Hepatitis C Virus in Uganda: Integrating Cultural Awareness into Global Health Interventions

Background

During my immersion experience with Integral Global in Atlanta, Georgia, I worked on formatting and writing a proposal for a Hepatitis C (HCV) initiative in Uganda. This immersion experience provides me with valuable insight into global health programming and the complex details that make a successful intervention. When presenting my findings and proposal to the Integral Global team, they raised a crucial point regarding the role of cultural practices and beliefs in the implementation and effectiveness of the initiative. This insightful discussion brought to light the necessity to identify traditional practices, beliefs, and societal norms that may influence HCV transmission, prevention, and treatment. Highlighting the significance of cultural competence in global health programming, which inspired me to explore how to integrate cultural awareness into my HCV intervention. In hopes of improving community engagement and health outcomes. This realization inspired my research, exploring the importance of understanding cultural impacts to aid in designing an impactful and sustainable HCV initiative in Uganda.

Introduction 

Hepatitis C Virus (HCV) represents a major global health challenge. Hepatitis C is a blood-borne viral infection that is mainly spread through unsafe medical practices, injection drug use, and exposure to blood contaminated with HCV (WHO). The World Health Organization (WHO) estimates over 185 million people are infected with HCV globally (Layden et al., 2014). Sub-Saharan Africa accounts for the majority of cases, with around 71 million people infected with HCV (Nankya-Mutyoba et al., 2021). Uganda, a country located in Sub-Saharan Africa, faces a significant HCV burden, with cultural practices and beliefs affecting the transmission of the disease. The prevalence of HCV in Sub-Saharan Africa ranges from 2.1% to 2.8%, with West Africa having the highest prevalence of 2.8% (Layden et al., 2014). However, data on HCV prevalence in Uganda and Africa remains limited, complicating the understanding of the issue. These traditional norms are important to understand when approaching global health, as they are deeply embedded into societal norms. Acknowledging these norms is crucial when approaching global health initiatives with local knowledge, including WHO’s goal of viral hepatitis elimination by 2030 (Sonderup et al., 2017). WHO’s elimination plan aims to reduce mortality rates caused by end-stage liver cancer and decrease the incidence of new HCV infections (Sonderup et al., 2017). Achieving this goal requires an understanding of how cultural norms in Uganda impact HCV transmission. Cultural competence is crucial to understanding the impacts and how it informs health decisions (Chowdhury et al., 2022). Resulting in the need for culturally competent global health interventions, as cultural beliefs and practices heavily influence health decisions and outcomes.

Hepatitis C Virus in Uganda Prevalence 

A study among blood donors in Uganda found a prevalence of 7.8%, extremely high, highlighting the current burden of the disease (Nankya-Mutyoba et al., 2021). This study was conducted since blood transfusions are a factor in the increased transmission of HCV. The majority of infections are transmitted through needle contamination, typically unclean or reused needles, or through traditional practices such as scarification (Nankya-Mutyoba et al., 2021). Scarification is a cultural practice in Uganda, where individuals cut, burn, or brand their skin to create representational marks on their bodies. Traditional Practices have a significant impact on the transmission of disease, including traditions such as scarification, tribal markings, home circumcisions, and home births (Layden et al., 2024). The specific practices are related to HCV transmission due to the use of non-sterile equipment outside of a medical facility. These risks highlight the need for HCV to be addressed, but there are barriers to prevention and treatment in Uganda. 

In addition to cultural practices, limited access to healthcare adds to the challenge. The high cost of HCV medication, with the appropriate laboratory setup and tests to confirm diagnosis, means that many people are unable to afford treatment (Layden et al., 2024). The financial barrier leads cultural practices to play an even bigger role. The limited access to HCV care, treatment, and prevention has led some individuals to seek alternative care through herbal medications or traditional healers (Nsibirwa et al., 2020). These cultural practices, deeply rooted in African traditions and passed down for generations, shape an individual’s trust in traditional treatments over standard medical care. This situation creates additional challenges to addressing HCV since some individuals may prioritize traditional medicine over biomedical care due to cultural beliefs and limited access to healthcare. The challenges and prevalence of HCV highlight the crucial overlap between cultural practices and health outcome barriers.

Cultural Practices and HCV Transmission 

In Uganda, there are more traditional healers than medical doctors, with a 35:1 ratio as of 2021 (Naiga et al., 2024). Highlighting the limited access to formal healthcare and the important role traditional healers play in filling healthcare gaps for Uganda’s population. The lack of medical doctors capable of properly diagnosing and treating HCV causes individuals to seek care elsewhere. In addition to healers, community members tend to consult religious leaders before medical professionals or formal care (Naiga et al., 2024). These norms are associated with medical care that lacks appropriate equipment, lack of knowledge, improper medical practices, and an increase in close contact of infection, which leads to the increase of new HCV infections (Naiga et al., 2024). 

Due to the high cost and limited availability of HCV medication, many individuals rely on herbal medicine as an alternative treatment option (Nsibirwa et al., 2020; Sonderup et al., 2017). Herbal medicine is easily accessible and an affordable option, which is why it is heavily marketed and encouraged for people to use (Nsibirwa et al., 2020). Societal and cultural encouragement influences people's medical decisions and what is the best option. Individuals heavily believe in herbal medicine since their ancestors relied on this method and never had any issues (Nsibirwa et al., 2020). Their belief in its efficiency is rooted in their ancestral traditions of traditional medicine that have serviced community health for generations. Additionally, limited access and reluctance to use modern medicine is associated with the belief that illnesses are supernatural, such as witchcraft or curses from the gods, creating even more barriers to seeking professional medical care (Naiga et al., 2024). The existence of traditional and modern medicine in Uganda complicates addressing HCV since the population is reliant on both. The coexistence of traditional and modern medicine in Uganda presents both challenges and opportunities to address HCV, as many people move between the two based on cultural preferences and access to resources.

Outside of traditional treatment and methods, there are additional cultural factors that play a part in the spread of diseases such as HCV. Hygiene and sanitation habits, such as washing hands, play a major role (Naiga et al., 2024). In regards to burial traditions in Africa, individuals touch the body of the deceased, mourning the loss, and do not wash their hands after (Naiga et al., 2024). As a result, infections are rapidly spread, as it still lives on the deceased individual's body and has spread to all who have had contact with the body. In the context of HCV, any exposure or contact with contaminated blood increases an individual's risk of HCV transmission. These burial practices were linked to an outbreak of Ebola in Uganda caused by contact with infected bodies after death (Naiga et al., 2024). There is such a prevalent overlap between cultural practices and resources with the spread of diseases, as the Ebola outbreak displays, which is why cultural competence is an integral part of global health interventions to properly address transmission and prevention. Common cultural practices that heavily influence HCV prevention, treatment, and transmission are healers, religious leaders, herbal medicine, and hygiene practices. The combination of societal and economic barriers with cultural beliefs and values creates a complex barrier to reducing HCV transmission.

The Role of Cultural Competence in Global Health 

Cultural competence in global health is crucial. To provide an effective intervention to stop a global health problem, it is necessary to understand all of the cultural practices and beliefs that may impact the spread of a disease (Naiga et al., 2024). To work properly with the community and gain their participation, an intervention needs to be designed while keeping in mind safety and respecting any important cultural aspects (Naiga et al., 2024). The importance of cultural competence is to help providers identify how cultural factors affect health outcomes, especially for vulnerable populations (Chowdhury et al., 2022). Cultural competence emphasizes a different approach, steering away from the typically ‘one size fits all’ approach. Making a more personalized approach, taking into account populations' backgrounds, aids in making a more effective global health intervention (Chowdhury et al., 2022). As seen in Uganda, it is typical for places around the world to lean on alternative health systems, like traditional health, which highlights the importance and necessity of understanding the existing behaviors and health systems to integrate them into global health strategies (Latif, 2020). A lack of cultural awareness and competence puts providers and interventions at risk of poor decision-making, which impacts the health outcomes and success of an intervention (Latif, 2020). The benefit of cultural competence is that it increases the chances of decision-making and appropriate care the community is willing to take part in (Latif, 2020). This is exactly why training in cultural competency is necessary for anyone wanting to work in the global health field, ensuring training and implementation of interventions (Latif, 2020). Training in cultural competence creates knowledgeable field personnel whom community members in other countries can trust and embrace their interventions based on cultural beliefs and values (Latif, 2020). Without cultural awareness in interventions, it may lead individuals to avoid the care, ignore professional advice, and feel annoyed with the intervention efforts (Latif, 2020). All of these leads to a mistrust in global health efforts, making them less effective over time.

Strategies for Culturally Competent HCV Intervention 

When it comes to approaching HCV elimination by 2030 in Africa, a different approach is needed, one that addresses cultural practices and aspects impacting HCV prevalence and incidence rates. Ensuring that trust is built with the community, such as religious leaders and traditional healers, has been known as an effective measure to strengthen interventions, such as the HCV initiative in Uganda. Especially in terms of traditional healers, there has been prior success in training traditional healers to properly recognize and link individuals to care in cases of infectious disease, like during Ebola in Uganda, which built trust and community engagement in disease efforts (Naiga et al., 2024). Additionally, religious leaders play a huge educational role in communities, especially when trained in education on health behaviors, discussing the importance of receiving care and transmission of disease, which highlights the importance of incorporating beliefs and values into intervention strategies, especially for communication efforts (Naiga et al., 2024). In addition, the part traditional medicine plays in health outcomes also needs to be addressed since many individuals in Uganda rely heavily on herbal medication and treatment for care of diseases. There is a necessity for communication between healthcare providers and patients regarding herbal medicine use, which can aid in promoting safe practices, but there need to be policies put in place to control traditional medicine in society (Nsibirwa et al., 2020). This is a way of aligning the intervention with the cultural norms, as not to diminish herbal medicine, but regulate it to improve acceptance of healthcare efforts. Vulnerable populations and high-risk individuals are a huge part of the spread of diseases, so targeted intervention and outreach are crucial in addressing the issue. This means taking into account populations who partake in traditional practices such as scarification, circumcision practices, herbal medicine, and usage of traditional healers (Sonderup et al., 2017). The final piece to a successful culturally competent intervention for HCV in Uganda is the need to expand testing and treatment efforts, especially in high-prevalence areas, to increase access to care, while building off of current resources will make an extremely effective and impactful initiative (Nankya-Mutyoba et al., 2021).

Conclusion

In conclusion, it is crucial when addressing HCV in Uganda to integrate culturally competent components into the approach that reflects an understanding of the role traditional practices, beliefs, and values play in disease transmission, prevention, and treatment. In Uganda, there is a heavy reliance on traditional healers, herbal medicine usage, and cultural practices deeply rooted in societal norms, including scarification, circumcision, and burial traditions. All of which play a significant role in the effectiveness of global health interventions implemented and typically why they fail. Without cultural awareness in initiatives such as HCV prevention in Uganda, there is a risk of lower community engagement and reduced impacts, which may affect efforts to reduce HCV transmission and improve access to treatment. To achieve the WHO’s goal of HCV elimination by 2030, the key is cultural competence intervention that engages traditional healers, religious leaders, and community members in HCV education and prevention measures. Also necessary to address access to testing and treatment in Uganda by combining traditional healthcare with modern healthcare, helping to bridge the healthcare access gap. Cultural competence fosters trust, cultural values, and community participation, ensuring global health initiatives are effective, sustainable, and impactful in reducing the burden of HCV in Uganda.

Learning Outcomes

This experience has taught me the importance of cultural competence and understanding in global health interventions. I learned through investigating HCV in Uganda that it requires an understanding of local practices, such as scarifiation and the use of traditional healers. Understanding and incorporating these cultural beliefs and values into health interventions will improve community trust and engagement. In addition, it will create a more effective and sustainable approach to the intervention. This insight will shape my future work in global health and ensure that I will always consider cultural context when designing interventions.