Traditional healing practices, factors influencing to access the practices and its complementary effect on mental health in sub-Saharan Africa: a systematic review

Abstract

Objectives

In areas with limited and unaffordable biomedical mental health services, such as sub-Saharan Africa (SSA), traditional healers are an incredibly well-used source of mental healthcare. This systematic review synthesises the available evidence on traditional healing practices, factors to access it and its effectiveness in improving people’s mental health in SSA.

Design

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach.

Data sources

PubMed, MEDLINE, CINAHL and Scopus studies published before 1 December 2022.

Eligibility criteria

Qualitative and quantitative studies reported traditional healing practices to treat mental health problems in SSA countries published in English before 1 December 2022.

Data extraction and synthesis

Data were extracted using Covidence software, thematically analysed and reported using tables and narrative reports. The methodological quality of the included papers was evaluated using Joanna Briggs Institute quality appraisal tools.

Results

In total, 51 studies were included for analysis. Traditional healing practices included faith-based (spiritual or religious) healing, diviner healing practices and herbal therapies as complementary to other traditional healing types. Objectively measured studies stated that people’s mental health improved through collaborative care of traditional healing and biomedical care services. In addition, other subjectively measured studies revealed the effect of traditional healing in improving the mental health status of people. Human rights abuses occur as a result of some traditional practices, including physical abuse, chaining of the patient and restriction of food or fasting or starving patients. Individual, social, traditional healers, biomedical healthcare providers and health system-related factors were identified to accessing traditional healing services.

Conclusion

Although there is no conclusive, high-level evidence to support the effectiveness of traditional healing alone in improving mental health status. Moreover, the included studies in this review indicated that traditional healing and biomedical services collaborative care improve people’s mental health.

PROSPERO registration number

CRD42023392905.

Strengths and limitations of this study.

• This systematic review used a comprehensive search not only on the effectiveness of traditional healing but also on the types of practices, the factors that determine access to the practices and human rights abuse reports.

• The systematic review included a number of papers (51) which applied qualitative and quantitative methods.

• As subjective effectiveness reports of studies are prone to biases, they were reported descriptively.

• Some studies might have been missed due to non-English language studies being excluded.

Introduction

Globally, 25% of the world’s population will experience a mental health problem at some stage in their life. Worldwide, 450 million people suffer from mental or neurological disorders, and over 150 million people suffer from depression.¹ Anxiety disorder is the most prevalent (7.3%) mental health problem in the world, followed by depressive disorder (4.7%).² In Africa, 5.3% of the population have been diagnosed with anxiety disorder³ and 4.1% have depression in sub-Saharan Africa (SSA).⁴ Mental health problems contribute to about 14% of the global burden of disease,⁵ 12% in low- and middle-income countries (LMICs),¹ 8.1% in high-income countries (HICs),¹ and 10% in SSA.⁵

According to the WHO Mental Health Action Plan 2013–2020, about 35–50% of people with mental health problems did not receive treatment in HICs, although this rises to 76–85% in LMICs. This status was even worse for people diagnosed with severe mental health problems in LMICs, where 90% of them did not receive treatment.⁶ When people with mental health problems are left untreated, the disorders can affect the functionality of individuals, self-care and adherence to treatments and increase healthcare costs.⁷ One of the main significant factors for the gap in mental health services in many LMICs is the lack of biomedically trained mental health professionals.⁸ However, there are many traditional healers in LMICs compared with biomedically trained mental health professionals. For example, the ratio of traditional healers to the population in Africa is 1:500, while the ratio of physicians to the population is 1:40 000.⁹

The WHO describes traditional healing/medicine as including knowledge and skills to practice based on the theories, beliefs and experiences of Indigenous cultures that were used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental health problems.¹⁰ When traditional healing/medicine is adopted or imported by healers outside the host culture, it is termed complementary medicine.¹⁰ In contrast to traditional medicine/healers, within this paper, we use the term ‘biomedicine’ or ‘biomedical services’ to refer to the broad range of healthcare professionals who are usually trained in universities (eg, medical doctors, nurses, psychologists) and formally recognised by professional organisations (eg, colleges of medicine or nursing). Other terms for biomedicine include conventional medicine, allopathy, Western, mainstream, orthodox and regular medicine.¹¹

Biomedical services in SSA face various challenges in mental health service delivery, ranging from inadequate staffing to sociocultural stigma and less focus from the government in terms of policies and budgeting.¹² In addition, the perception of the cause of mental health problems is a barrier to using biomedical mental healthcare as a high proportion of the population perceives mental health problems as caused by supernatural forces.¹³ Traditional healing responds to the perception that mental health is caused by supernatural forces by offering faith-based healing and divination, including praying and focusing on hope,¹⁴ in addition to incantation, confessions of wrongdoing and providing holy water or ash to patients.¹⁵

The regulation of traditional medicine products, practices and practitioners is described in the WHO Traditional Medicine Strategy 2014–2023.¹⁶ In a global survey conducted by the WHO, 170 Member States (88%) formally acknowledged their use of traditional medicine through the development of national policies, laws and regulations. In Africa, 39 member states responded that they have a national policy and regulation on traditional and complementary medicine, with 20 having laws or regulations on herbal medicines.¹⁷ However, in most parts of SSA, traditional medicine is provided in open markets, shops and even at traditional healers without providing any scientific evidence of their safety, efficacy or quality.¹⁸

A systematic review conducted in LMIC settings reported that despite differing conceptualisations of mental illness causation, both traditional healers and biomedical practitioners recognise that patients can benefit from combining both practices and demonstrate a willingness to work together. However, there were concerns about patient safety and human rights regarding traditional methods.¹⁹ A different systematic review of literature from Africa was less positive about the potential collaboration between traditional healing and biomedicine, stating that the relationship between traditional and biomedical health practitioners was influenced by power struggles, lack of mutual understanding, competition, distrust and disrespect.²⁰ Before we can argue for the need for a collaborative model, we first need to examine the effectiveness of traditional healing on mental health in particular settings and cultures, which, if effective, could be used as evidence to design a collaborative model between traditional and biomedical services.¹⁶

Evidence shows that traditional and biomedical healthcare systems can coexist and are used simultaneously with the healthcare-seeking pattern of patients traversing multiple systems of care.²¹ A systematic review of integrated health systems in Africa revealed that health service users’ satisfaction and acceptance of an integrated health system practice were high.²² However, the review noted that integrating traditional medicine was unsuccessful due to health system-related barriers.²² On the other hand, evidence indicates that integrating traditional healing and biomedical services in African mental health services is enabled by launching policies on integration, employing referral systems and training on integration for both practitioners and stakeholders.²³

A significant number of studies show that many people in LMICs visit traditional healers for mental health problems, sometimes in addition to using biomedical psychiatric services.^{24 25} Thus, traditional healers will continue to have a significant role in mental healthcare.²⁶

The WHO estimates that around 80% of the population in LMICs depends on traditional healers for their healthcare needs.²⁷ In Ethiopia, the use of holy water as a cure for chronic illnesses is high, with 60% of people with a mental illness using holy water.²⁸

Traditional healers play a significant role in recognising symptoms and treating mental health problems,²⁹ and they also often attribute these issues to spiritual, moral and supernatural causes.³⁰ Therefore, it is the core reason why the WHO’s Mental Health Action Plan (2013–2020) recommends the biopsychosocial and spiritual model intervention approach to effectively address mental healthcare by incorporating traditional healing practices.³¹

Traditional healers decide on the treatment options, considering their perceptions and knowledge of different traditional treatments, the type of mental health problems, and the cause of the problem.¹⁸ The treatment approaches by traditional healers to treat people with mental health problems varied according to the severity of problems and the type of symptom. Some of the treatment approaches comprise herbal treatments, holy water, spirituality to ‘remove’ the illness, talk therapy and rehabilitation as an additional service without standard training on rehabilitation care standards for people with mental health problems. Services administered by traditional healers are associated with high satisfaction in many cases for individuals with mental health problems. This may be due to the high number of traditional healers who are easily accessible, respected opinion leaders and offer culturally appropriate treatments, which facilitates open communication.^{32 33}

To our knowledge, there are only two systematic reviews of evidence on traditional healing effects in mental healthcare in LMICs,^{34 35} and none in SSA. The current review focuses on SSA, and addresses the following review questions: (1) what types of interventions/approaches are practiced by traditional healers for people with mental health problems? (2) what are the enabling and barriers to accessing traditional mental healthcare practices for people with mental health problems? and (3), what is the effectiveness of traditional healing and collaborative care on mental health outcomes of people with mental health problems?

Methods

Design, context and operational definitions

We employed a systematic review using a predefined protocol. This review considered primary studies conducted in SSA countries.³⁶ The study population were people with mental health problems in SSA visiting traditional healing places or biomedical healthcare institutions, traditional healers, religious or spiritual persons, biomedical professionals including mental health professionals. All qualitative and quantitative study designs published before 1 December 2022 were included in the systematic review. We have added operational definitions of key terms below.

Traditional healers were defined as: healers who are based on Indigenous experiences³⁷ and/or faiths who appeal to the spiritual, magical or religious explanations for mental health problems. The traditional healers typically used holy rituals, ceremonies, talismans, divination, prayer and physical treatments comprising, but not limited to, herbs or massage, provided as an additional and with magical/religious meanings of healing modality.³⁵ Mental health problems encompass conditions commonly characterised by unexpected disturbances in a person’s cognition, emotion and behavioural control, preventing them from functioning effectively.³⁸

Collaborative care means when traditional and biomedical services jointly provide care to patients. Access to healthcare implies access to the service, a provider or an institution,³⁹ engaging to start using and adhering to the benefits, including diagnosis of the problems, treatment and follow-up by the health service system.⁴⁰ Access takes into account the abilities of individuals and populations to perceive, seek, reach, pay and engage in healthcare.⁴¹

Eligibility of studies and interventions

Studies reporting the use of traditional healing practices with religious, spiritual or magical explanations of healing modalities and herbs or massage with magical or religious meaning used to complement or in addition to spiritual treatments were included. The traditional healing was aimed at treating mental health problems of any age group in the general population, including people with physical problems comorbid with mental health problems in SSA countries.

Collaborative care interventions with traditional and biomedical services to improve people’s mental health in SSA were also included. Healing practices aimed to treat mental health problems using herbal medication alone were excluded. We have also excluded studies focusing on traditional healing for physical, neurological, substance abuse and intellectual disorders. The effectiveness of the mental health outcome was measured using objective and subjective effectiveness measurements.

Outcome measures

The mental health outcomes in the included studies were determined using objective and subjective measurements. The mental health outcome measurement consists of assessing the effect of traditional healing alone and collaborative care on people’s mental health status.

Objectively measured mental health outcome refers to the mental health status determination using standardised scale-based quantifiable questionnaires including mental health problem symptom rating scales developed by biomedical experts. Whereas subjective measurement refers to assessments that rely on the individuals’ self-reports and perception of improvement in mental health status by the traditional healing visitors, visitors’ families and traditional healers.

Systematic review search strategy

A systematic search strategy was conducted to select published studies from PubMed, MEDLINE, CINAHL and Scopus. Initial research in Google Scholar was conducted to build the keywords for the search strategy, including concept words and synonyms for: (1) Traditional healers, (2) mental health and (3) SSA. The initial keywords for the systematic review were ‘Traditional healers’, AND ‘mental health problem’, AND ‘sub-Saharan Africa’. We developed a list of synonyms (online supplemental table 1 for a complete list of terms) for both traditional healing (eg, religious healing, Indigenous healing, diviner), mental health problems (eg, mental illness, specific psychiatric disorders and positive connotations of mental health problems such as mental health, mental health well-being) and a list of the 48 SSA countries.

Search strategies for each database were separately developed and results were produced using the key terms for a comprehensive search strategy, presented in online supplemental table 2. Search results were exported to EndNote to remove duplicates. Selected studies were exported to Covidence, and the titles and abstracts were screened in Covidence. Two independent reviewers (KTB and HAG) performed screening for the title and abstract, and both reviewers independently and blindly labelled each study with reasons for inclusion and exclusion. Full-text screening was then conducted, using the inclusion and exclusion criteria. Discussions were carried out among all research team members to decide on the final articles to be included. The included papers were grouped based on the systematic review’s three objectives and thematic areas.

Quality of the included studies

The methodological quality of the studies was evaluated by two reviewers (KTB and HAG) using quality appraisal tools in the Joanna Briggs Institute (JBI) manual for evidence synthesis (https://jbi.global/critical-appraisal-tools). 24 cross-sectional surveys and mixed method papers were evaluated using the JBI quality appraisal tools for analytical cross-sectional studies (online supplemental table 3A) for the appraisal outputs, 19 for qualitative papers studies (online supplemental table 3B), 2 for cohort (online supplemental table 3C), 2 for randomised controlled trials (RCTs) (online supplemental table 3D) and 4 for expert opinion pieces (online supplemental table 3E).

The methodological quality (or bias) of the studies included in the systematic review was good, as all studies scored above average in the quality appraisal output. There were four expert opinion studies with poor quality appraisal and a study that did not report its sample size.⁴² Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline (online supplemental table 4).⁴³

Data extraction and analysis

We extracted data on authors, type of study, population, study setting, sample size, publication year, objective of the study and summary of findings. The summary of findings was deductively grouped into: ‘effectiveness’ of traditional healers and collaborative care, type of traditional healing practices and enablers and barriers of access to traditional healing practices. Further inductive synthesis was then conducted using thematic framework analysis.⁴⁴

Briefly, the framework analysis includes familiarising with the data through reading and further re-reading of the transcripts, generating initial codes, developing a working analytical framework and grouping codes into themes. Online supplemental table 5 presents details about types of traditional healing and effectiveness outcome results, and online supplemental table 6 details the key enablers and barriers to accessing traditional healing main findings. Meta-analysis was not undertaken due to the heterogeneity nature of the available data in the included.⁴⁵

Ethics

Ethical approval is not required since the review did not collect primary data.

Patient and public involvement

Patients and the public were not directly involved as it was a systematic review. However, the research was considered in the design by measuring the relevance of the topic for the patient’s benefit. Studies with patient participants are included in the review, and the study results will be disseminated in workshops for community representatives.

Results

Characteristics of studies

A total of 644 search results obtained from electronic databases were imported to EndNote and then exported to Covidence, where 287 duplicates were removed. We further excluded 306 articles during the title, abstract and full-text screening: 269 through the title and abstract and 37 through the full-text screening phase. Finally, 51 studies were identified for data extraction (figure 1).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart of traditional medicine and mental health, a systematic review in sub-Saharan Africa, 1 December 2022.

Of the 51 identified studies, 48 were from individual countries: 14 in South Africa, 7 in Ghana, 6 in Ethiopia, 5 in Nigeria, 5 in Kenya, 5 in Uganda, 3 in Sudan, 1 in Burundi, 1 in Cameroon, 1 in Tanzania, 1 in Zimbabwe. Three were across more than one country (one in Nigeria and Ghana, one in Ghana, Kenya and Nigeria). The studies were published between 1982 and 2022, and majority (19) of them were qualitatively followed by 18 cross-sectional studies and 6 mixed methods. There were two experimental studies, one each cluster RCT and RCT. The other papers included were four opinion brief reports. All participants in the included studies were adults.

As described below, thematically, all studies described the different types of traditional healing practices, 12 studies investigated enablers to access traditional healing practices and 9 about the barriers to accessing the traditional healing.

Role and types of traditional healing

The types of traditional healing practices are summarised as faith (spiritual or religious), diviners healing practices, traditional healing and herbal medication as an adjunct treatment alongside one of the other forms of traditional healing. Some studies also reported that traditional healers provide services collaboratively with biomedical healthcare professionals for people with mental health problems in SSA (online supplemental table 5).

Evidence shows that patients with mental health problems visited traditional or religious healers when they developed mental health problems for the first time, although the number of visitors varied by setting ranging from 31% in South Africa to 95% in Nigeria.^{15 46} One study found that only 27% of people attending a traditional healer made the personal choice to attend, with their family members making the decision for them.⁴⁷

Faith (spiritual or religious) healing practices

Nineteen studies focused on faith healers’ traditional practices and mechanisms to treat mental health problems.1442 46 48,63 Pastor faith healers used methods of praying such as the pastor ‘laying hands’ on clients, using prayer aids like oils and holy water, fasting and spiritual directions.⁵⁹ The common holy water treatments were ceremonies, prayer, baptism, drinking and bathing in holy water and providing holy ash to patients.⁴⁹ Spiritual remedies included praying, comfort, advice, hope and social support such as personal hygiene, washing clothes and preparing foods in addition to the holy water treatments.^{49 50} In addition, exorcism, counselling and strings of holy stones tied around wrists and ankles were used during healing sessions.¹⁴

Christian and Muslim faith healers believe that praying means that the ‘devil’ leaves the patient for them to be ‘cured’ of a mental health problem, and priests also order holy water to treat mental health problems.50,52 The diviner wizards (tanquais) prepare and provide amulets,⁴² and other religious leaders order clients to kill goats or dogs for sacrifices to appease ‘God’ to forgive whatever has caused the mental health problems.⁵¹ Muslim healers treat people with a mental health problems by putting their hand on to the patient’s head and reading verses from the Qur’an, which are blown onto the client’s face directly, or sometimes they blow into natural products (eg, water, honey, sugar, salt, olive oil) and then the clients add the product to their food to ingest it. In addition, the verses of the Qur’an are written on a piece of paper to be kept with the person at all times, as complementary to spiritual practices like daily prayer and constant remembrance of the Almighty God (Zikr).⁵²

Diviners’ healing practices

12 studies reported diviners, magical or witchcraft healing practitioners consulted by patients with mental health problems.4653,63 The studies identified different divination methods of healing practices such as counselling and praying, casting out demons, witchcraft, erasure using prayers, confessing wrongdoing, laying hands on patients and praying or providing holy ash to their patients.4764,69

In one study, the majority of the divination healers (86%) reported that they possessed the skills and knowledge required to ‘cure mental health problems’.⁷⁰ The divination healers said that the Gods show them what the problem is, who is causing it and how to heal the person.⁴⁸ However, others reported that the predominant diagnosis was interviewing the patient and/or their relatives.⁷¹ They asked the patients about their dreams as a vital clue to identifying the underlying illness,⁷¹ and some said that they ‘just know’ the diagnosis with no further clarification.⁶³

Traditional healing and herbal medication as complementary

Traditional healers providing magical, religious and/or spiritual meanings of healing modality and using herbal medication as an adjunct to treat mental health problems were also reported. The traditional healers, including spiritualists, diviners, pastors/sheiks and other faith healers, administered herbal remedies through drinking, bathing, smoking, sniffing herbs and induced vomiting.1565 70 72,81 Two studies asked traditional healers about the name of the herbal therapy they used to treat mental disorders, and the healers’ responses were reported as ‘unknown names or they don’t want to tell’.^{65 73}

Few traditional healers who prescribe herbs with faith healing together also provide psychosocial support such as conflict resolution, monetary help, employment or housing assistance and spiritual or cultural rituals support used to treat mental health problems.^{73 82}

Collaborative care between traditional healers and biomedical healthcare professionals

Three articles reported that collaboration between traditional healers and biomedical psychiatric professionals improved the attitude of traditional healers towards biomedical care, and increased the referral of patients with psychosis to biomedical healthcare services.83,85

Spiritualists, male traditional healers and traditional healers who had previously been hospitalised for a mental health problem were more likely to report a willingness to refer patients to hospitals.⁶³ Some faith and traditional healers advise patients to use biomedical treatments alongside spiritual care.^{65 80 86} Traditional healers who use herbal medication as additional to faith and divination healing were less likely than other types of healers to refer patients with mental health problems to biomedical health professionals.⁷⁹

A study with biomedical health professionals reported that 89% of nurses perform traditional rituals and customs, 75% visit traditional healers themselves as patients and 58% of nurses agreed that traditional healers could play a positive role in mental healthcare.⁸⁷ The nurses believed that traditional healing practice could be used together with psychiatric medication or psychotherapy,⁸⁷ and Muslim general practitioners acknowledged that spiritual illness exists and acknowledged the existence of a belief in witchcraft, the ‘evil eye’ and spirit possession and noted that collaboration with and referral to traditional healers are essential.⁸⁸

Traditional healing and collaborative care practice outcomes

The following subsections demonstrate the findings of studies assessing the effectiveness of traditional healing and collaborative care in mental health outcomes as primary or secondary outcomes. Eight studies analysed the effects of traditional healing and collaborative care on improving the mental health conditions of people with mental health problems (online supplemental table 5).1559 72 73 83,85 89

Effectiveness of traditional healing in mental health

Five studies, which consisted of four subjectively measured analyses in which patients reported subjectively perceived effectiveness^{15 59 73 85} (online supplemental table 5) and one objectively measured study,⁸⁹ revealed the effect of traditional healing in improving mental health problems. The objectively measured and prospective cohort study measured the outcome of effectiveness using the Positive and Negative Syndrome Scale and at 4-month follow-up under the traditional healing intervention methods, including praying and fasting at traditional healing admission centres showed the reduction of psychosis symptoms (mean score 118 on admission and 69 on discharge (p=0.0001)).⁸⁹

A qualitative study conducted among pastors who worked as faith healers for at least 5 years explained the reduction of mental health problems symptoms as signs of improvement for patients with mental health problems after both biomedical care and the spiritual care service provision.⁵⁹ Another qualitative study that interviewed traditional healers described that providing formal training for traditional healers on introduction to mental health problems resulted in patients who sought care from trained traditional and biomedical healers recovering quickly from mental health problems.⁸⁵

A mixed quantitative and qualitative study explained that almost half (48%) of patients with depression receiving traditional treatments reported feelings of improvement from their mental health problems very much, followed by 45% of the patients reporting partial progress. Patients in the biomedical psychiatry clinical settings and the same study reported similar improvement and satisfaction with the services provided. But, patients at traditional clinics had nearly three times as many visits as those at psychiatric clinics.⁷³

The fourth cross-sectional study with subjective effectiveness measurement study stated that more than half (58%) of the patients with mental health problems reported perceived feeling better after they received the traditional healer’s religious praying healing and combined with unknown herbal treatments through oral, via enema and inhaled steam treatments compared with 7 (9%) who reported feeling worse and 18 (23%) who said no effect. However, 22% of the patients reported physical, emotional and sexual human rights abuses by the traditional healers.¹⁵

Effectiveness of collaborative care in mental health

Three papers on collaborative care effectiveness^{72 83 84} reported that collaborative care improves the mental health problems of patients with psychotic symptoms (online supplemental table 5).

A cluster randomised trial found that participants in the intervention arm who received treatments from faith healers and biomedical healthcare providers achieved a significantly better reduction in psychotic symptoms compared with participants in the control group who received enhanced routine care (p<0.0001).⁸³ A prospective cohort study also found more than 20% symptom reduction of psychotic symptoms (OR 24.87 (95% CI −7.03 to 94.84) among individuals who received both services as compared with the traditional alone or Western medicine.⁷² Another experimental study also depicted that participants who received collaborative care by a team of mental health professionals plus prayer care at the traditional healing site camp had significantly lower severity of symptom mental health problems symptoms compared with the control group who received enhanced routine care by either traditional or biomedical professionals or both as usual but with no formal collaborative care (p=0.003).⁸⁴

Satisfaction with traditional healers’ services

Three studies^{53 74 82} reported satisfaction of people with mental health problems to traditional healing services (online supplemental table 5). The two studies report that patients with mental health problems are satisfied with the traditional healers’ treatment and healing process services.^{74 82} The third study comprises families and patients reporting satisfaction with the service they received from traditional healers.⁵³

In a study where people with mental health problems and traditional healers participated, most (95%) of clients were satisfied with the treatment and healing process delivered by the traditional healers.^{74 82} The study included patients with mental health problems selected from biomedical psychiatric care institutions and with a history of seeking traditional healing. It reported that patients and their families said they were generally satisfied with the service they received from traditional healers. However, patients and families expressed dissatisfaction with the diviners’ services.⁵³

The common reasons for patient satisfaction with traditional healer’s services were that patients could engage in payment-in-kind (ie, to provide work or services and providing personal assets in lieu of a cash payment) or they could pay only if their symptoms improved. In addition, traditional healing is more affordable and more easily accessible than hospitals.⁸²

Traditional healing human rights abuse practices

There were numerous references to ‘human rights abuses’, including beating the patient,^{15 47 49 75 89} chaining of the patient,^{65 85 89} locking and restriction of visitors in a dark room,^{75 89} restriction of food or fasting or starving patients^{75 89} and incorporate modern ingredients that are potentially toxic (online supplemental table 5).⁷⁰

Holy water visitors reported stigma, physical and verbal abuse and physical restraint.⁴⁹ Traditional healers treat patients by praying and adding unknown herbs to drink, bathe and sniff, and have been reported to chain the patients forcefully to give the medications.⁷⁰ Given that families often decided for patients to go to the traditional healers, patients were also unable to refuse the non-humane treatments.⁴⁷

While some studies^{65 85 89} reported better mental health outcomes resulted from traditional healing services, these studies also reported human rights abuse. A study by Zingela et al revealed that there were clients who reported of feeling better after the religious faith traditional healer’s treatment, although the religious faith healer’s physical human rights abuse such as beating and forced fasting was simultaneously reported.¹⁵ This was also supported by another study that reported the effectiveness of traditional healing in the reduction of psychotic symptoms, although patients with psychotic mental health problems in the traditional healing centre reported human rights abuse.⁸⁹ However, after providing training on introduction to mental health problems and essential management provided to traditional healers, non-humane treatments such as chaining of patients by the healers were abolished, respect for the human rights of patients increased, referral systems to biomedical care enhanced and traditional healers’ knowledge about mental health problem improved.⁸⁵

Enablers and barriers to access traditional healing practices

In this review, we also summarised 15 studies1449 53 55 59 64,66 68 79 80 82 86 about the key enablers and barriers of people with mental health problems to access traditional mental health healing in SSA countries (online supplemental table 6). Within the barriers and facilitators subthemes, we have identified issues at different levels: individual, social, traditional healers, biomedical healthcare providers and health system-related factors.

Enablers to access traditional healing practices

Enablers to using traditional healers were reported by six qualitative studies,^{14 59 65 80 82 86} understood as both pull and push factors. Push factors explain why people with mental health problems were pushed away from biomedical care, while pull factors were influencing issues that pulled the people towards traditional healing.

The perception of patients of an improvement in their mental health due to traditional healing was a key enabler, resulting in patients frequently visit traditional healing sites.⁸² Further pull factors included traditional healers making the services being affordable and accessible, allowing patients to pay later and giving more time to patients for psychosocial support.^{82 86} In addition, social support such as hygiene, washing clothes and preparing foods at traditional healing sites motivate individuals to visit religious holy water healing services frequently.⁴⁹

Two studies reported the relationship of enabling factors and collaborative care that few faith-based traditional healers advise or suggest that patients use biomedical treatments alongside their healing practices, as patients need to follow both services. These were the enabling factors for patients to adhere to traditional healing therapies by allowing them to use both services.^{14 86} The traditional healers mainly recommend patients to receive both services were for those with clear physiological and psychological symptoms. They justify for the reason that spiritual forces can be manifested in psychological and physiological ways.^{59 80} Providing training to traditional healers on the nature of mental health problems symptoms, treatments and referral issues towards enhancing collaborative care were also reported as another enabling factor for adherence to traditional healing.^{64 65} In two studies, nurses and general practitioner doctors with positive attitude on the possibility of practicing traditional healing as an additional service with biomedical healthcare was also considered as another enabling factor for patients to adhere to traditional healing benefits.^{87 88}

The health system was considered a push factor away from biomedical healthcare and an enabling factor to receive traditional healing, due to an inadequate number of biomedical mental health service providers drive patients to prefer traditional healing,⁸⁶ insufficient and expensive drug supply in biomedical health facilities⁸² and using traditional service alone due to a poorly integrated system of government policies or regulations for both traditional and biomedical services.⁵⁵

Barriers to access traditional healing practices

Barriers to accessing traditional healing practices were reported in nine papers.5355 64,66 68 79 80 86 The lack of prognosis of patients who visited traditional healers, reflecting the ineffectiveness of traditional healers, may create a lack of trust in healers.^{66 68} On another note, families acted as the primary decision-makers for the treatment preference of patients without their consent, implying patients may be denied access to traditional healing sites by their families.⁶⁶

The barriers related to the traditional healers themselves included human rights abuses by traditional healers, such as maltreatment, including forced fasting, exorcisms, which include physical beatings (sometimes resulting in death) and chaining to contain agitated patients.^{80 86} Two studies also reported the poor competency and existence of ‘fake’ healers as challenges.^{55 66} Some traditional healers believed that traditional and biomedical treatments should not be taken simultaneously and suggested to stop either of the treatments^{53 64}; it was even worse among the traditional healers who combined herbal therapy.⁶⁵

The other reported barriers were related to biomedical health professionals’ perceptions of traditional healing services, including health professionals not believing the traditional healing therapy, saying that traditional healers cannot treat severe mental health conditions, considering them as dirty and having lower education status, believing that diviners charged unfair fees for treatments and lacking skills and abusing clients reports.^{55 64 65 80 86} Five studies presented that biomedical healthcare professionals were unwilling to collaborate with traditional healing and do not favour referring patients^{55 64 65 80 86} because they do not view them as effective.^{55 65 80} However, some said the collaboration would be possible if traditional practitioners obtained additional mental healthcare training from biomedical providers and the government regulated to monitor the traditional healing practices of patient care.⁸⁶

Most health system-related factors were also reported as barriers to access traditional healing, including a lack of effort to develop the relationship between the two systems of healing,⁶⁴ lack of financial resources support from the health system administration, such as lack of transport cost for faith healers to provide home-based level visit community service⁶⁶ and poor referrals systems in the ground from traditional healers to clinicians and vice versa.^{68 79}

Discussion

Two systematic review studies were previously conducted to assess the effectiveness of traditional healing in mental health outcomes in a global setting.^{34 35} Our systematic review synthesised evidence on the types of traditional healing, the factors that influence access to the healing service and its effectiveness in improving the mental health status of people in SSA. This review is the first of its type to the best of the author’s knowledge in SSA setting and the most recent study in the last 7 years in LMICs, including its broader objective with qualitative and quantitative methods.

Common types of traditional healing practices in mental health

Our systematic review found that traditional healing practices were categorised as either faith healing, divination or faith/divination with herbal medication as an adjunct therapy, which is similar to previous reviews.^{36 90 91} The traditional healers who used herbal treatment types to treat mental health problems were not interested in naming the herbal by saying they did not want to tell or report as unknown names.1565 70 72,81 Might be related to the patent registration of the intellectual property, lack of trust in its confidentiality for its ritual significance and commerciality issues.¹⁸ This may also result in difficulties in monitoring its standard by regulatory bodies about health side effects and measuring herbal effectiveness.

Specifically, the types of traditional healing modalities are related to the belief in traditional healing and they are mainly associated with the belief of a supernatural cause of the problem by the people with a mental health problem and the healers.^{55 58 60 75 92} This idea was also supported by a systematic review conducted elsewhere.⁹³ This implies that the reason for people with mental health problems visit the traditional healing first before accessing biomedical mental health care40,42 could be related mainly to the belief in the cause of mental health problems by patients and their families. In addition, only less than one-third of people attending a traditional healer made the personal choice of the type of traditional healing as their family members made the decision for them.⁴⁷ This may show the need to work with traditional healers and patients’ families as part of the healthcare system’s responsibility.

The types of healing methods were similar to previous review reports, with around half of individuals with mental health problems in SSA seeking care from traditional healers before visiting biomedical healthcare.⁹³ A significant number of studies also show that many people in LMICs visit traditional healers for mental health problems, sometimes in addition to using biomedical psychiatric services.^{24 25} This implies that traditional healers will continue to have a significant role in mental healthcare in SSA.²⁶ Therefore, introducing strategies such as traditional healers’ training to create better awareness of mental health conditions and the importance of biomedical psychiatry care collaboration improves the attitude of healers to the advantage of safe and effective collaborative service for people with mental health problems.83,85

Despite the reported difference in the concept of mental health problems, including the illness cause and treatments between the practitioners, other previous review studies recommend building agreement and interest between two practitioners is possible to work together aiming at improving the lives of the patients in LMICs.^{19 94} Such understanding can be introduced by recognising the benefit of collaborative service for the patients and by arranging training and discussion on fundamental mental health problems,¹⁹ and innovative approaches are needed to enhance the collaborative service to provide community-based mental healthcare.⁹³

Complementary nature of traditional healing effect on mental health outcomes

Evidence in this review^{72 83 84} and from previous review³⁵ show that people with mental health problems improved after receiving a combination of traditional healing and biomedical treatments. Some other studies also reported people’s improved mental health through collaborative care of traditional healing and biomedical care services.78,80 Another previous study also supported the effectiveness of traditional healing findings for mild-to-moderate levels of mental health problems and mental health problems caused by a person’s sinful behaviour related to the religion they follow was treated better by religious treatments through the priests’ psychosocial support.^{95 96} Therefore, the psychosocial content of the traditional healing method can help traditional healing users with mental health problems. This can be supported by the evidence that psychotherapies and pharmacotherapies efficacy showed that almost no significant differences in between the two therapies for short-term improvement.⁹⁷

Traditional healing types were reported to be both effective and ineffective. However, identifying the type of mental health problem and the healing type effectiveness was difficult as most of the studies did not specify the issues, and it was impossible to define which methods are perceived as effective and which are not. Despite the limitations, many people, especially those with less severe problems and positive expectations, reported subjective benefits from attending their chosen traditional or spiritual healers.³⁴ Traditional healers’ psychosocial support helps to improve the people’s mental health status,⁴⁵ as this was supported by biomedical scientific evidence revealing its capacity to treat mild-to-moderate severity of mental health problems.⁹⁸

Satisfaction with the traditional healers’ treatment and healing process services was reported as an additional outcome of the studies’ traditional healing effectiveness.^{53 74 82} The most common reasons for patient satisfaction with the services of traditional healers were the affordability and accessibility compared with hospitals, that patients could pay in-kind and only if their symptoms improved.⁸² In contrast, some patients were dissatisfied with traditional healing. For instance, a study on African Indigenous healers reported that patients and families expressed dissatisfaction with diviners’ services.⁵³ The difference could be the difference in human rights abuse practice by the traditional healers, the type of traditional healing and the severity of the mental health problems of traditional healing users.

Human rights abuse concerns of traditional healing practices in mental health

Even though the human rights abuse of the traditional practice was not separately discussed as ours in the previous systematic reviews in mental health, the harmful treatments were included in their finding reports.^{19 35 36} In discussing the relationship between the mental health traditional healing practices and human rights abuse, this review shows almost similar findings on the experiences of traditional healing visitor individuals who have faced human rights abuses, commonly physical abuse as reported by five studies,^{15 47 49 75 89} chaining of the patient,^{64 84 88} locking restriction of visitors in a dark room, restriction of food^{65 85 89} and incorporating herbal ingredients that are potentially toxic.⁷⁰

Our finding aligns with the previous research reports conducted in the area of traditional healing aimed at treating mental health problems regarding concerns about patients’ safety related to human rights abuse.¹⁹ In addition, the herbal methods also raised issues related to its safety such as incorporating herbal ingredients that are potentially toxic,⁷⁰ efficacy and quality problems.¹⁸

Even though there are human rights abuse reports in the traditional mental healthcare practices that can affect integration,³⁶ providing training to the healers on the introduction to mental health problems, mainly identification of its symptomatic manifestations and their basic management skills for proper care at the traditional healing sites was a means to reduce non-humane treatments.⁸⁶ Therefore, as the current and previous findings suggested, this implies a need for greater integration of traditional and biomedical care to enhance the quality of care by minimising human rights violations.

Factors determining the choice of traditional and collaborative mental healthcare

The current study findings revealed different reasons why people in SSA choose traditional healing practices for mental healthcare. Accessibility of traditional healing services, extended time for psychosocial support, flexibility of payment options for patients^{82 86} and provision of social support services⁴⁹ were among the big categories of identified as enabling factors. Previous studies in SSA also revealed that the traditional healers’ attractiveness could be due to the healers and the clients sharing a common culture and knowledge of mental health problems⁹⁹ and shared spiritual and religious beliefs of mental health problem causation.¹⁰⁰

Similar to our review, other studies^{50 77 81 101 102} also reported pushing factors from biomedical services play a role as enablers to access traditional healing; the factors reported were inadequate access to biomedical healthcare services,¹⁰¹ limited mental health education,¹⁰² patient’s attitude related the poor biomedical health-seeking behaviour,¹⁰¹ inadequate number of biomedical health professionals,⁸¹ drug supply problem⁷⁷ and poorly integrated system of government regulations and administrations.^{50 102}

Findings on the barriers in accessing traditional healing were almost similar to those previously conducted studies; the barriers in accessing traditional healing services were attitudinal barriers toward each other of traditional and biomedical practitioners, biomedical professionals concerns about traditional healers healing in the patients’ safety,¹⁹ poor referral systems regulations,⁶³ the efficacy of traditional healing, perceived lack of an appropriate dose and unregulated practitioner practice, absence of health financing for traditional healthcare, a perceived lack of training among traditional practitioners and traditional healers human right abuse reports.^{36 103} Few have also found that families act as barriers by making decisions for the treatment preference of patients without the consent of patients’ were reported as social-related barriers to access the traditional healing.⁶⁶ Therefore, social barriers can be minimised by enhancing family and community participation to improve people’s mental health as part of the health system.¹⁰⁴

Our findings showed an implication that training traditional healers on mental health conditions and biomedical psychiatry care collaboration helps to tackle the barriers and improves the attitude of healers toward collaborative service, and this was supported by several studies.^{19 22 105} Therefore, based on a collaborative mental healthcare systematic review result in LMICs, traditional healers and biomedical practitioners acknowledge that patients can benefit from a combination of both disciplines and show a willingness to collaborate, even though their conceptualisations of the cause of mental illness differ.¹⁹ Creating a joint dialogue among professionals aiming to conduct training on identified gaps to improve patients’ lives can minimise the obstacles of collaborative care, including human rights abuses.⁶⁸ The indications of evidence in SSA on the development of integration policies, the manifestation of existing referral systems and training on integration for practitioners and stakeholders were crucial enablers for integrating traditional healing and biomedical health services.²³

In general, integrating traditional medicine into health sciences curricula, conducting panel discussions for evaluation purposes, developing context-specific collaboration protocols, working on regulation implementation issues, establishing referral pathways and providing training for both practitioners on safe integration by including content on how to minimise abuse, narrowing the misunderstanding about respecting clients’ preferences in using both services could help in enhancing safe, collaborative services. The advantage of engaging communities through community health workers and traditional healers training in the utilisation of integrating services was also supported by a review study on traditional medicine in primary healthcare in LMICs.¹⁰⁶ These collaborating mechanisms could be practiced to integrate with the healthcare system in SSA as most of the African WHO member states have a national policy and regulations on traditional and complementary medicine.¹⁷ However, as the resource limitation and lack of commitment will continue as a challenge, advocacy through professional associations, awareness creation and review meetings with stakeholders could enhance the implementation of the policies.

Limitations and strengths of the study

The current systematic review addressed broad issues, including the types of traditional healing, influencing factors to access traditional healing, effectiveness of healing and potential harms of traditional healing practices from quantitative and qualitative studies. However, the study has the following limitations, first, some of the subjective reports of mental health outcomes are prone to biases. Second, some studies might have been missed due to non-English language studies being excluded, leading to information bias.

Conclusion and recommendations

Despite the barriers to accessing traditional healing, many people with mental health problems continue to seek help from the different types of traditional healing such as faith healing, divination and either faith or divination with herbal medication as complementary are reported findings in SSA to treat mental health problems. Traditional healing, especially when combined with biomedical treatments as collaborative care, has been shown to be effective in treating mental health problems. Collaborative service can reduce the harmful practices in traditional healing sites through workshop discussion and training. Furthermore, working on reducing human rights abuse by traditional healers can improve collaborative care by providing training and conducting workshop discussions with both practitioners and health system leaders. Therefore, traditional healing methods can have a role and significantly affect mental healthcare in SSA. Context-specific types of healing, perceptions and strategies of collaborative care need to be researched and identified. Context-specific effectiveness of collaborative care requires further investigation.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.