Development of a framework for the standardization of management of diabetes and hypertension: the case of Tswanas and Zulus of South Africa.

Abstract

Introduction: In sub-Saharan Africa, available World Health Organization data indicate an increase in the prevalence rate of non-communicable diseases such as diabetes and hypertension. Dwindling economies, rising costs of orthodox conventional medicines (OCM) and a lack of health care facilities in indigenous communities have led to the patronage of Traditional Medicine (TM) by the general population, with the assistance of traditional health practitioners (THPs) to combat these chronic conditions. However, the nonexistence of standardized and formalized Tswana and Zulu diabetes and hypertension treatment guidelines for THPs indicates the need to compare their methods and treatments approaches in the two culturally diverse environments. Understanding the similarities and differences of their methods and treatment approaches could serve as the basis of affirming evidence-based practice in TM that will lead to the development of a framework to assist in managing these two diseases in indigenous African communities. This study aimed to develop a framework for the standardization of traditional health practices to manage diabetes and hypertension among Tswanas and Zulus THPs in the North-West and KwaZulu-Natal (KZN) Provinces, South Africa. Methods: A comparative cross-sectional descriptive study with mixed-method (embedded) approach was conducted in the uMgungundlovu and uThukela Districts of KZN, and the Bojanala and Dr. Ruth Sekgopomati Districts of the North-West Province. Phase 1A entailed a series of focus group discussions (FGDs) with 67 THPs in KZN and 40 in the North-West Provinces about their management of diabetes and hypertension in three geospatial areas (urban, traditional/tribal and farm areas), the data being analysed using thematic content analysis. In Phase 1B, a researcher-administered questionnaire was used to conduct face-to-face interviews about the management of diabetes and hypertension among 437 THPs in KZN and 426 in North West Province. The qualitative data was analysed using thematic content analysis while the quantitative data was examined and reported using descriptive statistics. In Phase 2, an analytical approach was used to develop a modified interventional tool that was adapted from the Ayurveda treatment guidelines for both diabetes and hypertension based on findings from Phases 1A and Phase 1B. OCM and Ayurveda health traditions experts’ opinion regarding the developed diabetes and hypertension guidelines were sought after their validation process that led to the development of a framework for the standardization of traditional health practices regarding the two conditions.

Results: This study found that most Zulu and Tswana THPs acquired their knowledge and training from one of the following ways: by a family member, other person, and gift from birth, a calling without any form of training and through professional training. The majority of Zulu THPs acquired their knowledge as a gift from birth, while the majority of Tswana THPs acquired their knowledge and training via family members. Acquisition of knowledge as a gift from birth entails a call to practice via ancestral spirits initiation, while from family members involves training received from other experienced THPs in the family. There were similarities in the Zulu and Tswana THPs cultural understanding of both diabetes and hypertension. Most THPs regarded diabetes and hypertension as the same condition, as one (having diabetes) leads to the other (hypertension). The following symptoms: weight loss, sweating easily, shortness of breath, feeling dizzy, and difficulties in breathing, excessive hunger and eyesight problems, were the most commonly reported clinical features for both diabetes and hypertension by the THPs. Ethnopharmacological modalities and treatment approaches used by the Zulu and Tswana THPs to manage both diabetes and hypertension diseases were mainly the use of herbal mixtures, with Aloe vera as a major constituent. Besides, the following medicinal plants: Hypoxis hemerocallidea, Persea americana, Sutherlandia frutescens and Harpagophylum procumbens were used by both groups of THPs in its management. Commonalities in their responses from the findings in Phase 1A and Phase 1B compared to adapted Ayurveda treatment guidelines for both diabetes and hypertension led to the development of treatment guidelines for both conditions. The developed framework to manage diabetes and hypertension for use by Zulu and Tswana THPs was validated by experts in the field of OCM and Ayurveda health traditions. Conclusion: Some similarities were noted between the Zulu and Tswana THPs and OCM in terms of the description of clinical features of diabetes and hypertension. The use of several medicinal plants by the Zulu and Tswana THPs to manage the two diseases has been proving scientifically to be effective against them. The interventional tool will assist Tswana and Zulu THPs to manage diabetes and hypertension within traditional African communities. Recommendations, including signing of intellectual property (IP) agreement between the Department of Science and Technology (DST) legal experts and THPs, will help OCM researchers to obtain samples of herbal mixtures to conduct scientific research through in vivo, in vitro and randomized control trials (RCT) studies to make a meaningful contribution to updated versions of the developed guidelines.