The importance of epistemology and translation for health and integration: A commentary on the special issue 'Integrative approaches to health'.

In this commentary on the J-AIM Special Issue 'Integrative Approaches to Health', we argue for plural narratives of health to balance and to reconnect human populations with their environments, to foster a renewed culture of health and wellbeing. Integration of our inner and outer ecosystems with pluralistic health systems requires 'movement' and 'change' and the special issue provides papers on integration and health from multiple disciplinary perspectives that study humans, non-human, animals, and plants in relation to clinical trials, individual and population studies and health systems. All these perspectives provide new insights to map integrative approaches in health, illness and wellbeing in times of the climate emergency. To ameliorate the biomedical and biopharmaceutical industries 'medicalisation of life' as the hegemonic and thus totalising human and more-than-human health systems and approach, the special issue acknowledges, situates and authorises broader visions and epistemologies of health and disease. These complementary epistemologies, their words, their movements (Ayu) and their health (Swastya) and balance (Soukya) are contained within indigenous health systems that include Ayurveda and Traditional Chinese Medicine (TCM) amongst a vast array of local health cultures across the globe. In contrast with the narrower approach of medicalisation; integrative, inclusive, plural and sustainable approaches to health involve the respect for a population's self-reliance in health (the 4th Tier) and the dignity of the Sanskrit word for health, 'Swastya' which means 'being rooted within'. These perspective and epistemologies will help to create a vision for health and health systems that encourage integration through the dignity of the individual (Atmasnman/Anubhuti), respect for the other (Pratiksa/Adara), trust in community (Nyasa) and the creation of systems of equity (Samata) and social justice for all (Nyaya).

Medicalisation and Ayurveda: the need for pluralism and balance in global health systems.

The current global economic and biomedical perspectives contribute content, strategy, and values to global health systems, like objectification and competition, which encourage the medicalisation of the system. Medicalisation overlooks our interdependence with other beings, the environment and biosphere. In contrast, ancient health traditions like Ayurveda, derived from Asian cultures, provide knowledge of the human being's composition of five basic states of nature that need to remain in constant equilibrium to ensure health (Svasthya). Asian health traditions encourage values like vulnerability and respect to facilitate an inherent relationship with the internal and external environment. The recent pandemic has revealed the fragile vulnerability in this nexus and the consequences to human health and well-being when that equilibrium is disturbed. Serious deliberations and discussions are needed between the modern economic and the Asian frameworks for healthcare which result in two different approaches to health and to health systems. This debate may encourage the creation of a philosophy and structure for a new global pluralistic health system more aligned to nature. These deliberations need to encourage the discussion of Svasthya (health), Soukhya (sustainable happiness), and the inner and outer ecological landscapes experienced by human beings that can be understood through mindful self-awareness. Global health systems need to evolve in the direction of a different, pluralistic philosophy of health that encourages a 'population's self-reliance in health' through an intimate and integrated connection with nature.

'Population self-reliance in health' and COVID-19: The need for a 4th tier in the health system.

The COVID-19 pandemic is straining health systems globally. The current international biomedical focus for disease control and policies fails to include the resource of a population's capacity to be self-reliant in its health care practices. The ancient wisdom of Ayurveda ('the knowledge of life') and Local Health Traditions (LHTs) in India understand that health is about Svasthya, 'being rooted within'; a concept that includes the relationship and balance between the individual, their families, communities and the environment in creating and maintaining their own health. This 'population self-reliance in health' is the focus of the 4th tier in the health system which honours and respects an individual's capacity for self-care and their inherent responsibility to the health system and its values. It encourages the inclusion of this knowledge in the creation of health systems and in the policies that direct them. Research and practice into the 4th tier will provide health systems and policy information into how communities are managing the COVID-19 epidemic. These insights will help in the creation of future health systems that are better aligned to the 'self-reliance in health' of individuals and their communities.

Private Practitioners' Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State.

BACKGROUND: Public and private health sectors both play a crucial role in the health systems of low- and middle-income countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India. METHODS: The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis. RESULTS: PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector's dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as 'partners with the TB programme.' CONCLUSION: Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supported.

A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants.

OBJECTIVE: To assess effects of a combined microfinance and training intervention on HIV risk behavior among young female participants in rural South Africa. DESIGN: : Secondary analysis of quantitative and qualitative data from a cluster randomized trial, the Intervention with Microfinance for AIDS and Gender Equity study. METHODS: Eight villages were pair-matched and randomly allocated to receive the intervention. At baseline and after 2 years, HIV risk behavior was assessed among female participants aged 14-35 years. Their responses were compared with women of the same age and poverty group from control villages. Intervention effects were calculated using adjusted risk ratios employing village level summaries. Qualitative data collected during the study explored participants' responses to the intervention including HIV risk behavior. RESULTS: After 2 years of follow-up, when compared with controls, young participants had higher levels of HIV-related communication (adjusted risk ratio 1.46, 95% confidence interval 1.01-2.12), were more likely to have accessed voluntary counseling and testing (adjusted risk ratio 1.64, 95% confidence interval 1.06-2.56), and less likely to have had unprotected sex at last intercourse with a nonspousal partner (adjusted risk ratio 0.76, 95% confidence interval 0.60-0.96). Qualitative data suggest a greater acceptance of intrahousehold communication about HIV and sexuality. Although women noted challenges associated with acceptance of condoms by men, increased confidence and skills associated with participation in the intervention supported their introduction in sexual relationships. CONCLUSIONS: In addition to impacts on economic well being, women's empowerment and intimate partner violence, interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior.

Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004.

OBJECTIVES: To estimate HIV incidence and explore evidence for changing sexual behaviour over time among men and women belonging to different socioeconomic groups in rural South Africa. DESIGN AND METHODS: A cohort study conducted between 2001 and 2004; 3881 individuals aged 14-35 years enumerated in eight villages were eligible. At least three household visits were made to contact each eligible respondent at both timepoints. Sexual behaviour data were collected in structured, respondent-focused interviews. HIV serostatus was assessed using an oral fluid enzyme-linked immunosorbent assay at each timepoint. RESULTS: Data on sexual behaviour were available from 1967 individuals at both timepoints. A total of 1286 HIV-negative individuals at baseline contributed to the analysis of incidence. HIV incidence was 2.2/100 person-years among men and 4.9/100 person-years in women, among whom it was highest in the least educated group. Median age at first sex was lower among later birth cohorts. A higher number of previously sexually active individuals reported having multiple partners in the past year in 2004 than 2001. Condom use with non-spousal partners increased from 2001 to 2004. Migrant men more often reported multiple partners. Migrant and more educated individuals of both sexes and women from wealthier households reported higher levels of condom use. DISCUSSION: HIV incidence is high in rural South Africa, particularly among women of low education. Some risky sexual behaviours (early sexual debut, having multiple sexual partners) are becoming more common over time. Condom use is increasing. Existing HIV prevention strategies have only been partly effective in generating population-level behavioural change.