Utilization of Local Healing Practices Among Patients Admitted to a Remote Tertiary Care Hospital in Eastern Bhutan: A Cross‐Sectional Study

ABSTRACT

Background and Aims

In Bhutan, patients frequently choose between allopathic health professionals and Traditional Medicine (Sowa Rigpa) practitioners based on personal faith and cultural preferences. However, beyond these formally recognized systems, uncertified local healers provide alternative cultural and spiritual healing methods that are often associated with ethical dilemmas and delayed clinical management. This study aimed to comprehensively describe the socio‐demographic characteristics, clinical diagnoses, and specific types of local healing treatments received by patients admitted to a remote tertiary care hospital in eastern Bhutan.

Methods

A cross‐sectional study was conducted at the Eastern Regional Referral Hospital in Mongar from January 1 to December 31, 2021. The study included all hospitalized patients who had consulted a local healer prior to hospital admission, identified through structured admission interviews. Data were gathered via interviewer‐administered standardized pro forma to ensure accuracy across all demographics, particularly given educational disparities, and analyzed using SPSS software (version 23). Ethical clearance was obtained from the Research Ethical Board of Health, Ministry of Health, Bhutan.

Results

Among 5,041 total admissions during the study period, 8.6% (n = 434) had utilized local healers prior to presentation. These individuals were predominantly young adults (38.7%), married females (63.4%), farmers (56.5%), and individuals with no formal education (58.8%). Motivations for seeking traditional care included positive past experiences, family pressure, community hearsay, firm belief in traditional healing, and skepticism toward allopathic medicine. Furthermore, 80% reported healthcare delays based on healer advice, with primary presentations spanning trauma or surgical conditions (27%), pregnancy and delivery (22.8%), and non‐communicable diseases (18.4%). Nearly all patients (98.4%) received treatments lasting under 7 days, and over half spent less than Nu 1,000.

A pediatric subgroup analysis of 60 children (0–12 years) who received Local Healing revealed that most treatment episodes were brief (median 1 day, IQR 1–2) and moderately costly (median Nu 1,000, IQR 300–4,250), with trauma as the leading diagnosis among school‐age children and non‐specific (‘Other’) conditions predominating in younger children. Notably, sucking of the genitalia was reported in all pediatric respondents with valid data (100%), raising child‐safeguarding concerns.

Conclusion

Approximately one in twelve admitted patients initially sought care from local healers, delaying formal medical intervention until traditional methods failed. While shaped by community trust and familial influence, this reliance underscores the need to address pre‐hospital delays through targeted public health messaging.

1. Background

Globally, traditional healers are the first to offer treatments in the forms of rituals, counselling or with the use of plants or herbs to sick persons, especially in places where there are no modern healthcare facilities [1]. Traditional healing practices are more prevalent and reported across Africa, Asia and the Americas. The World Health Organization (WHO) has estimated that over 80% of people in African and Asian countries avail treatment from traditional healers due to inaccessible and unaffordable modern healthcare services [2]. In India, the prevalence of treatment from traditional healers was over 7%, though around 36% of tribal communities in India prefer taking treatment from traditional healers [3]. In rural Sri Lanka, 70% of the population utilizes traditional healing treatment as a primary healthcare service [4].

Traditional healers acquire knowledge of traditional healing treatment from their ancestors, teachers, or through self‐learning [5, 6]. Traditional healers are generally of two types: those with formal training and those without formal training (Local Healers). Healers with formal training represent the textual tradition and are codified and institutionalized, whereas untrained healers (Local Healers) remain non‐codified and non‐institutionalized, though both practice treatment on patients [7].

Spiritual‐based healing techniques are used by Local Healers, and some use extracts from herbal plants, to treat various illnesses including fever, snake bite, arthritis, wounds, dysentery, jaundice, diabetes, hypertension, asthma, eye infection, menstrual disorders, burns, allergy, toothache, headache, lung infections, mental illness, and peptic ulcer disease [6, 8, 9, 10, 11]. A significant beneficial impact of Local Healer treatment has been reported for psychological distress, depression, and anxiety, with minimal benefit demonstrated for other conditions [10, 12].

In Bhutan, two types of traditional healing practice are prevalent. The first is Sowa Rigpa, the formally trained Bhutanese Traditional Medicine system, practiced by certified traditional medicine physicians and clinical assistants who undergo formal training, are licensed, and are regulated by the medical council [13]. Bhutanese Traditional Medicine services are provided through units co‐located with allopathic hospitals. The 5th National Health Survey reported that one out of five patients visiting health facilities consults traditional medicine professionals for Sowa Rigpa treatment [14].

The second type is Local Healing practice, commonly found in rural areas and passed down through generations rather than formal education. Local Healers often rely on herbs, bloodletting, heated irons, sucking blood, or sucking genitalia, minerals, bamboo splints, and other indigenous methods [6]. Their practices are based on the belief that diseases are caused by revengeful spirits or poisoning by a witch called a Dhuama. Cure is generally believed to occur by appeasing the evil spirit or by bloodletting from the site of pain [6].

A report on nationwide mapping and documentation of Local Healers found the majority of practices concentrated in the eastern region of Bhutan (64.3%), followed by western (16.5%), southern (11.2%), and central (8.1%) regions. The highest number of Local Healers was found in Mongar district; most were elderly, male, farmers with no formal education, and had been practicing for more than 10 years. The majority practiced sucking blood, sucking genitalia, and bone‐setting [6].

Local Healers not only perform rituals to address perceived causes of illness but also advise on the timing of hospital visits and predict outcomes of hospital‐based treatment. Many patients consult Local Healers as a first point of contact and seek hospital care only when illness fails to improve. Given this socio‐cultural context of health behavior in Bhutan, this study describes the socio‐demographic profile, diagnoses, and types of Local Healing treatment received by patients admitted to the Eastern Regional Referral Hospital (ERRH), Mongar, Bhutan.

2. Methods

2.1. Study Design

This was a cross‐sectional study conducted at ERRH, Mongar, Bhutan, from January 1 2021 to December 31, 2021. The study protocol was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

2.2. Study Setting

Bhutan has a three‐tiered healthcare system comprising both allopathic and traditional medicine services. The primary level comprises Primary Healthcare Centres and Outreach Clinics focused on preventive, promotive, and basic curative services. The secondary level consists of district hospitals providing general medical, surgical, obstetric, and pediatric services, and acting as referral centers for primary units. The tertiary level comprises Regional Referral Hospitals and the National Referral Hospital, providing specialized care and serving as training institutions [15].

ERRH is located in eastern Bhutan and serves all 17 Gewogs of Mongar district (population 37,017), functioning as the sole tertiary‐level referral center for the entire eastern region of the country [16].

Patients from surrounding districts—including Lhuntse, Trashigang, Trashiyangtse, Pemagatshel, Samdrupjongkhar, and Bumthang—are referred to ERRH when care needs exceed the capacity of local district hospitals. The nearest higher‐level facility, the National Referral Hospital, is located in Thimphu, several hours away by road across mountainous terrain, further limiting timely access to specialized care for patients from this region. This combination of sole tertiary‐level status, an extensive rural catchment area, and physical distance from the country's highest level of care underscores ERRH's role as a remote tertiary care hospital, serving a largely dispersed rural population with limited alternative access to specialized medical services.

It is a 150‐bedded hospital with general surgery, obstetrics and gynecology, maternal fetal medicine, orthopedics, dental surgery, ENT, internal medicine, emergency medicine, pediatrics, radiology, pathology, ophthalmology, and a separate Department of Traditional Medicine [17].

2.3. Study Population

For this study, a Local Healer was operationally defined as an individual without formal biomedical or Sowa Rigpa training who provides indigenous healing interventions such as incision, cupping, cauterization, or bone‐setting, typically within the patient's home community. All patients who had received a form of treatment from a Local Healer before admission to the Inpatient Department (IPD) during 2021 were included, identified through self‐report during the standardized admission interview conducted by ward nursing staff. Patients who had not received Local Healing treatment prior to admission were excluded.

2.4. Sample Size and Sampling Method

Sample size was estimated using the single‐proportion formula ($n=\frac{z^{2}p(1-p)}{d^2}$) assuming a prevalence (p) of 50% (due to lack of prior local prevalence data), 5% margin of error (d), a 95% confidence interval (z = 1.96), and 15% anticipated dropout or non‐response, yielding a target of 442 patients.

A consecutive sampling method was utilized: all eligible patients admitted during the 1‐year study period who met the inclusion criteria were approached consecutively, as no formal sampling frame or pre‐existing registry of local healer users existed.

2.5. Study Tools and Data Collection

A standardized pro forma was used for data collection, consisting of four sections: Section A, socio‐demographic variables (age, sex, residence, ethnicity, marital status, occupation, educational status, family type, monthly income); Section B, reasons for availing treatment from Local Healers; Section C, reasons for delay in seeking healthcare services; and Section D, diagnosis, treatment duration, and cost of Local Healing.

The instrument was developed by the investigator team based on prior literature and clinical experience, and its content was reviewed for validity by a panel of five experts comprising traditional medicine specialists, public health physicians, clinicians, and researchers. The pro forma was subsequently pilot‐tested on 20 patients, who were excluded from the final analytic sample; items were revised following the pilot to improve clarity and comprehensibility. A unique patient ID was assigned to each participant to avoid data duplication.

Admission diagnoses were extracted from hospital medical records and discharge summaries, as originally documented by the attending clinical team using International Classification of Diseases (ICD) coding conventions. These individual diagnoses were subsequently grouped by the investigator team into broader clinical categories (pregnancy and delivery, communicable disease, gynecological cases, non‐communicable disease, trauma and surgery, and other) to enable descriptive summarization. The ‘Other’ category comprised dermatological conditions, minor soft‐tissue injuries, and undifferentiated acute pain syndromes that did not fit these primary categories.

Because diagnoses were derived directly from existing clinical documentation rather than through independent, blinded dual review specifically for this study, formal inter‐rater reliability (e.g., Cohen's kappa) was not assessed.

2.6. Safeguarding Considerations for Minors

Because the study population included infants, children, and adolescents, and given that reported local healing practices occasionally involved sensitive physical contact, the study team aligned data collection procedures with institutional child‐protection standards. Ward nurses and interviewers were instructed to immediately report any disclosures raising child‐protection or safeguarding concerns to the hospital's medical social work and pediatric departments for appropriate clinical management and follow‐up. No formal safeguarding concerns or adverse disclosures were identified or triggered during the data collection period.

2.7. Statistical Analysis

Data were entered and analyzed using IBM SPSS Statistics (Version 23; IBM Corp., Armonk, NY, USA; licensed to Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu). Socio‐demographic variables and diagnosis were single‐response items and are presented as frequencies and percentages. Reasons for availing Local Healer treatment, types of treatment received, and reasons for delay in seeking healthcare were collected as multiple‐response items, as participants could endorse more than one reason or treatment modality; these are likewise presented as frequencies and percentages, with each percentage reflecting the proportion of respondents endorsing that specific item rather than mutually exclusive categories. Continuous variables (treatment duration and total payment) are presented as median and interquartile range (IQR), given the skewed distribution of these variables.

2.8. Ethical Consideration

This study was conducted according to the principles of the Declaration of Helsinki. Administrative approval was obtained from the Ministry of Health, and ethical clearance was obtained from the Research Ethical Board of Health, Ministry of Health, Bhutan (Ref. No: REBH/Approval/2019/044, dated 12/12/2019). Written informed consent was obtained from adult participants. For participants younger than 18 years, informed consent was obtained from a parent or legal guardian, with assent obtained from the child where developmentally appropriate.

3. Results

In 2021, a total of 5041 patients were admitted to the hospital, of whom 8.6% (434/5041) had availed treatment from Local Healers prior to admission. Among these patients, the majority (38.7%) were young adults (age 19–35 years), married females (63.4%), and farmers (56.5%) with no formal schooling (58.8%). Full sociodemographic details are shown in Table 1.

Table 1.

Sociodemographic characteristics of patients who had availed treatment from Local Healers prior to hospital admission at the Eastern Regional Referral Hospital, Mongar, Bhutan, 2021 (n = 434).

Age	Frequency	Percent
Infant (< 1 year)	21	4.8
Toddler (1–3 years)	9	2.1
Preschool (3–5 years)	4	0.9
School age (6–12 years)	26	6.0
Adolescent (13–18 years)	16	3.7
Young adult (19–35 years)	168	38.7
Middle aged adult (36–55 years)	84	19.4
Older adult (56–64 years)	35	8.1
Elderly (> 65 years)	71	16.3
Gender
Female	275	63.4
Male	159	36.6
Place of residence
Bumthang	19	4.4
Lhuntse	54	12.4
Mongar	189	43.5
Pemagatshel	41	9.4
Samdrupjongkhar	28	6.5
Trashigang	65	15.0
Trashiyangtse	38	8.8
Ethnicity
Sharchop	418	96.3
Lhotsampa	10	2.3
Ngalop	6	1.4
Marital status
Divorced	17	3.9
Married	275	63.4
Single	115	26.5
Widowed	27	6.2
Occupation
Armed force	3	0.7
Business	15	3.5
Civil servant	19	4.4
Corporate worker	11	2.5
Farmer	245	56.5
Housewife	53	12.2
Religious personnel	18	4.1
Others	70	16.1
Educational status
Degree or higher	15	3.5
Diploma	7	1.6
Higher secondary	88	20.3
Non‐Formal Education	10	2.3
No schooling	255	58.8
Primary	59	13.6
Family type
Joint	135	31.1
Nuclear	299	68.9
Family monthly income (in Nu) a
≤ 5000	110	25.3
5001–8000	51	11.8
8001–12000	72	16.6
12001–17000	64	14.7
≥ 17000	137	31.6

^a Nu: Ngultrum (1 United States dollar = 73.1 Ngultrum in 2021).

3.1. Motivations, Treatment Modalities, and Delay Factors

Over 90% of participants cited positive past experiences, community hearsay, family pressure, perceived superiority of traditional healing, and skepticism toward allopathic medicine as drivers of their care‐seeking behavior (Table 2). Because these variables were collected as multiple‐response items, individual participants endorsed several reasons simultaneously.

Table 2.

Patient‐reported reasons for opting Local Healing, forms of treatment received, and reasons for delay in hospital presentation among patients admitted at ERRH, Mongar, Bhutan, 2021 (n = 434).

Characteristics	n (%)
Reasons for opting local healing a
Truly believe that Local Healing helps in curing a disease	291 (67.1)
Just because someone is resorting to Local Healing, I am copying them	398 (91.7)
My friends, relatives and family forced me to undergo Local Healing	397 (91.5)
I have been cured of a disease due to Local Healing in the past	394 (90.8)
I felt that I have been cured of a disease by Local Healing in the past	394 (90.8)
I follow Local Healing because I want to preserve our culture	335 (77.2)
I believe that Local Healing is better than allopathic medicine	401 (92.4)
I have no faith in allopathic medicine	399 (91.9)
The Local Healer forced me to listen to his advice	337 (77.6)
Types of local healer treatments a
Suction with cut over the skin	397 (91.5)
Suction with mouth directly	372 (85.7)
Suction with syringe/glass with cut over the skin	378 (87.1)
Sucking genitalia	398 (91.7)
Application of heated red‐hot iron over the skin	400 (92.2)
Manipulation of dislocation and fracture	397 (91.5)
Splinting of fracture sites	402 (92.6)
Application of any substances over the lesion	359 (82.7)
Provided medication for consumption	395 (91.0)
Religious puja (Rimdro)	188 (43.3)
Sorcery	367 (84.6)
Reasons for delay in seeking health care services a
Due to advice from lay monks	362 (83.4)
Due to advice from Local Healing practitioners	357 (82.3)
Due to advice from family members	353 (81.3)
Due to advice from friends	362 (83.4)
Due to hearsay	361 (83.2)

^a Multiple‐response items; percentages reflect the proportion of total participants endorsing each specific category.

Similarly, over 90% of patients received one or more invasive or spiritual interventions (Table 2, Figure 1). Over 80% reported healthcare delays resulting from advice provided by lay monks, local healers, family members, or peers (Table 2).

Figure 1.

Forms of Local Healing treatment practiced in Bhutan (a) Cupping done on the face of a lady caused induration, (b) Cupping done on the neck of the lady, (c) Multiple cuts on the legs superimposed with infection, (d) Multiple cuts and suction done on the abdominal wall over the pain sites, (e) Multiple skin burns from application of red‐hot heated iron over the chest superimposed cellulitis, (f) Multiple burn marks over the back from heated iron rod, (g) Sucking blood from the umbilical region with mouth, (h) Manipulation of fracture and application of splint over the arm, (i) Application of bamboo sticks and paper to immobilize the joints, (j) Cleaning breast abscess with herbal extracts with bare hand.

3.2. Reasons for Delay in Seeking Healthcare Services

Over 80% of patients reported delay in seeking healthcare due to advice from lay monks, Local Healers, family members, friends, or hearsay (Table 2).

3.3. Diagnosis, Treatment Duration and Expenditure

The majority of patients received local healing for trauma and surgery (27.0%), pregnancy and delivery complications (22.8%), and non‐communicable diseases (18.4%). The “Others” category (25.3%) comprised dermatological conditions, minor soft‐tissue injuries, and undifferentiated acute pain syndromes. Over 98% of patients received local healing for 0–7 days, and more than half spent less than Nu 1,000 (Table 3).

Table 3.

Diagnosis, duration of hospitalization and expenditure for Local Healing among patients admitted at the Eastern Regional Referral Hospital, Mongar, Bhutan, 2021 (n = 434).

Characteristics	Frequency	Percent
Diagnosis
Pregnancy and delivery	99	22.8
Communicable disease	13	3.0
Gynecological cases	15	3.5
Non‐communicable diseases	80	18.4
Trauma and surgery	117	27.0
Others*	110	25.3
Local treatment duration
0–7 days	427	98.4
8–14 days	5	1.2
> 14 days	2	0.5
Expenditure for local healing
Nu < 1000	241	55.5
Nu 1000–5000	99	22.8
Nu > 5000–10000	42	9.7
Nu > 10000	52	12.0

Note: Nu: Ngultrum (1 United States dollar = 73.1 Ngultrum in 2021); * Comprises of dermatological conditions, minor injuries, and undifferentiated pain.

3.4. Sociodemographic, Clinical, and Treatment Characteristics of Pediatric Patients

Among the 60 pediatric patients (0–12 years) who received Local Healing treatment prior to admission at ERRH, Mongar in 2021, the largest proportion belonged to the school‐age group (6–12 years; n = 26, 43.3%), followed by infants (0–1 year; n = 21, 35.0%), toddlers (2–3 years; n = 9, 15.0%), and preschoolers (4–5 years; n = 4, 6.7%).

Overall, males comprised a slightly higher proportion of cases (53.3%) than females (46.7%), although this pattern varied by age group: females predominated among infants (61.9%), while males predominated among toddlers (55.6%), preschoolers (100.0%), and school‐age children (57.7%).

The majority of patients resided in Mongar district (58.3%), followed by Trashigang (16.7%) and Lhuntse (8.3%); smaller proportions came from Bumthang, Trashiyangtse (5.0% each), and Pemagatshel and Samdrupjongkhar (3.3% each). This pattern was broadly consistent across age groups, with Mongar residents accounting for the majority in each band, notably 100.0% of preschoolers.

Regarding diagnosis, “Other” conditions were the most common reason for Local Healing use overall (58.3%), particularly among infants (81.0%), toddlers (77.8%), and preschoolers (75.0%). In contrast, trauma was the leading diagnostic category among school‐age children (42.3%), and was the second most common diagnosis overall (23.3%). Surgical conditions (8.3%), non‐communicable diseases (5.0%), birth/delivery‐related conditions (3.3%), and communicable diseases (1.7%) accounted for smaller proportions of cases.

The median duration of Local Healing treatment for the total pediatric sample was 1 day (IQR 1–2), indicating that most children across all age groups received treatment for a brief period. Toddlers had the longest median duration (2 days, IQR 1–3), while infants, preschoolers, and school‐age children each had a median duration of 1 day, with preschoolers showing the narrowest spread (IQR 1–1.5).

The median total payment for Local Healing treatment across the pediatric sample was Nu 1,000 (IQR 300–4,250). School‐age children incurred the highest median payment (Nu 1,500, IQR 500–5,375), followed by infants (Nu 1,000, IQR 500–3,000), toddlers (Nu 500, IQR 100–1,000), and preschoolers (Nu 400, IQR 300–1,625). The wide interquartile ranges relative to the medians, particularly among school‐age children and infants, indicate considerable variability in payment amounts within these groups (Table 4).

Table 4.

Sociodemographic, clinical, and treatment characteristics of pediatric patients (0–12 years) who received Local Healing treatment prior to admission at ERRH, Mongar, Bhutan, 2021 (n = 60).

	Infant	Toddler	Preschool	School age
	(0–1 year)	(2–3 years)	(4–5 years)	(6–12 years)	Total
Characteristic	(n = 21)	(n = 9)	(n = 4)	(n = 26)	(n = 60)
Gender, n (%)
Female	13 (61.9)	4 (44.4)	0 (0.0)	11 (42.3)	28 (46.7)
Male	8 (38.1)	5 (55.6)	4 (100.0)	15 (57.7)	32 (53.3)
Place of residence, n (%)
Bumthang	2 (9.5)	0 (0.0)	0 (0.0)	1 (3.8)	3 (5.0)
Lhuntse	2 (9.5)	0 (0.0)	0 (0.0)	3 (11.5)	5 (8.3)
Mongar	12 (57.1)	6 (66.7)	4 (100.0)	13 (50.0)	35 (58.3)
Pemagatshel	0 (0.0)	1 (11.1)	0 (0.0)	1 (3.8)	2 (3.3)
Samdrupjongkhar	1 (4.8)	0 (0.0)	0 (0.0)	1 (3.8)	2 (3.3)
Trashigang	3 (14.3)	1 (11.1)	0 (0.0)	6 (23.1)	10 (16.7)
Trashiyangtse	1 (4.8)	1 (11.1)	0 (0.0)	1 (3.8)	3 (5.0)
Diagnosis, n (%)
Birth/delivery	1 (4.8)	0 (0.0)	0 (0.0)	1 (3.8)	2 (3.3)
Communicable disease	0 (0.0)	0 (0.0)	0 (0.0)	1 (3.8)	1 (1.7)
Non‐communicable disease	1 (4.8)	0 (0.0)	0 (0.0)	2 (7.7)	3 (5.0)
Other	17 (81.0)	7 (77.8)	3 (75.0)	8 (30.8)	35 (58.3)
Surgical	1 (4.8)	1 (11.1)	0 (0.0)	3 (11.5)	5 (8.3)
Trauma	1 (4.8)	1 (11.1)	1 (25.0)	11 (42.3)	14 (23.3)
Treatment duration and payment, Median (IQR)
Local healing treatment duration (days)	1 [1, 2]	2 [1–3]	1 (1–1.5)	1 [1, 2]	1 [1, 2]
Total payment for local healing (Nu)	1000 (500–3000)	500 (100–1000)	400 (300–1625)	1500 (500–5375)	1000 (300–4250)

Note: Categorical variables presented as n (%), calculated within each age‐group column (denominator = valid pediatric patients in that age band: Infant n = 21, Toddler n = 9, Preschool n = 4, School age n = 26; Total n = 60). Continuous variables (treatment duration and total payment) presented as median (interquartile range [IQR]), based on all valid pediatric patients in each age band (Infant n = 21, Toddler n = 9, Preschool n = 4, School age n = 26; Total n = 60). Nu: Ngultrum. Data for gender, residence, and diagnosis reflect hospital admission records; responses for infants and toddlers regarding treatment characteristics were guardian/parent‐reported.

3.5. Reasons for Opting Local Healing and Types of Local Healing Treatment Received by Pediatric Patients

Among the 56 respondents with valid data on reasons for opting Local Healing, several beliefs and social pressures were reported by nearly all respondents across age groups. Copying others who resort to Local Healing (100.0%), feeling cured of a disease by Local Healing in the past (100.0%), believing Local Healing is better than allopathic medicine (100.0%), and having no faith in allopathic medicine (100.0%) were each endorsed universally across the total sample. Similarly, having been cured of a disease by Local Healing in the past was reported by 98.2% of respondents overall, and being forced by friends, relatives, or family was reported by 98.2%, with near‐uniform endorsement across all age groups.

Feeling forced by the Local Healer to follow his advice was reported by 89.3% of respondents overall, ranging from 84.6% among school‐age children to 100.0% among toddlers and preschoolers. A genuine belief that Local Healing helps cure disease was somewhat less uniformly endorsed (75.0% overall), being lowest among preschoolers (50.0%) and highest among school‐age children (80.8%). Following Local Healing to preserve culture was reported by 80.4% of respondents overall, with relatively consistent endorsement across age groups (75.0–87.5%).

Regarding types of Local Healing treatment received, cupping suction, application of heated red‐hot iron, and splinting of fractures were each reported by 100.0% of respondents across all age groups. Manipulation of dislocations/fractures and provision of oral medication were nearly universal (98.2% overall), while suction with a cut over the skin and suction with syringe/glass with a cut were each reported by 96.4% of respondents overall. Suction performed directly with the mouth was reported by 94.6% overall, slightly lower among school‐age children (88.5%) compared to younger age groups (100.0%).

Sorcery was reported by 92.7% of respondents overall, ranging from 75.0% among toddlers to 100.0% among preschoolers. Application of substances over a lesion was reported by 87.5% overall, with the lowest endorsement among toddlers (75.0%). Religious puja (Rimdro) was the least commonly reported treatment type, endorsed by 57.1% of respondents overall, ranging from 50.0% among preschoolers and school‐age children to 66.7% among infants.

Overall, these findings indicate that pediatric patients across all age groups were exposed to a broad and largely consistent range of Local Healing practices, often involving multiple invasive procedures (e.g., suction, cautery, sorcery) in combination, and that social and familial pressure—alongside strong beliefs in the efficacy of Local Healing and mistrust of allopathic medicine—were near‐universal drivers of this care‐seeking behavior (Table 5).

Table 5.

Reasons for opting Local Healing and types of Local Healing treatment received, by pediatric age group, among patients admitted at ERRH, Mongar, Bhutan, 2021 (n = 60).

	Infant	Toddler	Preschool	School age
	(0–1 year)	(2–3 years)	(4–5 years)	(6–12 years)	Total
Variable	n = 18 (%)	n = 8 (%)	n = 4 (%)	n = 26 (%)	n = 56 (%)
Reasons for opting local healing
Truly believe local healing helps in curing a disease	13 (72.2)	6 (75.0)	2 (50.0)	21 (80.8)	42 (75.0)
Copying others who resort to Local Healing	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Forced by friends, relatives, or family	18 (100.0)	8 (100.0)	3 (75.0)	26 (100.0)	55 (98.2)
Have been cured of a disease by Local Healing in the past	18 (100.0)	8 (100.0)	4 (100.0)	25 (96.2)	55 (98.2)
Felt cured of a disease by Local Healing in the past	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Follows local healing to preserve culture	14 (77.8)	7 (87.5)	3 (75.0)	21 (80.8)	45 (80.4)
Believes local healing is better than allopathic medicine	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Has no faith in allopathic medicine	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Felt forced by the local healer to follow his advice	16 (88.9)	8 (100.0)	4 (100.0)	22 (84.6)	50 (89.3)
Types of local healing treatment received
Suction with cut over the skin	18 (100.0)	8 (100.0)	4 (100.0)	24 (92.3)	54 (96.4)
Suction with mouth directly	18 (100.0)	8 (100.0)	4 (100.0)	23 (88.5)	53 (94.6)
Suction with syringe/glass with cut	18 (100.0)	8 (100.0)	4 (100.0)	24 (92.3)	54 (96.4)
Sucking genitalia	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Application of heated red‐hot iron over the skin	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Manipulation of dislocation/fracture (joint)	18 (100.0)	8 (100.0)	4 (100.0)	25 (96.2)	55 (98.2)
Splinting of fracture site	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)
Application of substances over the lesion	17 (94.4)	6 (75.0)	4 (100.0)	22 (84.6)	49 (87.5)
Provided medication for oral consumption	18 (100.0)	8 (100.0)	4 (100.0)	25 (96.2)	55 (98.2)
Religious puja (Rimdro)	12 (66.7)	5 (62.5)	2 (50.0)	13 (50.0)	32 (57.1)
Sorcery	16 (94.1)	6 (75.0)	4 (100.0)	25 (96.2)	51 (92.7)
Total respondents	18 (100.0)	8 (100.0)	4 (100.0)	26 (100.0)	56 (100.0)

Note: Multiple‐response items; percentages are calculated within each age column based on valid respondents (excludes cases coded “not recorded” for that item). Column denominators: Infant n = 18 (of 21; 3 not recorded), Toddler n = 8 (of 9; 1 not recorded), Preschool n = 4 (of 4), School age n = 26 (of 26), Total n = 56 (of 60). Denominator for Sorcery differs slightly (Total n = 55; Infant n = 17) due to one additional case with a “not recorded” response specific to that item. Responses for infants and toddlers were guardian/parent‐reported.

4. Discussion

This study describes the socio‐demographic profile, diagnoses, and types of Local Healing treatment received by patients admitted to a remote tertiary care hospital in eastern Bhutan. Approximately one in twelve admitted patients had sought treatment from a Local Healer prior to hospital admission. The majority (38.7%) were young adults aged 19–35 years. Similarly, a qualitative study in Bangladesh on traditional medicine practices reported that most patients (76%) were between 18 and 45 years of age, reflecting the cultural influence on health‐seeking behavior in young adults [18].

Approximately 5% of participants were infants who had also received Local Healing treatment. These finding warrant attention, as infants represent a physiologically vulnerable population, and the safety profiles of certain traditional practices and preparations used in this age group remain insufficiently studied. In Bhutan, and in many countries, Local Healing practices are neither documented nor regulated, while patients and families bear the cost of delayed treatment or complications. It remains important, however, to respect cultural practices and community knowledge regarding disease and healing. The WHO's Traditional Medicine strategy recommends that countries subject such practices to scientific review and generate local evidence on their impact [19].

Female patients accounted for 63.4% of those who sought Local Healing treatment, comparable to a Bangladeshi study in which women comprised approximately 69% of traditional medicine users [18]. This pattern may reflect socio‐cultural influence, established trust in traditional practices, and barriers to accessing or accepting formal healthcare. Engaging women through health awareness programs may help direct timely care‐seeking for themselves and their families.

Most patients who sought Local Healing had no formal education and were farmers or housewives, consistent with findings from Bangladesh [18]. These associations between lower educational attainment, socioeconomic vulnerability, and traditional healthcare use support the case for targeted, gender‐sensitive health‐seeking interventions.

More than 90% of participants cited prior perceived benefit, family or community recommendation, belief in the effectiveness of Local Healing, or limited confidence in allopathic medicine as drivers of their health‐seeking behavior. In Bhutan, it is common to consult Local Healers or attempt home remedies before accessing formal services, particularly for symptoms perceived as mild, with medical care sought once symptoms persist or worsen [20]. A similar pattern has been reported in Bangladesh [18]. These findings underscore the need to address physical, financial, and socio‐cultural barriers to timely health‐seeking.

These findings can also be interpreted through the Three Delays Model, which frames delayed access to care as arising from three sequential phases: delay in the decision to seek care, delay in reaching a healthcare facility, and delay in receiving adequate treatment on arrival.

Phase 1 (delay in deciding to seek care) predominates in this study population. Patients and families actively chose Local Healing over hospital care, driven by strong personal belief in the efficacy of traditional treatment, family and community pressure, hearsay, and skepticism toward allopathic medicine (Table 2). This decisional delay was not incidental but often actively encouraged by Local Healers themselves, over three‐quarters of whom reportedly urged patients to continue traditional treatment before considering hospital care.

Phase 2 (delay in reaching a healthcare facility) was also present, though less directly measured. Patients frequently remained in their home communities for the duration of Local Healing treatment‐often several days‐undergoing repeated ritualistic, herbal, or invasive interventions before travel to ERRH was initiated. Given that Mongar district's terrain and dispersed rural population already present geographic and transport challenges, this treatment‐seeking delay likely compounds pre‐existing physical access barriers, extending the interval between symptom onset and hospital arrival beyond what geography alone would predict.

Phase 3 (delay in receiving adequate treatment on arrival) appeared to be minimal in this cohort, as patients were managed promptly once admitted to ERRH. However, the cumulative effect of Phases 1 and 2—particularly repeated invasive procedures and prolonged pre‐hospital intervals—may have complicated clinical presentation on arrival (e.g., secondary infection, advanced disease progression, or complications from prior local interventions), thereby indirectly extending the time to effective treatment even when in‐hospital care itself was timely.

Taken together, this pattern suggests that the critical bottleneck for this population lies overwhelmingly in pre‐facility, decision‐stage delay, rather than in transport logistics or hospital‐based inefficiencies. Interventions aimed at improving timely presentation should therefore prioritize community‐level engagement and belief‐modification strategies over infrastructure‐focused approaches alone.

Over 90% of patients received one or more Local Healing interventions, including skin incision, cupping or suction, application of heated instruments, joint manipulation, herbal or traditional preparations, and ritual‐based interventions. Comparable practices have been documented across African countries, where illness is often understood within spiritual or cosmological frameworks [21]. Similarly, tribal communities in India, including the Mishing tribes of Arunachal Pradesh and Assam, rely on ritual sacrifice, steaming therapies, purgative rituals, inhalation therapies, skin incisions, and protective charms or piercings [22].

A systematic review of 51 studies from sub‐Saharan Africa reported a wide range of traditional healing modalities, including faith‐based interventions and herbal therapies, and documented human rights concerns such as physical and sexual abuse, physical restraint, and food deprivation [23]. Concerns of a similar nature involving Local Healers have been informally reported in Bhutan, though disclosure may be limited by social, cultural, and personal factors; Bhutan‐specific published evidence on this issue remains lacking.

The high reported frequency of genital‐contact‐based Local Healing practices, including among minors, raises concerns extending beyond clinical safety to child protection. During data collection, any disclosures or observations raising immediate child‐protection or safeguarding concerns were referred in real‐time to the hospital's medical social work and pediatric departments for evaluation and support in accordance with institutional child‐protection guidelines. At the national policy level, standardizing inter‐sectoral referral pathways between traditional health practices and child protection services is strongly recommended to safeguard vulnerable minors. Further research and clinical guidance are needed on how frontline health workers should respond when such disclosures arise during routine care.

Over 80% of patients experienced delays in hospital admission while undergoing Local Healing, often on the advice of Local Healers, lay monks, family, friends, or community networks. Conditions most commonly managed by Local Healers included trauma, pregnancy‐ and childbirth‐related conditions, and non‐communicable diseases. While individuals generally seek such care intending recovery, delays in accessing formal healthcare may be associated with disease progression [24].

Patients and their attendants often attribute poor outcomes to the hospital rather than to the preceding delay caused by Local Healing. Given that healthcare in Bhutan is provided free of cost, a country‐specific strategy to improve timely hospital presentation is recommended. Given the demographic profile of patients using these services, Local Healing practices are likely to persist in some form; allopathic healthcare workers should be made aware of these practices and their impact on patient management.

This study has several limitations. First, while the minimum sample size was calculated using a single population proportion formula assuming simple random sampling to establish baseline statistical power, the study employed a consecutive sampling framework due to the hospital‐based clinical setting. Because consecutive sampling is non‐probabilistic, it cannot guarantee equal selection probability across the broader population, introducing selection bias.

Second, the single‐center design at a regional referral hospital limits the generalizability of findings to outpatient settings or non‐hospitalized individuals. The inclusion exclusively of admitted patients creates survivorship bias, omitting individuals with mild conditions managed entirely in the community, those presenting solely to emergency outpatient departments, or patients who succumbed to illnesses before reaching a healthcare facility. Furthermore, because this study sampled exclusively patients who utilized local healing, the lack of a comparison group of patients who did not use local healing prevented the execution of inferential statistical analyses‐such as multivariable logistic regression‐to determine independent sociodemographic or clinical predictors associated with local healer utilization. Additionally, diagnostic categorization relied on a single‐reviewer classification of existing medical record diagnoses rather than independent dual coding, and inter‐rater reliability was therefore not formally assessed; future studies would benefit from a structured, dual‐coder diagnostic classification protocol with reliability testing (e.g., Cohen's kappa) to strengthen reproducibility.

Third, data collection relied on self‐reporting, exposing the findings to recall bias, social desirability bias, and interviewer bias‐particularly concerning sensitive traditional practices. Additionally, several items assessing reasons for opting Local Healing and reasons for delay in seeking care were endorsed by more than 80% of respondents; while these items were developed and reviewed by an expert panel and pilot‐tested prior to use, the consistently high endorsement rates raise the possibility of acquiescence bias, whereby respondents tend to agree with statements presented to them regardless of content, or of leading‐question effects inherent to the item wording. Future studies could mitigate this risk by incorporating reverse‐worded or neutrally framed items and by validating response consistency through test‐retest or split‐sample approaches. Additionally, the study pro forma did not capture discrete date fields for symptom onset, initial contact with a Local Healer, or hospital arrival; consequently, this study was unable to quantify the specific interval of delay between symptom onset and hospital presentation, as distinct from the duration of Local Healing treatment itself. Future studies should incorporate structured, date‐stamped data collection at each of these time points to enable precise measurement of pre‐hospital delay and its relationship to clinical outcomes. Finally, because the study did not systematically track longitudinal clinical endpoints (such as specific complication rates, morbidity, length of hospital stay, or mortality), direct conclusions regarding the precise clinical impact of pre‐hospital delays could not be quantified. Future prospective cohort studies incorporating proper control groups and longitudinal clinical tracking are warranted to thoroughly evaluate the safety, predictors, and health‐system implications of local healing practices in Bhutan.

4.1. Recommendations

There is an urgent need to educate communities about the potential harmful effects of Local Healer practices. Community sensitization should be conducted through local leaders, religious personnel, and community‐based organizations to promote timely care‐seeking from qualified health professionals.

Many patients who visited Local Healers underwent invasive practices such as cutting or piercing the skin with sharp instruments. A few patients reportedly acquired hepatitis B infection following such treatment, though these cases were not formally reported; additional patients may have been exposed to other blood‐borne infections, including HIV. Strict regulation of invasive Local Healer procedures is warranted.

Certain Local Healer practices, particularly selected herbal preparations and manual techniques for managing dislocated joints and fractures, are perceived as beneficial and merit systematic scientific validation [19]. Effective and safe practices should be formally recognized and, where appropriate, incorporated into the Sowa Rigpa framework, potentially helping preserve indigenous knowledge while ensuring patient safety and standardization.

5. Conclusion

Roughly one in twelve patients admitted to this tertiary hospital had sought initial treatment from Local Healers, presenting to hospital only after these treatments failed to improve their condition. Preference for Local Healing was largely shaped by family, friends, hearsay, and Local Healers themselves, and was associated with delayed medical care. Given the study's design limitations, these findings should be interpreted as descriptive and hypothesis‐generating rather than conclusive evidence of harm.

Author Contributions

Pelden Wangchuk: conceptualization, methodology, formal analysis, data curation, supervision, investigation, writing – original draft, visualization, validation, writing – review and editing. Phuntsho Norbu: conceptualization, methodology, formal analysis, data curation, writing – original draft, visualization, writing – review and editing. Yeshey Dorjey: conceptualization, methodology, formal analysis, software, data curation, supervision, validation, visualization, writing – review and editing, investigation, writing – original draft. Sonam Lhundrup: conceptualization, methodology, formal analysis, data curation, writing – original draft, writing – review and editing. Thinley Dorji: conceptualization, methodology, formal analysis, data curation, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

All methods were performed in accordance with the relevant guidelines and regulations in the Declaration of Helsinki. Informed consent was obtained from all the study participants.

Consent

Written informed consent for publication was obtained from all participants (or guardians) for the use of their anonymized data and images in this article. Written informed consent was obtained from adult participants. For participants younger than 18 years, informed consent was obtained from a parent or legal guardian, with assent obtained from the child where developmentally appropriate.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The corresponding author Yeshey Dorjey affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.