There is a general misconception that tuberculosis (TB) is a disease associated with poverty, as most related deaths occur in the world's poorest countries (1). The population most affected by tuberculosis tends to be young adults, who are also generally the most productive members of society (2). In poor communities, treatment is often unavailable, and when it is available, it comes at significant indirect costs (e.g., travel costs and lost work). A harmful stigma is attached to TB, due to real and perceived links to poverty and other diseases, particularly HIV/Aids. An academic contribution by Awe (3) notes that changes in physical condition, which are common to tuberculosis sufferers, can make the infection visible and open the door to prejudice. With that in mind, diagnosis rates are considered lower and treatment discontinuation rates higher, when the stigma of TB is more pronounced (4). Governments, companies, global institutions and non-governmental organisations are actively involved in the fight against TB. Religious organisations, through their charismatic leaders, often play an active role in global efforts, especially when they act as primary healthcare providers (5). Faith-based organisations which are linked to local community structures and represent the full spectrum of religious traditions around the world, play a multifaceted role in some parts of the world (including Namibia) in the fight against TB. Despite their obvious scope, the work of religious organisations in the fight against TB has not yet been studied in depth. This study reflects the findings of an investigation into the various contributions of religious organisations to TB prevention.
Challenges in TB prevention are associated with factors such as shame and a lack of community support for TB patients. In addition, those patients are often stigmatized, as the disease is highly contagious (6). As a result, failure to implement TB prevention plans could also be due to inadequate awareness on early detection and non-adherence to treatment, due to neglect or a lack of support to promote patient recovery. Therefore, it is important to support TB suspects and motivate them to undergo medical screening. The TB screening programme is considered to be more of a community-based approach, using primary healthcare structures. However, the spread of TB remains a problem to this day. Involving the full potential of the community in TB prevention is a necessary alternative to address the problem. The limited knowledge of religious leaders about TB screening and treatment is an obstacle to the recovery of both suspects and patients. It should be noted that religious leaders could provide adequate support if they have sufficient knowledge and skills (5). TB-related training is effective in improving knowledge and skills to prevent transmission of the disease (4), while local support would increase motivation to search for TB suspects (3).
Namibia has experienced an increase in the number of TB cases reported since 2015. In 2018, Namibia reported a TB incidence rate of 423/100 000 population. These statistics maintain the notion of Namibia as one of the 30 countries most affected by TB globally, with Khomas region being the most affected among the 14 regions of this state (6).These data fostered the researchers’ interest in conducting a study in the region. The alarming rates of TB infection have called for partnerships and collaborations amongst all sectors and religions in the country. There seems to be a limited body of literature on TB and religion in Namibia, according to the literature search undertaken by the researcher. However, according to Idler, Levin (7), faith and health are closely linked throughout the world, including in countries where TB is present. Care for the sick and infirm is at the centre of many faith-based traditions, and often religious institutions fund or operate extensive medical facilities, usually in places where government healthcare offerings are inadequate or absent. Religious health institutions are mostly tied to communities, therefore they may be in a position to facilitate the intensive, community-level work required for current TB treatments to be effective (8). Many religious leaders have special influence in their communities, and can play a role as educators about important social and health issues, including TB.
The Catholic Relief Services (CRS) in the Philippines has been working with religious leaders who are predominantly Muslim, to heighten awareness about TB. Armed by CRS with information about TB, over 135 Muslim spiritual leaderss campaign for TB prevention in their mosques, before beginning formal worship. These religious leaders are well respected by the community, and take an active role in educating them about the spread of TB, as well as its treatment and prevention, to diminish related stigma. Community members who have been treated for TB are encouraged to join support groups and awareness programs led by religious leaders (9). A study by Lambert, Kisigo (10) found that religious leaders’ improved awareness about TB facilitated in conveying the message about the disease to the masses. Ong, Migliori (11) found that involving religious leaders in raising awareness amongst the community proved to have a beneficial impact on the health-seeking behaviour of TB suspects. In Namibia, the Ministry of Health and Social Services (MoHSS) has an initiative that aims to improve health-seeking behaviour through engagement and empowerment of community leaders, church leaders, schools, and traditional healers in early TB case detection in their communities (12). To develop sustainable strategies for the community and religious leaders on TB prevention, their knowledge regarding practices aimed at TB prevention, is key.
To understand why the current study focuses on religious leaders, a discussion on religion and health is presented. This paper gives a synopsis of the history of religion and health, as well as the importance of religious organisations and leaders in healthcare. The involvement of religious organisations in healthcare is an ancient, established concept, causing such entities to be popularly referred to as faith-based organisations (FBOs). Such FBOs were pioneered by the missionaries who accompanied the colonisers throughout Asia, Africa, and the Americas. Most FBOs have been integrated into local communities with distinctive characteristics, such as strong commitment to quality of care and support for rural, inaccessible communities. The FBOs have attracted a great deal of interest in the field of health, due to the influence they exert in the communities they serve (10).
In Malaysia, Ong, Migliori (11) Tuberculosis, Knowledge and attitude (KAP) study found that the practices of participants towards TB prevention were only partially implemented. Only a few participants adopted positive TB prevention strategies, such as wearing a mask in public post-diagnosis. However, almost all the participants in the study by Salle et al indicated that they would immediately go to the hospital if they experienced TB signs and symptoms. Similar results emerged from Saudi Arabia (Machmud, Medison (13) and China (14). If this is taken to be consistent with the rest of the world and Namibia, in particular, the World Health Organisation’s (WHO) End TB Strategy can become a reality. A study of the literature reveals good practices on TB prevention being followed in Ethiopia, where study participants indicated that they opened windows to ensure good ventilation, if they contracted TB (11).
FBOs have played a vital role in healthcare development (14). As Palinkas, Pickwell (15) point out, health departments have utilised FBOs as a means of enabling messages to reach the masses who inhabit remote areas. Among many incredible contributions of church and religious organisations in the community, they established schools and hospitals. Of the same interest to the community, faith-based organisations have been instrumental in the implantation of human behaviour change programmes in America (16), because of their influence in the communities they serve.
Notably, a study by Pichon, Williams Powell (16) described faith leaders as key in shaping the behaviour of their congregants. Such health behaviour influence is not limited to individuals, but extends to socio-cultural and environmental levels through scriptural influence, as social influence and as role models (Rachlis, Naanyu (17). According to Robert (18), congregants view faith leaders as having an immense influence on their health behaviour. As reinforced by Spruijt, Haile (19), Nigerian faith leaders have unique characteristics, including interfaith cooperation. A study by Vyborny (20) revealed that interfaith engagement facilitates the coordination of TB plans (11). FBOs have been involved in TB programmes in high TB-burden countries such as Zambia, Cambodia, and Peru, and in particular in the(Direct observed treatment)DOTS (21) strategy (22). FBOs have helped with the fight against stigma attached to persons with TB, reaching out to rural communities, and providing support to those affected by TB in different forms, by providing food and shelter. The question remains which strategies religious leaders in Namibia might use to prevent the spread of TB in their communities, if they are to utilise the trust they earn in the community, as indicated by the successful reports above.
In America, the findings of Koh and Coles (23) and Idler, Levin (7) converge with those of the Berkley Centre (2016), in reporting that FBOs are an important component of TB prevention and care. They indicated that there have been some partnerships between the US government and the FBOs in health promotion.
In the same vein, in Ethiopia concerns about the TB burden have attracted the attention of traditional leaders. Machmud, Medison (13) found that, in a single year, traditional leaders referred 24 patients with TB symptoms to a health facility, of whom 13 were confirmed TB cases. This was an incredible event, given the fact that these traditional healers had not received any formal training on TB. By contrast, in South Africa, traditional healers tend to resort to using special herbs to treat TB, and no referrals to health facilities were noted in the extant literature (15).
Traditional leaders have been involved in healthcare: in Nigeria, Hardison-Moody and Yao (24) described the importance and role of religious leaders in TB prevention and care. Communities tend to trust religious leaders, therefore the latter can be vital in delivering health education to their congregants. Pande, Vasquez (25) assert that Nigerian government officials acknowledge that citizens listen to faith leaders more so than government officials. Hence, training faith leaders on appropriate practices and treatment-seeking could bolster TB campaign efforts tremendously. In relation to TB treatment, trained faith community health workers could be instrumental in respect of treatment adherence, strengthened by the trust the community has in them. The same applies in the Namibian context, where faith leaders tend to have the trust of their community. The statistics show that almost the entire population of Namibia subscribes to one religion or another(26). Religious leaders can therefore be a good source of information on TB prevention and care. In Namibia, none of the partner organisations for TB prevention and care are religious or faith-based, which creates a gap in the health system, given that the studies cited above emphasise the fundamental influence of FBOs on human behaviour. Notably, this study does not discredit the fact that representatives from FBOs are involved in MoHSS consultative meetings for planning different programmes. The gap in the literature in Namibia on religion and health gives rise to a problem in analysing their level of involvement in health matters, regardless of their potential influence, because Namibia is a multireligious country. Successful programmes have been rolled out through religious entities and FBOs to combat HIV/Aids and other diseases in Namibia.
Here, the purpose was to describe the TB prevention practices adopted by religious leaders and their congregants in the Khomas region of Namibia.