'The man who believed he had AIDS was cured': AIDS and sexually-transmitted infection treatment-seeking behaviour in rural Mwanza, Tanzania.
ABSTRACT Most people living with AIDS in sub-Saharan Africa have had neither a biomedical diagnosis nor antiretroviral medication, leading to the question of how individuals understand and treat AIDS. This study examined general illness, sexually-transmitted infection (STI) and AIDS treatment-seeking behaviour in rural Mwanza, Tanzania. From 1999-2002, participant observation was carried out in nine villages for a total of 158 person-weeks. Treatments were pluralistic and opportunistic, usually beginning with home remedies (western or traditional), followed by visits to traditional healers (THs) and/or health facilities (HFs). THs were sometimes preferred over HFs because of familiarity, trust, accessibility, expense, payment plans, and the perceived cause, nature and severity of the illness, e.g. only THs were believed to successfully treat bewitchment. Some people, particularly young girls, delayed or avoided seeking treatment for STIs for fear of stigma. Most STIs were attributed to natural causes, but AIDS was sometimes attributed to witchcraft. Locally available biomedical care of people with AIDS-like symptoms consisted of basic treatment of opportunistic infections. Most such individuals repeatedly visited THs and HFs, but many stopped attending HFs because they came to believe they could not be cured there. Some THs claimed to cure witchcraft-induced, AIDS-like illnesses. There is an urgent need for improved biomedical services, and TH interventions could be important in future HIV/AIDS education and care.
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ABSTRACT: Despite the introduction of free antiretroviral therapy (ART), the use of voluntary counselling and testing (VCT) services remains persistently low in many African countries. This study investigates how prior experience of HIV and VCT, and knowledge about HIV and ART influence VCT use in rural Tanzania. In 2006--7, VCT was offered to study participants during the fifth survey round of an HIV community cohort study that includes HIV testing for research purposes without results disclosure, and a questionnaire covering knowledge, attitudes and practices around HIV infection and HIV services. Categorical variables were created for HIV knowledge and ART knowledge, with "good" HIV and ART knowledge defined as correctly answering at least 4/6 and 5/7 questions about HIV and ART respectively. Experience of HIV was defined as knowing people living with HIV, or having died from AIDS. Logistic regression methods were used to assess how HIV and ART knowledge, and prior experiences of HIV and VCT were associated with VCT uptake, with adjustment for HIV status and socio-demographic confounders. 2,695/3,886 (69%) men and 2,708/5,575 women (49%) had "good" HIV knowledge, while 613/3,886 (16%) men and 585/5575 (10%) women had "good" ART knowledge. Misconceptions about HIV transmission were common, including through kissing (55% of women, 43% of men), or mosquito bites (42% of women, 34% of men).19% of men and 16% of women used VCT during the survey. After controlling for HIV status and socio-demographic factors, the odds of VCT use were lower among those with poor HIV knowledge (aOR:0.5; p = 0.01 for men and aOR = 0.6; p < 0.01 for women) and poor ART knowledge (aOR:0.8; p = 0.06 for men, aOR:0.8; p < 0.01 for women), and higher among those with HIV experience (aOR:1.3 for men and aOR = 1.6 for women, p < 0.01) and positive prior VCT experience (aOR:2.0 for all men and aOR = 2.0 for HIV-negative women only, p < 0.001). Two years after the introduction of free ART in this setting, misconceptions regarding HIV transmission remain rife and knowledge regarding treatment is worryingly poor, especially among women and HIV-positive people. Further HIV-related information, education and communication activities are urgently needed to improve VCT uptake in rural Tanzania.BMC Public Health 09/2013; 13(1):802. · 2.32 Impact Factor
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ABSTRACT: This study's objective was to describe awareness of, access to, belief in, and utilization of the healing tea Kikombe cha babu and other alternative treatments for HIV in Tanzania. Associations with HIV testing, treatment, and prevention behaviors are also explored. A survey with questions about alternative medicine was administered to a sample in Tanzania using a stratified, multistage random selection method. Adults were interviewed face-to-face. Items concerning alternative HIV treatments addressed awareness, access, beliefs, and treatment-seeking behaviors. Questions about HIV prevention and treatment were also asked. Results showed participants indicated a high awareness of alternative treatments available in Tanzania, with 95.3% of 2313 adults having heard of these treatments. Of those, 6.0% had actually sought the treatment, and 46.8% had an acquaintance seek it. However, 81.0% indicated these treatments were not easily accessible. There is a high level of belief in the ability of these alternative treatments to cure HIV, with 44.0% of people who had heard of these treatments indicating they believe such treatments can cure HIV. Additionally, many people indicated having these alternative treatments available would result in decreased condom use (15.6%), no need to use condoms (94.9%), and no need to take antiretroviral therapy (81.7%). However, 57.4% indicated they would be more likely to get tested for HIV if alternative treatments were available. Belief in the ability of alternative treatments to cure HIV in Tanzania is high and should be further explored due to its implications for potentially sidelining HIV prevention and treatment initiatives.AIDS Care 07/2014; · 1.60 Impact Factor
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ABSTRACT: Early HIV testing is critical to prevention and timely treatment. Missed opportunities for HIV diagnosis can result in unnecessary deaths at a time when access to antiretroviral treatment proves life saving. While HIV prevention and treatment research has increased, less research exists on women's experiences with HIV diagnosis, despite the fact that women are most affected. Insights from local women are critical in designing culturally meaningful interventions that thwart missed opportunities for early HIV diagnosis. The purpose of our study was to uncover steps women took to know their HIV diagnosis. Using narrative inquiry methodology informed by post-colonial feminism, we interviewed 40 HIV- positive women in Kenya. Five themes emerged related to uptake of HIV testing for women: (a) spouse's critical illness or death; (b) years of suffering from HIV-related symptoms; (c) sick children; (d) prenatal testing; and (e) personal desire to know one's HIV status. These findings centered on women experiences provide an important basis for health promotion interventions related to HIV prevention, earlier detection, and treatment.International Journal of Health Promotion and Education 05/2013; 51(5).
‘The man who believed he had AIDS was cured’: AIDS and
sexually-transmitted infection treatment-seeking behaviour in
rural Mwanza, Tanzania
MARY L. PLUMMER1, GERRY MSHANA2, JOYCE WAMOYI2, ZACHAYO S. SHIGONGO2,
RICHARD J. HAYES1, DAVID A. ROSS1, & DANIEL WIGHT3
1Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK,2National
Institute for Medical Research, Mwanza, Tanzania, and3Social and Public Health Sciences Unit, Medical Research Council,
Most people living with AIDS in sub-Saharan Africa have had neither a biomedical diagnosis nor antiretroviral medication,
leading to the question of how individuals understand and treat AIDS. This study examined general illness,
sexually-transmitted infection (STI) and AIDS treatment-seeking behaviour in rural Mwanza, Tanzania. From
1999?2002, participant observation was carried out in nine villages for a total of 158 person-weeks. Treatments were
pluralistic and opportunistic, usually beginning with home remedies (western or traditional), followed by visits to traditional
healers (THs) and/or health facilities (HFs). THs were sometimes preferred over HFs because of familiarity,
trust, accessibility, expense, payment plans, and the perceived cause, nature and severity of the illness, e.g. only THs
were believed to successfully treat bewitchment. Some people, particularly young girls, delayed or avoided seeking treatment
for STIs for fear of stigma. Most STIs were attributed to natural causes, but AIDS was sometimes attributed to witchcraft.
Locally available biomedical care of people with AIDS-like symptoms consisted of basic treatment of opportunistic
infections. Most such individuals repeatedly visited THs and HFs, but many stopped attending HFs because they came
to believe they could not be cured there. Some THs claimed to cure witchcraft-induced, AIDS-like illnesses. There is
an urgent need for improved biomedical services, and TH interventions could be important in future HIV/AIDS
education and care.
Sexually-transmitted infections (STIs) are wide-
spread in sub-Saharan Africa (SSA) (Over & Piot,
1993). STI treatment may substantially reduce HIV
incidence in some situations (Grosskurth et al.,
1995), but effective treatment requires symptom
recognition, a health facility visit, correct treatment,
and patient compliance (Hayes et al. 1997). Only
one-quarter of rural women with STIs or reproduc-
tive tract infections in SSA are believed to both
recognise their symptoms and attend health facilities
for treatment (Hayes et al., 1997). In addition,
many people living with AIDS in SSA have neither
had an HIV-antibody test nor an AIDS diagnosis
To understand STI and AIDS treatment practices
in SSA today, one must first understand cultural
beliefs about illness aetiology. An illness may be
attributed to natural/biological causes, ancestral
influence, witchcraft, evil spirits and/or bad luck,
and treatments are often chosen according to the
perceived cause of the illness (Pool and Washija,
2001; Green et al., 1994; Haram, 1991; Young,
1982; Lasker, 1981). Traditional treatment of STIs
may also be preferred because of perceived effec-
payment options, and/or confidentiality (Kiapi-Iwa
& Hart, 2004; Kusimba et al., 2003; Zachariah et al.,
2002; Muela et al., 2000; Ndulo et al., 2000;
Okonofua et al., 1999; Crabbe ´ et al., 1996; Satimia
et al., 1998; Kale, 1995; Green et al., 1993; Lasker,
1981). To date, the few studies of AIDS treatment
practices in SSA have found that people with AIDS
serially or simultaneously using multiple forms of
health care (Chimwaza & Watkins, 2004; Hatchett et
al., 2004; Ngalula et al., 2002; Awusabo-Asare &
This paper examines beliefs about general illness,
STI and AIDS treatment practices in rural Mwanza,
Tanzania, where Sukumas are the predominant
ethnic group. A 1994?95 survey in rural Mwanza
Correspondence: Dr Mary L. Plummer, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical
Medicine, Keppel St., London, WC1E 7HT, UK. Tel: ? /44-20-7927-2302; Fax: ? /44-20-7612-7860. E-mail: firstname.lastname@example.org
AIDS Care, July 2006; 18(5): 460?466
ISSN 0954-0121 print/ISSN 1360-0451 online # 2006 Taylor & Francis
estimated that HIV/AIDS caused one-third of
all deaths for adults aged 15?59 years (Boerma
et al., 1997). This qualitative study complements
a community randomised trial of the adoles-
Vijana (MkV) (Hayes et al., 2005; Obasi et al.,
This study was approved by the London School of
Hygiene and Tropical Medicine Ethics Committee
and the Tanzanian Medical Research Coordinating
Participant observation (PO) has been described
in detail elsewhere (Plummer et al., 2004; Wight et
al., 2006). PO was conducted by six young East
Africans in nine villages from 1999?2002 for a total
of 158 person-weeks. Working alone or in mixed sex
pairs, researchers lived in separate villagers’ house-
holds and befriended, accompanied, assisted and
informally interviewed young people in their daily
lives. Researchers wrote daily fieldnotes, which were
transcribed, translated into English, and coded prior
In this paper, all excerpts are from fieldnotes;
quotation marks within an excerpt indicate infor-
mant comments recorded verbatim. Field notes are
identified by an abbreviation in brackets following
each quote, indicating method (PO), year (’99?‘02),
MkV intervention or comparison status (I or C),
village (nos. 1?9), and researcher number and sex
(nos. 1?6; m or f), e.g. PO-00-I-3-3m.
General illness treatment-seeking
Symptoms were very important in illness recogni-
tion, diagnosis, and treatment, and people generally
believed that they were cured once symptoms
opportunistic. Most people began with home reme-
and cheap. Adults who claimed knowledge of an
illness recommended that certain wild plants be
harvested, processed (Figure 1), and then either
swallowed, placed on an incision, in a bath, or ?
in the case of a breastfeeding baby ? on the
mother’s breast. Many people also used western
medicines (e.g. anti-malarials, headache tablets, and
antibiotics) bought at a kiosk without a prescription
Traditional healers. If home remedies failed, villagers
generally sought treatment from a traditional healer
(hereafter referred to simply as a ‘‘healer’’) and/or
(less frequently) a health facility (HF). Reasons why
people preferred a healer included familiarity, trust,
accessibility, expense, payment plans (e.g. credit or
in kind), and the perceived cause, nature and
severity of the illness. Healers were reported to
successfully treat both naturally caused and witch-
craft-induced illnesses, but HFs were not believed to
successfully treat the latter. There was widespread
belief in witchcraft, i.e. the human use of super-
natural means to harm others.
Each PO village had five or more resident healers.
Healers identified illnesses by diagnosing symptoms,
Figure 1. Woman grinding traditional medicine for household use.
AIDS and sexually-transmitted infection treatment-seeking behaviour in rural Mwanza, Tanzania
dream interpretation, and/or performing rituals with
special plants or animals. Treatment usually involved
ingestion or external application of processed wild
herbs, bark and/or roots. Some healers also per-
formed minor surgery, and some had compounds in
which they provided long-term care for patients
Sometimes healers identified an immediate cause
(e.g. an infectious organism) and an original, super-
natural cause (e.g. angry ancestral spirits, or witch-
craft) of an illness. Treatment sometimes included
rituals against the original cause, e.g. casting a
counter-spell to harm the witch. Most villagers
seemed to believe in healers’ abilities to identify
witches. Healers often were both respected and
feared in villages.
Western medicine. Many villagers also or instead
sought treatment from people trained in western
medicine. In some villages, one or more untrained
people routinely used western medicine to treat
minor or urgent problems for a fee, e.g. stitching
wounds, giving injections and/or prescribing drugs.
For more substantial biomedical treatment, villagers
Figure 3. A traditional healer’s compound, showing ancestral shrines in centre, and patient huts surrounding them.
Figure 2. Materials for sale at a village kiosk, including headache pills, laundry soap, and body oil.
M. L. Plummer et al.
attended HFs. Most villagers walked 3?10 kilo-
metres to visit one, or if unable to walk, they
were carried on locally made stretchers or bicycles
for a fee.
Most HFs had several medical staff who had
completed 7thor 10thgrade, with 2?4 additional
years of training. Treatment was mainly limited to
syndromic management of common illnesses, such
as fever, cough, bloody urine, and genital discharge.
More serious conditions were referred to district or
regional hospitals. HFs were frequently reported
to suffer from basic equipment and medication
shortages, and during PO visits there were several
reports of children dying after being turned away
for lack of supplies. A Village Chairman described
problems he encountered with his own child:
He gave his child local medicines ... but the
condition continued to be very serious, so he
took the child to [the nearest facility, 6 km east].
They did not have enough equipment ... so he
went to [the district hospital, 13 km west], where
the equipment had also been stolen. ... The next
day he had to take the child to [a hospital 33 km
Many informants could name common STIs, such
as syphilis and gonorrhoea, and also could describe
STI symptoms. Most people believed that STIs were
caused by natural (sexual) transmission. STIs were
stigmatised, so some people reported delaying or not
seeking treatment. A female researcher learned of
one example at a female bath shelter:
I noticed TE4-f scratch her private parts. ... She
was at first uncomfortable talking about it, but
later ... said that she has felt itchy [for three
months] and when she scratches, small pimples
appear. ... TE4-f said she had been shown med-
icines/herbs by her mother-in-law ... and hoped to
start using them tonight. [PO-00-C-3-2f]
Almost all reports of STI treatment initially involved
traditional home remedies. Many also involved
western medicine. For example, a 20 year old single
She was diagnosed [and given tablets] by a health
worker ... who told her she had syphilis or gonor-
rhoea.... She was also given traditional medicines
by her paternal aunt ... [and was shown others] by
U2-f’s husband and a 20 year old single woman
who had also suffered from an STI. [PO-00-C-
STI medications were supposed to be available and
provided free-of-charge at government HFs. In
practice, some HFs may not have always had a
complete stock, especially if health workers were
involved in illegal re-selling of drugs and supplies, as
was sometimes reported. Health workers reported
that women were relatively shy in requesting STI
treatment, but they nonetheless did so much more
often than men because it was free and they already
visited HFs for their children’s health care. Kiosk
staff reported that some men but very few women
purchased STI medications from them.
Adults condemned young people’s out-of-wedlock
sexual relationships and severely punished girls who
were caught (Wight et al. in press), so secrecy about
young people’s STIs was great. This is illustrated by
the comments of two men in their late 20s:
N4-m heard that the girl who infected him also
infected other young men, but he says youth ...
try to secretly obtain medicine until they are
cured. N3-m said girls are secretly given medicine
by their mothers, so that others will not know, and
prevent their daughters from getting marriage
Some young people feared that STI treatment would
not be confidential. For example, a 16 year old who
had had symptoms for over a year explained why she
had not gone to a HF:
She said that since HN-m [a health officer] came
from within this village, he was bound to tell
others about it ... [She said] ‘‘If I start to tell the
doctor that I have this and that pain, he/she will
ask me lots of questions. Really, I just can’t.’’
Concern about confidentiality may have been war-
ranted. For example, while visiting a HF, a research-
er overheard a young man being diagnosed with an
STI in the next room, and the health worker then
directly mentioned his diagnosis to her. Notably,
young people sometimes equally feared that local
healers who specialised in STI treatment would not
respect their confidentiality.
Most villagers had heard of AIDS, but had little
understanding of asymptomatic HIV infection and
how AIDS can manifest itself as a variety of
opportunistic infections. HIV-antibody tests were
only available at hospitals, and many ? probably
most ? of the people with AIDS in rural Mwanza
were undiagnosed. Even when diagnosed, they may
not have been informed of it themselves, as many
AIDS and sexually-transmitted infection treatment-seeking behaviour in rural Mwanza, Tanzania
health workers found it difficult to convey. For
example, a 23 year old divorced woman said:
‘‘Someone can discover she has AIDS if she goes
to the clinic to be treated for an ailment, and the
doctor tells her she is suffering from a certain
disease, but doesn’t mention its name.’’ [PO-99-C-
5-2f] Anti-retroviral medicines were not available, so
medical treatment was limited to basic treatment of
A few individuals were widely rumoured to have
AIDS. One such woman described how she had
struggled with schistosomiasis, hook worms, ma-
laria, high blood pressure, chest infections, skin
infections, frequent fevers and extreme thinness for
seven years [PO-01-I-7-5f]. Often, individuals with
such repetitive and severe illnesses were also, or
instead, rumoured to have been bewitched, either in
a vague, undefined way (particularly in the case of
afflicted children), or specifically with a ‘‘false’’
AIDS, i.e. an illness intended to appear like AIDS
(Mshana et al., 2006).
When faced with AIDS, many people repeatedly
consulted both healers and HFs. For example, at the
funeral of a man in his 20s, who was rumoured to
have had AIDS:
They said he was suffering from a stomach illness
and ... a skin infection. ... he had a stomach op-
eration [at the hospital]. ... After a short while he
started ailing again. He was treated by traditional
healers, but ... continued being sick until he was
taken to [the local HF] last week. [PO-02-I-4-1m]
Many people with AIDS seemed to pursue tradi-
tional treatments for longer than biomedical treat-
ment because they offered more hope of a cure. For
example, a 30 year old, widowed food kiosk worker,
who was rumoured to have AIDS:
... appeared emaciated and weak. She walked
slowly and talked softly. ... She said the first and
second time [she went to a HF] she had pain all
over her body, especially in her head ...[and] a
third time, she had a rash all over her body. ... She
did not have the 5,000 Tanzanian Shillings [6 US
Dollars] to have the blood tests done [to deter-
mine the problem] and thus just came back home.
A week after the above interaction, the same woman
optimistically reported that she had raised 5,500
Tanzanian Shillings (6.50 US Dollars) for treatment
by a healer who had told her she was bewitched by
her deceased husband’s relatives.
Some healers claimed that they could cure some
people diagnosed with AIDS, who they believed
actually had an AIDS-like illness caused by mal-
iciousness, such as witchcraft. A healer and Sub-
village Chairman’s account follows:
He said that there are two main types of
AIDS. ... He gave me an example of a certain man
who had come ... believing he had the real
AIDS. ... The man had received treatment for a
longtimefromamodernhospital,butinvain. ... He
him a drug so that he would die. ... He gave [the
man] some medicines to stop the diarrhoea and
said thatthe man was cured. [PO-99-C-2-1m]
In contrast, the account of a healer and Village
He said he has healed many people of illnesses
such as paralysis, worms, leg diseases and many
others, but not AIDS. He said that traditional
healers who advertise themselves as being able to
cure AIDS are liars, for there is no medicine [cure]
for AIDS. ... At the most he used to give [his
AIDS patients] medicines to calm them and give
them more time to live. [PO-01-C-2-6f]
‘‘True’’ AIDS was more stigmatised than ‘‘false’’
AIDS, and some people who suspected that they had
the former may have become hopeless. This may
have been more of an issue for HIV/AIDS education
participants, as they comprehended both the severity
of their condition and the lack of options open to
them. For example, one health worker was ru-
moured to have attempted suicide by overdosing
on chloroquine tablets because he had AIDS [PO-
99-C-5-2f]. A similar despair was shown by an AIDS
education teacher whose husband, two co-wives, and
four step-children had died:
N6 said her only male child was killed due to the
hatred [witchcraft] of the people of [that villa-
ge]. ... She said even she herself sometimes falls
into a critical state, a situation which makes her
fail to work. N6 was almost weeping whenever she
Finally, one man reported that when his sister tested
positive for HIV, his eldest brother told the family
not to take her for treatment, as her condition was
For example, self diagnosis and treatment may be the
first and an on-going strategy (Geissler et al., 2000;
M. L. Plummer et al.
Msiska et al., 1997; van der Geest, 1987), increasing
the chance of inappropriate medication and dosage,
and the development of drug resistance. Healers may
healers and their patients may have faith in their
treatments because: symptoms may go into latent
stages; simultaneous use of different therapies may
blur the successful treatment; some traditional med-
icines may indeed be biomedically effective; and
biomedical treatment may be ineffective, e.g. due to
antimicrobial resistance, or not taking the full course
This study may provide uniquely valid insights
into AIDS treatment-seeking behaviours, as data
were not collected in structured research settings,
and people with AIDS-like symptoms were not
solicited through HF participation. As elsewhere in
SSA, most people with AIDS lived with disturbingly
little understanding of their disease and grossly
inadequate services (Chimwaza & Watkins, 2004;
Hatchett, 2004; Kapata, 2004). As they experienced
painful, drawn out illnesses, they and their commu-
nities attempted to make sense of them within a
cosmology that allowed for both natural and super-
natural causes, and biomedical and traditional treat-
ments. Of particular concern is the widespread belief
that AIDS may sometimes be caused by witchcraft,
because traditional medicines were generally be-
lieved to be the only way to cure bewitchment.
However, knowledge of AIDS and attempts to
obtain biomedical treatment were also not sufficient
to ensure adequate health care. While HFs some-
times treated AIDS-related illnesses, they lacked the
medicines needed to treat the underlying HIV
disease, so further opportunistic infections were
inevitable. This contributed to a sense of hope-
lessness for people with AIDS and their families.
There is an urgent need for educational interven-
tions and improved biomedical treatments focused
on AIDS in rural Mwanza, possibly including
interventions focused on healers. As elsewhere in
SSA some healers did not appreciate the nature of
AIDS and claimed that they could cure it (Awusabo-
Asare & Anarfi, 1997; Chirwa & Sivile, 1989?1990).
The development of culturally-specific and safe
healer interventions may be challenging (Bodeker
et al., 2000; Green, 1988; Neumann & Lauro,
1982). However, studies have shown that, once
educated about HIV/AIDS themselves, many healers
used their health care and leadership positions to
better educate, treat and refer people (Homsy et al.,
2004; UNAIDS, 2000; Green, 1997).
Most urgent, however, is the need for improved
biomedical health care in general (Shiner, 2003), and
antiretroviral therapy (ART) in particular. Recently,
limited ART services were introduced in several
suggest that it may be feasible to implement ART in
rural Mwanza, e.g. villagers demonstrate initiative
and commitment in seeking treatments, and they are
own medicines. However, other results highlight
potential challenges, such as the belief that an illness
is cured once symptoms resolve, and the pluralistic
nature of treatment-seeking, which makes it difficult
for people to distinguish between effective and in-
compliance with ART over time, or a false sense of
safety when engaging in unprotected sex.
Limited research on voluntary HIV-antibody test-
ing and antiretroviral therapy in poor African popula-
tions suggests that such services can be feasibile,
efficacious and acceptable (Diomande ´ et al., 2003;
Desclaux et al., 2003) although adherence interven-
tions that focus on information, motivation and
behavioural skills may be essential to making them
effective (Popp and Fisher, 2002). The terrible con-
similar to those elsewhere in SSA, emphasising the
We are very grateful to study participants, field
researchers, transcribers, translators, coders, and
the MkV intervention and impact evaluation staff.
The study was funded by the Medical Research
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