blind*:ti) OR (doubl*:ab AND blind*:ab)) OR ((singl*:ti AND blind*:ti) OR (singl*:ab AND blind*:ab)) OR (assign*:ti OR assign*:ab) OR (allocat*:ti OR allocat*:ab) OR (volunteer*:ti OR volunteer*:ab) OR (((('crossover procedure'/exp OR 'crossover procedure') OR ('crossover procedure'/exp OR 'crossover procedure')) OR (('crossover procedure'/exp OR 'crossover procedure') OR ('crossover procedure'/exp OR 'crossover procedure')))) OR (((('double‐blind procedure'/exp OR 'double‐blind procedure') OR ('double‐blind procedure'/exp OR 'double‐blind procedure')) OR (('double‐blind procedure'/exp OR 'double‐blind procedure') OR ('double‐blind procedure'/exp OR 'double‐blind procedure')))) OR (((('single‐blind procedure'/exp OR 'single‐blind procedure') OR ('single‐blind procedure'/exp OR 'single‐blind procedure')) OR (('single‐blind procedure'/exp OR 'single‐blind procedure') OR ('single‐blind procedure'/exp OR 'single‐blind procedure')))) OR (((('randomized controlled trial'/exp OR 'randomized controlled trial') OR ('randomized controlled trial'/exp OR 'randomized controlled trial')) OR (('randomized controlled trial'/exp OR 'randomized controlled trial') OR ('randomized controlled trial'/exp OR 'randomized controlled trial'))))) AND [1980‐2008]/py
#5	('traditional medicine'/exp OR 'traditional medicine') OR 'native healer' OR 'native healers' OR 'aboriginal healer' OR 'aboriginal healers' OR 'indigenous healer' OR 'indigenous healers' OR ('traditional healer'/exp OR 'traditional healer') OR 'traditional healers' OR 'aboriginal medicine' OR 'indigenous medicine' AND [1980‐2008]/py
#6	#3 AND #4 and #5

3) Gateway was searched on 10 April 2008 to retrieve meeting abstracts using the search strategy documented in Table 3.

3. Gateway Search Strategy.

Number	Search Terms
#1	(HIVInfections[MeSH]ORHIV[MeSH]ORhiv[tw]ORhiv‐1*[tw]ORhiv‐2*[tw]ORhiv1[tw]ORhiv2[tw]ORhivnfect*[tw] OR human immunodeficiency virus[tw] OR human immunedeficiency virus[tw] OR human immuno‐deficiency virus[tw] OR human immune‐deficiency virus[tw] OR ((human immun*) AND (deficiency virus[tw]))) OR (acquired immunodeficiency syndrome[tw] OR acquired immunedeficiency syndrome[tw] OR acquired immuno‐deficiency syndrome[tw] OR acquired immune‐deficiency syndrome[tw] OR ((acquired immun*) AND (deficiency syndrome[tw])))
#2	(genital ulcer) OR (genital ulcer disease) OR (genital ulcer diseases) OR (genital ulcers) OR (venereal disease) OR (venereal diseases) OR (venereal infections) OR (venereal infection)) OR ((sexually transmitted disease) OR (sexually transmitted diseases) OE sexually transmitted infection) OR (sexually transmitted infections)) OR ((bacterial sexually transmitted disease) OR viral sexually transmitted disease))
#3	#1 OR #2
#4	((randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR random allocation [mh] OR double‐blind method [mh] OR single‐blind method [mh] OR clinical trial [pt] OR clinical trials [mh] OR ("clinical trial" [tw]) OR ((singl* [tw] OR doubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw]))) OR (( placebos [mh] OR placebo* [tw] OR random* [tw] OR research design [mh:noexp] OR (comparative study) OR (comparative studies) OR (evaluation studies) OR (evaluation study) OR follow‐up studies [mh] OR prospective studies [mh] OR control* [tw] OR prospectiv* [tw] OR volunteer* [tw]))) NOT (animals [mh] NOT human [mh])
#5	(traditional medicine) OR native healer or native healers or aboriginal healer or aboriginal healers or indigenous healer or indigenous healers or traditional healer OR traditional healers
#6	#3 AND #4 AND #5 Limit: 1980:2008

4) AIDSearch was searched on 10 April 2008 using the search strategy documented in Table 4.

4. AIDSearch Search Strategy.

Number	Search Terms
#1	(hivinfections)orhivorhivorhiv‐1*orhiv‐2*orhiv1orhiv2or(hivinfect*)or(humanimmunodeficiencyvirus)or(human immunedeficiency virus) or (human immuno‐deficiency virus) or (human immune‐deficiency virus) or ((human immun*) and (deficiency virus)) or (acquired immunodeficiency syndrome) or (acquired immunedeficiency syndrome) or (acquired immuno‐deficiency syndrome) or (acquired immune‐deficiency syndrome) or ((acquired immun*) and (deficiency syndrome)) or (sexually transmitted diseases, viral)
#2	(viral sexually transmitted diseases) or (bacterial sexually transmitted diseases) or (sexually transmitted disease) or (sexually transmitted diseases) or (sexually transmitted infection) or (sexually transmitted infections) or (genital ulcer) or (genital ulcer disease) or (genital ulcer diseases) or (genital ulcers) or (venereal disease) or (venereal diseases) or (venereal infections) or (venereal infection)
#3	#1 OR #2
#4	((randomized controlled trial) or (controlled clinical trial) or (randomized controlled trials) or (random allocation) or (double‐blind method) or (single‐blind method) or (clinical trial) or (clinical trials) or ("clinical trial") or ((singl* or doubl* or trebl* or tripl* and (mask*  or blind* )) or  placebos  or placebo* or random* or (comparative study) or (evaluation studies) or (follow‐up studies) or (prospective studies) or control* or prospectiv* or volunteer*)) not (animals  not human )
#5	(traditional medicine) or native healer or native healers or aboriginal healer or aboriginal healers or indigenous healer or indigenous healers or traditional healer or traditional healers
#6	#3 AND #4 AND #5 AND PY>=1980

5) The Cochrane Central Register of Controlled Trials (from 2004‐ 2008) was searched on 10 April 2008. See Table 5 for search strategy.

5. Cochrane Library Search Strategy.

Number	Search Terms
#1	(hivinfections)orhivorhivorhiv‐1*orhiv‐2*orhiv1orhiv2or(hivinfect*)or(humanimmunodeficiencyvirus)or(human immunedeficiency virus) or (human immuno‐deficiency virus) or (human immune‐deficiency virus) or ((human immun*) and (deficiency virus)) or (acquired immunodeficiency syndrome) or (acquired immunedeficiency syndrome) or (acquired immuno‐deficiency syndrome) or (acquired immune‐deficiency syndrome) or ((acquired immun*) and (deficiency syndrome)) or (viral sexually transmitted diseases), from 1980 to 2008
#2	(viral sexually transmitted diseases) or (bacterial sexually transmitted diseases) or (sexually transmitted disease) or (sexually transmitted diseases) or (sexually transmitted infection) or (sexually transmitted infections) or (genital ulcer) or (genital ulcer disease) or (genital ulcer diseases) or (genital ulcers) or (venereal disease) or (venereal diseases) or (venereal infections) or (venereal infection), from 2004 to 2008
#3	#1 AND #2
#4	(traditional medicine) or native healer or native healers or aboriginal healer or aboriginal healers or indigenous healer or indigenous healers or traditional healer or traditional healers, from 2004 to 2008
#5	#3 AND #4

Searching other sources

1) Personal communication: Key personnel and organizations working in HIV/AIDS intervention programs in developing countries were contacted for published and unpublished references and data.

2) Conference proceedings of international conferences related to AIDS (e.g., the International Conference on HIV/AIDS and STIs in Africa [ICASA]) were searched.

3) Additional randomised controlled trials (RCTs) were sought in the reference lists of the retrieved articles.

Data collection and analysis

Selection of studies 
 RCTs identified were independently assessed for inclusion by two raters (KS and JI), based on information included in the abstract and/or methods section of the trial report. Non‐RCTs and other studies requiring additional information to determine their suitability for inclusion in the review were listed in the "studies awaiting assessment" table in the Review Manager (RevMan) software pending the availability of this information. Any disagreements in the trial selection procedures were resolved by discussion with a third rater (DS).

Data extraction and management 
 Spreadsheet forms were designed for the purpose of recording descriptive information, summary statistics of the outcome measures, the quality scale ratings and associated commentary. Once these data were entered, they were exported to the RevMan software, which was used to conduct the meta‐analysis. Where information was missing, the reviewers contacted investigators by e‐mail in an attempt to obtain this information.

The following information was independently collated by two reviewers for each trial:

(a) Description of the trials, including the primary researcher, the year of publication, and the source of funding.

(b) Characteristics of the interventions, including the number of participants in the intervention and control groups, the number of total drop‐outs per group as well as the elapsed time between the intervention and post‐assessment.

(c) Characteristics of study methodology, including whether randomisation was employed.

(d) Characteristics of participants, including category of traditional healer (Inyanga, Sangoma, faith healer), gender distribution, mean and range of ages and descriptions of traditional healer practices.

(e) Outcome measures employed and summary of continuous (means and standard deviations) and dichotomous data.

Assessment of methodological quality of included studies

There has been some debate about how best to measure the quality of trials, and further work in this area remains necessary. In this review, we used the quality criteria recommended by EPOC to assess study quality of all studies included in the review (EPOC Review Group Checklist, 2002).

The criteria used to assess RCTs were:                                                                                                          

1. Concealment of allocation;                                                                                                                           

2. Follow‐up of professionals;                                                                                                                      

3. Follow‐up of patients or episodes of care;                                                                         

4. Blinded assessment of primary outcomes(s);                                             

5. Baseline measurement;                                                                                                                         

6. Reliable primary outcome measure(s);                                                                                                       

7. Protection against contamination.

The criteria used to assess CBA studies were:

1. Baseline measurement;                                                                                                                                 

2. Characteristics for studies using second site as control;                                                                             

3. Blinded assessment of primary outcome(s);                                                                                            

4. Protection against contamination;                                                                                                        

5. Reliable primary outcomes measure(s);                                                                                                  

6. Follow‐up of professionals;                                                                                                                     

7. Follow‐up of patients.

We assigned an overall quality rating (high, moderate, low protection against bias) to each study. We gave a high quality rating if all criteria were rated as done (or not applicable); we gave a moderate quality rating if one or two criteria were not done or not clear; and we gave a low quality rating for studies if three or more criteria were not done or not clear.

Analysis

Ideally, we would have conducted a meta‐analysis of study outcomes for this review. This was not possible, however, due to the small number of included studies and the differences in relation to methodological design and outcome measures across the studies. Consequently, we have presented the results in a narrative format.

Results

Description of studies

Results of the search

The search of the electronic databases yielded the following results: PubMed (210 records), EMBASE (35 records), Gateway (390 records), AIDSearch (4 records), and CENTRAL (70 records) .

Included studies

Two studies met the inclusion criteria; both assessed the effectiveness of interventions compared with control groups which received no education intervention. Two additional studies have been located (see "Studies awaiting classification" table), and will be included pending further information from the authors on the outcome measures used. A description of all four studies is provided below:

The first study (Peltzer 2006) was a CBA study investigating the effectiveness of an HIV/AIDS, STI, and tuberculosis (TB) intervention for traditional healers in KwaZulu Natal, South Africa. A quasi‐experimental intervention design was conducted in four selected communities in KwaZulu Natal, South Africa (two urban and two rural).The intervention consisted of a 3.5‐day training session led by one professional nurse, one traditional healer, and two researchers who facilitated the training. The intervention itself focused on information on HIV, STI, TB, nutrition and family planning, and motivation for risk behavior reduction. A follow‐up session 2 to 3 months after the initial training was conducted by the trainers to review and clarify any misunderstandings of the material provided and to overcome any challenges the healers had experienced. Traditional healers were assigned to an intervention (n=160) or control group (n=73). The questionnaires were interviewer‐administered in Zulu by two researchers, one traditional healer and one professional nurse trained in administration of this interview schedule. Post‐questionnaires were administered 7 to 9 months following the intervention. Participants assigned to the control condition completed assessments during the same periods as intervention participants.

The second study (Poudyal 2003) was a controlled trial (CT) that evaluated an intervention program designed to train traditional healers in Western medicine. Traditional healers were randomly selected from a list of 269 healers from 10 village development committees in rural Nepal. Fifty traditional healers were randomly selected to participate in the intervention group and 30 untrained healers were randomly selected to participate in the control group. The intervention focused on increasing traditional healers' knowledge of malnutrition, acute respiratory infection, diarrhoea, night blindness and HIV; however, only the HIV/AIDS component of the training will be reported in this review. The training lasted for 7 days and was lead by four trained instructors. Data collection was conducted 1 year following the intervention using a semi‐structured interview scheduled.

The third study (Nations, 1977), for which further details are needed, was a controlled before‐and‐after study (CBA) using a quasi‐experimental intervention design.The study evaluated an intervention designed to train traditional healers in the HIV/STI management with a focus on risk practices in Fortaleza, Brazil. This study differs from the others in that the trainers in this study were themselves Umbanda healers who had participated in extensive training. In this study 126 traditional healers were selected for the intervention condition and 100 for the control condition. The intervention focused on safe sex practices, avoidance of ritual blood behaviours and sterilization of cutting instruments. The impact of the training was assess within 3 weeks following the session, using an orally administered questionnaire.

The fourth study (Wellington, 1997), for which we are also awaiting more information, was a CBA study using a quasi‐experimental intervention design. Fourteen districts in Zimbabwe were randomly assigned to either an intervention or control condition. Although 261 traditional healers participated in the study by completing pre and post tests, it is not clear how many healers were allocated to each group. This unpublished study investigated the effectiveness of a 4‐day training program designed to alter knowledge and attitudes and the potentially harmful treatment practices of traditional healers. Traditional healers in both conditions were surveyed prior to the intervention and 6 months following the training.

Risk of bias in included studies

Both of the included studies have been rated as being of low quality and prone to systematic bias (see Table: "Quality assessment of included studies"). Furthermore, the power to detect an effect in one of the studies (Poudyal 2003) is limited, given its small sample.

Effects of interventions

Peltzer 2006 reported a statistically significant increase in HIV/AIDS knowledge (F=8.09, P<0.01) and improvement in HIV/STI patient management practices amongst traditional healers following the training program (F=17.43, P<0.01). However, there was no evidence of differences in the incidence of HIV/STI risk practices (F=4.25, NS, P=NS) between the experimental and control conditions after training.

Poudyal 2003 described a significant increase in knowledge of how to prevent HIV/AIDS (P<0.001) as well as of its signs and symptoms (P<0.001) after training. Furthermore, almost all of the trained traditional healers (92%) had referred patients to Western healthcare professionals when their own methods were not proving effective, whereas only 70% of the untrained traditional healers had done so (P<0.05).

Discussion

This review of HIV training interventions aimed at traditional healers located two eligible studies. Unfortunately, methodological heterogeneity, small samples and the risk of biased results limit the conclusions that can be drawn from these studies. .

The two included studies reported positive outcomes for knowledge of HIV and STIs; however, the type of knowledge assessed varied between the studies. Peltzer 2006 utilized a structured scale of 13 items to measure HIV knowledge focusing on major HIV transmission routes, prevention methods and ARV treatment. Poudyal 2003 on the other hand, employed an open‐ended questionnaire as a measure of knowledge gain. As an example, knowledge of the prevention of HIV was assessed in Poudyal 2003 by asking the healer "How can people prevent themselves from infection with HIV/AIDS." The traditional healer was correct if they mentioned two of the following: a) Stopping having sex with many partners; b) Using safe sex practices; c) Not receiving HIV‐infected blood transfusion; d) Not using unsterilized syringes and needles. Although it is promising that both included studies reported a positive impact on knowledge gain, there is a wealth of literature demonstrating the increased knowledge of health practices does not necessarily equate to behaviour change (Ajzen 1991). Thus, Peltzer 2006 reported that training resulted in greater knowledge of HIV/AIDS, but at the same time was not able to find evidence for a reduction of HIV/STI risk behaviours.

Although the findings of the studies included in this review indicate that educational interventions may be effective in educating traditional healers in the fundamentals of STI and HIV medicine, their efficacy remains unclear at this time partly due to the methodological heterogeneity amongst the studies in relation to the length and format of the educational intervention. The study conducted by Peltzer 2006 consisted of a 3.5‐day workshop, with post‐assessment occurring 6 to 7 months following the intervention. In Poudyal 2003 the duration of the workshop was 7 days, and the post‐assessment was not done until a year following the intervention. In addition, the training programs in the two included studies provided information on other health problems besides HIV and AIDS. The program described in Peltzer 2006 included a training session on tuberculosis, while Poudyal 2003 focused on a variety of other common illnesses, including malnutrition, acute respiratory infection, diarrhoea, and night blindness

It is important to acknowledge criticism of current collaborative efforts involving Western and traditional practitioners as adopting a unidirectional and paternalistic approach to health education (Wreford 2005). A forum to facilitate input from other stakeholders (e.g. traditional healers, consumers) must be established for this process to be truly collaborative and ultimately successful. Measures also will have to be taken to protect traditional healer patients, not only through standards and regulations ensuring that they are qualified, but also through compliance with evidence‐based practices in ensuring the efficacy and safety of their medicines as well.

Authors' conclusions

Implications for practice.

Although the studies included in this review reported a range of positive outcomes, the small number of studies, combined with the heterogeneity of interventions, means it is not possible to draw generalizable inferences about the effects of these interventions. Despite marking a step forward in beginning to establish an evidence base for traditional healer interventions, more rigorous research (those employing RCTs, CBA, or ITS designs) is needed to demonstrate evidence of the impact of this type of intervention on professional practice or healthcare outcomes or both.

Implications for research.

Although numerous studies have been conducted assessing HIV/AIDS interventions aimed at traditional healers, only four were randomized control trials. Future randomised controlled studies explicitly focused on interventions with rigorous randomisation procedures and allocation concealment, larger sample sizes, and more appropriate control groups, would improve the evidence base for interventions aimed at traditional healer in HIV/AIDS medicine. Furthermore, a systematic review assessing interventions for educating traditional healers, not just about HIV/AIDS but about all Western health care practices, would be beneficial.

History

Protocol first published: Issue 2, 2008
 Review first published: Issue 4, 2009

Date	Event	Description
25 April 2008	Amended	Converted to new review format.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Peltzer 2006.

Methods	This controlled before and after study (CBA) used a quasi‐experimental design where traditional healers practicing in a particular area were assigned to either an intervention or control group
Participants	233 traditional healers (160‐intervention and 73‐control group)
Interventions	Two researchers gave a workshop over 3.5 days focusing on HIV/AIDS, sexually transmitted infections (STI) and tuberculosis (TB). TB data will not be used in this review
Outcomes	Semi‐structured Questionnaire (self‐report): 13 items on HIV/AIDS knowledge ; 9 items on HIV/STI Management Practices; 7 item TB knowledge index; 5 item Risk Index
Notes	Study Quality: Low
Risk of bias
Bias	Authors' judgement	Support for judgement
Baseline measurement	Low risk	Traditional healer outcomes were measured prior to the intervention and there were no substantial differences.
Characteristics for studies using second site as control (CBA) or Concealment of allocation(CCTs)	High risk	There are significant differences between the control and the experimental group with regards to gender.
Blinded assessment of primary outcome(s) (protection against detection bias)	Unclear risk	The study did not specify whether the primary outcome measure was assessed blindly
Protection against contamination ‐ Studies using second site as control	Low risk	Cluster sampling was used to include all traditional healers from four selected communities
Reliable primary outcome measure(s)	High risk	The reliability of the measures were relatively low. HIV/AIDS knowledge‐0.72; HIV/STI Management Practices‐0.81; TB knowledge index‐0.50; Risk Index‐0.48.
Follow‐up of professionals (protection against exclusion bias)	High risk	Of the 233 traditional healers in the study, 155 (67%) completed the 7–9 months follow‐up interview; 66% intervention and 69% control

Poudyal 2003.

Methods	This study used a cross‐sectional design with a comparison group
Participants	48 trained traditional healers (intervention group) vs. 30 untrained traditional healers (control) participated in the study
Interventions	The 7 day intervention focused on increasing traditional healers knowledge of malnutrition, acute respiratory infection, diarrhoea, night blindness and HIV, Hoewever, only the HIV/AIDS component of the training will be reported in this review.
Outcomes	Semi‐structured interview schedule for the traditional healers, included questions about causes of illness, knowledge of preventive measures, signs and symptoms of illnesses, and methods of treatment.
Notes	Study Quality: Low
Risk of bias
Bias	Authors' judgement	Support for judgement
Baseline measurement	Unclear risk	The study did not indicate whether baseline measure were statistically different between the control and intervention group.
Characteristics for studies using second site as control (CBA) or Concealment of allocation(CCTs)	Unclear risk	Although characteristics are reported in the text, no data is presented.
Blinded assessment of primary outcome(s) (protection against detection bias)	High risk	The outcomes were not blindly assessed.
Protection against contamination ‐ Studies using second site as control	Unclear risk	Participants in the study were randomly selected from a list of 10 village development committees. Therefore, communication between traditional healers in the experimental and control group was likely to occur.
Reliable primary outcome measure(s)	Unclear risk	Reliability was not reported for the outcome measures.
Follow‐up of professionals (protection against exclusion bias)	Low risk	Only 2 traditional healers did not complete the study.

Characteristics of studies awaiting assessment [ordered by study ID]

Nations, 1977.

Methods	This study used a cross‐sectional design with a comparison group
Participants	126 trained traditional healers (interventions group) vs. 100 untrained traditional healers (control)
Interventions	Biomedical prevention of AIDS, including safe sex practices, avoidance of ritual blood behaviours and sterilization of cutting instruments was provided to the healers in 3 hours sessions for 3 days.
Outcomes	The impact of the intervention was assessed 3 weeks after the workshop using a 187‐ item, orally administered questionnaire about AIDS awareness, knowledge, transmission, risk behaviours and preventative strategies.
Notes

Wellington, 1997.

Methods	This controlled before and after study (CBA) used a quasi‐experimental design where traditional healers practicing in a particular area were assigned to either an intervention or control group
Participants	261 traditional healers participated in the study by completing pre and post tests, how many healers were allocated to each group is unclear
Interventions	A 4 day training program designed to alter knowledge, attitudes, and the potentially harmful treatment practices of traditional healers was provided. Traditional healers in both conditions were surveyed prior to the intervention and 6 months following the training.
Outcomes	The knowledge that "biting out" could result in HIV transmission (P=0.0016); reported attitudes that were commensurate with safe practices on scarification (p=0.011); and scarification enhancing medicines (P=0.048).
Notes	only an abstract was available

Differences between protocol and review

Due to the small number of included studies and the differences in relation to methodological design and outcome measures across the studies a meta‐analysis of study outcomes for this review was not conducted. Therefore, there were a number of differences in the methods section between the review and the protocol.

Contributions of authors

Katherine Sorsdahl was responsible for compiling the original protocol, responding to editorial comments, and writing the methodology and results section of the review; Jonathan Ipser and Katherine screened studies for inclusion, extracted data from the RCTs and wrote the interpretive components of the review (discussion and conclusion). Dan Stein resolved disagreements in identifying studies for inclusion and provided feedback on draft versions of the protocol and review.

Katherine Sorsdahl stands as guarantor of this review.

Declarations of interest

Katherine Sorsdahl has no known conflicts of interest. 
 Jonathan Ipser has no known conflicts of interest. 
 Dan Stein has no known conflicts of interest

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