Background

Methods

Study Sites

ILembe District Municipality is situated on the east coast of KwaZulu-Natal bordering the Indian Ocean, it is surrounded by: Umzinyathi to the north, the Indian Ocean to the east, eThekwini to the south (Durban), Umgungundlovu to the west and Uthungulu to the north-east. ILembe consists of four local municipalities located between Durban and Richards Bay: Mandeni, KwaDukuza, Maphumulo and Ndwedwe. The town straddles the Tugela River [25]. This study was conducted in areas surrounding Kwadukuza and Mamphumulo municipalities where healthcare facilities visited citing Primary Healthcare Centre (PHC): Amandlalathi, Mpise, Otimati, Oqaqeni, Mpumelelo and Shakaskraal Clinics, one Community Healthcare centre (CHC): Kwadukuza Clinic, Level one of Healtchcare: Umphumulo and Untunjambili Hospitals, Level two of healthcare: Stanger Hospital. A previous study in ILembe district reported that schistosomiasis was prevalent over the past years [26].

Figure 1. A geographic map of the in iLembe district.

Figure 1. A geographic map of the in iLembe district.

Results

Phase 1: Assessment of healthcare professionals and patients’ perception towards use of TM and orthodox medicine for the treatment of Schistosomiasis with co-morbidities

The phase one enrolled 20 patients referred to researchers by THPs in the previous study, 124 HCWs in healthcare facilities selected in the study as well as 15 patients who have been using the mainstream healthcare system for the management of schistosomiasis.

Self-Reports of HCWs on Availability of Praziquantel (Biltricide^®)

The comparison of the availability of Praziquantel (Biltricide^®) and the level of healthcare facilities shows that out of the 124 respondents, the majority (106/124; 85.5%) argued that Praziquantel (Biltricide^®) was available in the facilities. Most of the respondents (114/124; 91.9%) reported that medicines were purchased directly by the facilities for free distribution to patients. Although about (10/124; 8.1%) of the respondents argued that they did not know if medicines were purchased directly by the facilities for distribution to patients. More so, out of the 91.9% of the respondents that argues that medicines were purchased directly by the facilities for distribution to patients, 49.2% of them worked in rural areas and 42.7% of them worked in semi-urban areas.

A correlation has been found with a p-value set at < 0.05, suggesting that there is a strong relationship between level of healthcare facilities and the availability of Praziquantel (Biltricide^®). The level of a healthcare facilities is a key factor that determines the availability of Praziquantel (Biltricide^®) in rural area facilities (p = 0.006).

Table 2. Assessment of HCWs perception on Praziquantel (Biltricide^®) availability.

Table 2. Assessment of HCWs perception on Praziquantel (Biltricide^®) availability.

	Praziquantel (Biltricide®) Availability by respondents(n)
Healthcare Facilities/ Number of facilities (10)	Yes	No	Don’t Know	Total, n= 124, N, (%), [CI 95%]
PHC (6)	29	Nil	1	30 (24.2%) [17 – 32.7]
CHC (1)	7	Nil	Nil	11 (5.6%) [2.3 – 11.3]
Level 1 (2)	28	4	9	41 (33.1%) [24.9 – 42.1]
Level 2 (1)	42	Nil	4	46 (37.1%) [28.6-46.2]
Total	106	4	14	124 (100.0%)

* PHC (Amandlalathi, Mpise, Otimati, Oqaqeni, Mpumelelo, Shakaskraal Clinics), CHC (Kwadukuza Clinic), Level1 of Healtchcare (Umphumulo and Untunjambili Hospitals), Level 2 of healthcare (Stanger Hospital).

When testing the relationship between the Praziquantel (Biltricide^®) availability perception and the concurrent use of TM and conventional treatment (CT) perception for the treatment of Schistomiasis, there was no significant relationship between the concurrent use of TM and CT by patients for the treatment of schistosomiasis in the study area (X² = 3.042, p = 0.551).

Self-Reports by HCWs About Patients’ Record Keeping and Visits to Healthcare Facilities for Schistosomiasis

It is indicated that all respondents working in the different level of healthcare facilities kept record of patients suffering from schistosomiasis using patients’ files in most cases (105/124; 84.7%). Most of the 124 respondents (111/124; 89.5%) always retrieved and consulted patients’ files for follow up each time they visit facilities.

Table 3. Assessment of record keeping and visits to healthcare facilities for schistosomiasis.

Table 3. Assessment of record keeping and visits to healthcare facilities for schistosomiasis.

	Types of Record Keeping
Facilities	Filing System	Registry System	Notification form (NMC)	Others	Total N, (%), [CI 95%]
PHC	18	Nil	12	Nil	30 (24.2%) [17– 32.7]
CHC	7	Nil	Nil	Nil	7 (5.6%) [2.3 – 11.3]
Level 1	36	Nil	Nil	5	41 (33.1%) [24.9 – 42.1]
Level 2	44	2	Nil	Nil	46 (37.1%) [28.6 – 46.2]
Total	105	2	12	5	124 (100.0%)

* PHC (Amandlalathi, Mpise, Otimati, Oqaqeni, Mpumelelo, Shakaskraal Clinics and Mobile clinics 1 and 2), CHC (Kwadukuza Clinic), Level1 of Healtchcare (Umphumulo and Untunjambili Hospitals), Level 2 of healthcare (Stanger Hospital).

Perceptions of HCWs about the Concurrent Use of Traditional Medicine and Conventional Prescribed Medicines

Majority of healthcare professionals (76/124; 61.3%) reported that they did not know whether their patients used concurrently TM and CT for the treatment of Schistomiasis. In comparing the availability of Praziquantel (Biltricide^®) in facilities with its concurrent use with TM showed that most of the respondents (62/124; 50.0%) of the 85.5% of the respondents that argued positively on the availability of the Praziquantel (Biltricide^®) in the facility reported that their patient do not concurrently used TM and CT for the treatment of schistomiasis.

Knowledge and Prevalence of Schistosomiasis among Patients Seen by Both THPs and HCWs

On views and experiences of respondents on the treatment of schistosomiasis, 12 respondents out of 15 who visited healthcare facilities and met THPs were women. The maximum duration of the disease reported was a month as reported many respondents using TM and those using CT. A treatment, which consisted of antibiotics (15 days prescription) and Praziquantel (Biltricide^®) (single dose), was reported by respondents. Patients referred by THPs to the researchers indicated the use of medicinal plants in the management of schistosomiasis. They all reported that they did not use conventional treatment for schistosomiasis. Most respondents (8/20, 40%) seen by THPs used TM occasionally while the ones who crossed the two systems used TM only once.

On the other side, patients seen by HCPs reported that schistosomiasis were frequent in women (10/15, 66.7%), they reported as well that the disease duration was a month (11/15, 73.3%). It is reported that 8/15, 53.3% have crossed CT and TM but they used the mainstream healthcare facility to be examined as asked me them THPs to find out if the disease was treated well. Most respondents reported to have been on Biltricide^®, single dose and Antibiotics (12/15, 80%). Results showed that 10/15, 66.7% agreed to have used TM for schistosomiasis not on regular basis but only once.

Table 4. Table 4. Knowledge and prevalence of schistosomiasis among patients.

Table 4. Table 4. Knowledge and prevalence of schistosomiasis among patients.

Category (variables)		Patients seen by only by THPs, n=20	Patients seen by HCPs, n=15	Total, N= 35 N (%) [CI 95%]
Type of Schistosomiasis	Bilharzia in women	Nil	12	12 (34.3%) [19.1-52.2]
	Bilharzia in man	Nil	3	3 (8.6%) [1.8-23.1]
Disease duration	Two weeks	Nil	2	2 (5.7%) [0.7-19.2]
	Almost month	Nil	1	1 (2.9%) [0.1-14.9]
	A month	14	11	25 (71.4%) [53.7-85.4]
	Two months	6	1	7 (20%) [ 8.4-36.9]
Treatment duration	No modern treatment, I went to the facility to be examined as asked me the THP to find out if the disease was treated well	Nil	8	8 (22.9%) [10.4-40.1]
	15 days	10	Nil	10 (28.6%) [14.6-46.3]
	One day	10	1	11 (31.4%) [16.9-49.3]
Types of treatment received in the past for this disease	Biltricide	Nil	3	3 (8.6%) [1.8-23.1]
	Imbiza	Nil	12	12 (34.3%) [19.1-52.2 ]
Current treatment for the disease	Imbiza (Herbal medicine mixture)	18	15	33 (94.3%) [80.8-99.3]
	Modern medicine (didn’t use TM after consulting the THP)	2	Nil	2 (5.7%) [0.7-19.7]
Other treatment used than conventional medicines for schistosomiasis	Yes	Nil	12	12 (34.3%) [19.1-52.2 ]
	No	Nil	3	3 (8.6%) [1.8-23.1]
Conventional medicine used for schistosomiasis	Biltricide, single dose	Nil	2	2(5.7%) [0.7-19.7]
	Biltricide, single dose and Antibiotics	Nil	12	12(34.3%) [19.1-52.2]
	None	Nil	1	1(2.9%) [0.1-14.9]
Frequency of use of TM/ CT for schistosomiasis	Occasionally	8	5	13(37.1%) [21.5-55.1]
	Only once	5	10	15 (42.9%) [26.3-60.6]
	Weekly	7	Nil	7 (20%) [8.4-36.9]

Perceptions about the Use of TM Either Alone or in Combination with Conventional Medicines among Patients Seen by Both THPs and HCWs

Respondents reported that they used TM only when stopped the use of modern medicine for those who have crossed the two healthcare systems (9/15, 60%), they were motivated by their curiosity and belief on the choice of the use of traditional medicines (12/15, 80%). They reported to have used TM because it stopped the bleeding for those who visited healthcare facilities and used TM (12/15, 80%).

The majority (12/15, 80%) of respondents reported that TM can be recommended to be used widely against schistosomiasis. Patients (8/15, 53.3%) who crossed the two systems mentioned that they did not disclose to HCPs that they used TM because they usually tell them to avoid the use of TM because it damages organs or makes the modern treatment not work properly when using conventional treatment with traditional herbs. The overall yearly cost for TM used was R1000 or 84.75$ (Rate 1$=11.8R at the time of data collection) reported by the majority (8/15, 53.3%) of patients who have used CT and TM.

Respondents who consulted THPs self-reported a particular perceived benefit obtained from the use of TM including a good treatment of the disease and relief of its symptoms (18/20, 90%). Few respondents (8/20, 40%) reported experiencing unwanted effects after the use of TM such as running stomach (diarrhoea), vomiting and nausea; however, they were satisfied on the performance of TM used for schistosomiasis. Most respondents seen by THPS (18/20, 90%) reported that TM can be recommended to be used widely against schistosomiasis.

Table 5. Table 5. Perceptions on the use of TM either alone or in combination with conventional medicines.

Table 5. Table 5. Perceptions on the use of TM either alone or in combination with conventional medicines.

Category (variables)		Patients seen only by THPs, n=20	Patients seen by HCPs, n=15	Total, N= 35 N (%) [CI 95%]
Explanation of the use of conventional and Traditional medicine	The respondent started using TM only when stopped the use of modern medicine	Nil	9	9 (25.7%) [12.5-43.3]
	Was using conventional medicine during the same period as he was using TM so that both will work together	Nil	6	6 (17.1%) [6.6-33.6 ]
Motivation/ perceptions of the choice of the use of traditional medicines	Curiosity and belief	Nil	12	12 (34.2%) [19.1-52.2 ]
	MM disappoint	Nil	3	3 (8.6%) [1.8-23.1]
Benefit obtained from the use of TM	Yes, no more bleeding, nor blood and itching when urinating	Nil	12	12 (34.3%) [19.1-52.2 ]
	None	Nil	3	3 (8.6%) [1.8-23.1]
	Disease treatment and relieved symptoms	18	Nil	18 (51.4%) [34-68.6]
	It didn’t work well	2	Nil	2 (2.7%) [0.7-19.7]
Any unwanted effect from the used of any medicines either alone or in combination (CT and/or T) for Schistosomiasis	Yes	8	Nil	8 (22.9%) [10.4-40.1]
	No	12	15	27 (77.1%) [59.9-89.6]
Experience on any unwanted effect from the TM use (specification)	Running stomach (diarrhoea), vomiting and Nausea	9	Nil	9 (25.7%) [12.5-43.3]
	None	11	Nil	11 (31.4%) [16.9-49.3]
Satisfaction on the performance of TM/CT used for Schistosomiasis	Satisfied	18	12	30 (85.7%) [69.7-95.2]
	No idea	2	3	5 (14.2%) [4.8-30.3]
Use of either TM/both against Schistosomiasis and recommend it for someone with Schistosomiasis	Yes	18	12	30 (85.7%) [69.7-95.2]
	Not sure	2	3	5 (14.2%) [4.8-30.3]
Choice of TM over CT	Yes, just went to Hospital for exam not treatment	Nil	5	5 (14.2%) [4.8-30.3]
	Yes, Solution and no coming back of the infection	Nil	7	7 (20%) [8.4-36.9 ]
	No	Nil	3	3 (8.6%) [1.8-23.1]
Mention to the HCPs of TM use for Schistosomiasis management	Yes	Nil	3	3 (8.6%) [1.8-23.1]
	No	Nil	12	12 (34.3%) [19.1-52.2 ]
Patient disclosure to Doctor on TM use	He said it doesn’t work and might not be helpful	Nil	1	1 (2.9%) [0.1-14.9]
	He said that traditional medicines can have side effects that won’t be controlled if used together with traditional herbs	Nil	6	6 (17.1%) [6.6-33.6]
	The HCP said that it damages organs or make the modern treatment not work properly	Nil	8	8 (22.9%) [10.4-40.1]
Traditional medicine supply	From the market of traditional herbs	Nil	5	5 (14.2%) [4.8-30.3]
	From the relations	Nil	2	2 (2.7%) [0.7-19.7]
	From the TM practitioner	Nil	8	8 (22.9%) [10.4-40.1]
Cost of TM for a year	Almost R 1000 (84.75$)	Nil	8	8 (22.9%) [10.4-40.1]
	Almost R 1500(127.11$)	Nil	5	5 (14.2%) [4.8-30.3]
	Almost R 2000 (169.49$)	Nil	2	2 (2.7%) [0.7-19.7]

Note: 1$=11.8R at the time of data collection.

Phase 2: Assessment of Medical Chart Records of Patients with History of Schistosomiasis

Evidence of Documentation of the Use of TM for Schistosomiasis and Comorbidities among Patients

In phase two, medical chart records of patients with schistosomiasis were analyzed. Overall, 39 medical chart records were analyzed and none documented the use of TM. Out of 39 files retrieved, two medical records were from patients seen in phase one. The information given verbally to researchers on the use on traditional treatment was not reported in their medical chart records. These two above patients fell among seven cases of patients with history of schistosomiasis and other comorbidities including HIV and other STIs.

Table 6. Schistosomiasis with other associated conditions.

Table 6. Schistosomiasis with other associated conditions.

Categories	Frequency of associated disease conditions to schistosomiasis			Total	N (%) 95% CI
	Frequency of schistosomiasis	Sub-categories
schistosomiasis alone	11	None		11	(8.5%) [4.3-14.6 ]
schistosomiasis associated with HIV	5	Diarrhoea (3), Genital ulcers or itching (1) and other (5)	9	14	(10.8%) [6-17.4 ]
	7	STI & TB (7) and other (31)	38	45	(34.6%) [26.5– 43.5]
	3	other non-infectious diseases: Hypertension (3) and other (5)	8	11	(8.5%) [4.3-14.6]
	5	Hematuria (5), respiratory problem (2) and other (5)	12	17	(13.1%) [7.8-20.1]
schistosomiasis associated with other diseases conditions	2	Hypertension (2), Blood in urine (1), Genital ulcers or itching (1) and other (9)	13	15	(11.5%) [6.6 – 18.3]
	6	Hematuria (6), STI & TB (1) and other (4)	11	17	(13.1%) [7.8 – 20.1]
Total	39	91		130

* NB: More than one disease was documented per patients beside the 11 with schistosomiasis alone.

Assessment of Prescribed Conventional Medicines for Schistosomiasis and Comorbidities

Table 7 below presents the most prescribed medicines for patients with history of schistosomiasis and comorbidities. The most frequent documented medicine for schistosomiasis was Praziquantel (Biltricide^®). For infectious comorbidities, antiretroviral medicines (60/219, 27.39%) and antibiotics (44/219, 20.1%) were the most prescribed medicines with Praziquantel (Biltricide^®).

Discussion

Conclusion

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