Western-trained health care practitioners’ knowledge of and experiences with traditional healing

Abstract

Traditional healing has been used alongside western allopathic medicine for many years. Studies have shown that majority of people in developing countries use the services of traditional healers. The question remains – how much do western-trained health care practitioners know about traditional healing and what are their experiences of traditional healing? The objective of this study was to investigate western-trained health care practitioners’ knowledge and experiences with traditional healing, in order to contribute to the current debate and discussion on the possible integration of traditional healing and western healing in South Africa. This study used a Within-Stage Mixed Model design to collect data among 319 health care practitioners in South Africa namely Limpopo province and Gauteng province. Participants were sampled by using a convenient sampling method in which only health care practitioners who were at work during data collection had a chance of being selected. The Kruskal-Wallis Test revealed no significant difference in knowledge of traditional healing across the four groups of health care practitioners. However, significant differences were found in experiences with traditional healing across the four groups of health care practitioners. Overall, health care practitioners had a limited knowledge and experience of traditional healing. In conclusion, health care practitioners should be encouraged to engage in activities that would enhance their knowledge and experiences with traditional healing.

Introduction

In his April 2008 article ‘Giving aspirin for cancer’ in a South African City Press newspaper, Mooki (2008) revealed that one of the top Gauteng provincial hospitals had been without vital antibiotics normally used for the treatment of meningitis. He further stated that doctors at Helen Joseph Hospital in Johannesburg reported that this hospital had run out of Amphotericin B, an antifungal drug used for the treatment of systemic fungal infections and often prescribed to patients with Human Immunodeficiency Virus (HIV)-related infections. This revelation was not surprising and there have been similar reports in other provincial hospitals in the past ten years or so. These revelations attest to the dire state of some of the country's state hospitals and clinics in both rural and urban areas. Poor people, who are in the majority and who cannot afford the high fees that the private health care facilities charge, are in such instances left to fend for themselves. For them, good health care remains far-off.

In this state of affairs, a solution has to be sought. Several approaches could be considered for dealing with this problem. One is to look at the feasibility of integrating the traditional African and the Western health care models. This is suggested because apart from the abovementioned reasons, according to the 2007 mid-year population estimates as well as the 2011 national census, nearly eight out of ten (79.6% and 79.2%, respectively) people in South Africa were classified as African (Statistics South Africa, 2007; Statistics South Africa, 2012) and between 70% and 80% of Africans utilise the services of traditional African healers for various physiological, psychiatric and spiritual reasons (Abdullahi, 2011; Bodibe, 1993). This, therefore, necessitated an investigation into health care practitioner's knowledge of and experiences with African traditional healing. With this in mind, the objective of this study was to contribute to the current debate about the possibility of the integration of the two health care perspectives in state hospitals and clinics in rural and urban South Africa. One of the persistent questions is - how much do western-trained health care practitioners know about traditional healing and its cultural construction of some illnesses?

Awareness and acknowledgment of the cultural constructions of illness are important if health care practitioners are to effectively deal with illnesses that their patients present with. Some physical illnesses, such as epilepsy and some psychiatric conditions, such as schizophrenia tend to be viewed culturally. Therefore, such illnesses cannot simply be understood and treated from the strict Western medical point of view (Keikelame & Swartz, 2007). It is therefore important to establish the patient's social and cultural background as well as their own understanding of the conditions that they are presenting with. A knowledge and understanding of local communities’ cultural background and perceptions about illnesses can help modern health care practitioners in clarifying the illnesses and can therefore help in the proper treatment and the recovery process of patients (Nzimakwe, 1996). In pluralistic societies, Mulato and Berry (2001) suggested that an understanding of people's cultural background is essential to understanding human behaviour, which includes health and illness. In the view of Mulato and Berry (2001) “cultural ignorance is simply bad medicine”. For example, many people in African communities on the African continent perceive epilepsy as a man-made condition. This perception has led to El Sharkawy, Newton and Hartly (2006) to make a recommendation that modern health care practitioners should acquire knowledge of local communities’ cultural perceptions about the causes of this disease. People in some communities, for example in Tanzania, understand epilepsy as being caused by witchcraft, sorcery or the breaking of taboos (Winkler et al., 2010). As such, for those who believe that epilepsy is man-made, will first seek medical attention from traditional African healers while other communities, such as in Taiwan, traditional Chinese medicine is commonly used for epilepsy (Kuan et al., 2011).

This attests to the fact that many Africans have different perceptions about the causes, treatment and management of such conditions. Africans believe that, although Western healing is effective in treating many illnesses, traditional healing is superior to Western healing in the treatment of psychiatric conditions (Odebiyi, 1990). Thus, cultural beliefs about schizophrenia in African communities (that it is man-made in the sense that it is usually inflicted by those who practise witchcraft) may make these communities skeptical about its treatment by Western-trained health care practitioners. In such cases, in place of Western healing, traditional communities tend to prefer traditional African healers as they are believed to understand schizophrenia better than western-trained health care practitioners (Versola-Russo, 2006). As such, this study aimed to investigate western-trained health care practitioners’ knowledge of and experiences with traditional African healing to determine if there were differences between groups in terms of their knowledge and experiences with traditional healing. It was hypothesised that there would be significant differences between the four categories of health care practitioners in terms of their knowledge of and also in terms of their experiences with the traditional African healing system.

Methodology

Participants

A total of 319 psychiatrists, general physicians, general nurses and psychiatric nurses were conveniently sampled from State hospitals and clinics in both Limpopo province and Gauteng province, South Africa. The 319 participants out of 500 distributed questionnaires represented a response rate of 63.8%. From this sample, 52.7% were general nurses (n = 168), 27.9% psychiatric nurses (n = 89), 11.6% general physicians (n = 37) and 7.8% psychiatrists (n = 25). The majority (72.4%, n = 231) of the health care practitioners worked in the Gauteng province while 27.6% (n = 88) were employed in the Limpopo province.

Research design

The present study used a Within-Stage Mixed Model design which combined elements of both quantitative and qualitative techniques (Johnson & Onwuegbuzie, 2004). The combination of quantitative and qualitative techniques was done by using a Likert-type quantitative questionnaire that included some open-ended items. Open-ended items were only included in the Knowledge sub- scale and none were part of the Experiences sub-scale of the KETHQ. Responses from the open-ended items were intended to supplement, further clarify or elaborate on responses given regarding the close-ended items.

Procedure

Permission to conduct the study was obtained from different entities depending on the province in which the study was conducted. Potential participants were recruited during their regular morning staff meetings and participation was on a voluntary basis. Ethical clearance was obtained from the Ethics Committee in the Department of Psychology at the University of South Africa.

The Knowledge and Experiences with Traditional Healing Questionnaire (KETHQ) was designed for the purposes of this study. The KETHQ was piloted on 25 health care practitioners to determine if it would be suitable for the intended population. After the pilot study was completed, minor changes were made on the wording of a number of questionnaire items as recommended by some of the respondents.

After data collection the KETHQ was then subjected to the Principal Component Analysis using IBM SPSS version 19 to determine if items formed coherent sub-scales. Two factors with eigenvalues greater than 2 (eigenvalue > 2) were extracted by using Varimax with Kaiser Normalization rotation method. The scree plot also indicated a two factor model. Regarding the suitability for factor analysis for the current data, it was found to be suitable particularly with the large sample size of 319 participants. In addition, the Kaiser-Meyer-Olkin Measure of Sampling Adequacy indicated a higher value of 0.927 which was higher than the recommended value of 0.6 (Brace, Kemp & Snelgar, 2003). Bartlett's test of sphericity was significant with p < 0.0001.

Health care practitioners’ knowledge of traditional healing was measured on the Knowledge sub-scale. The Knowledge sub-scale was made up of 10 items modeled on the Likert-type scale of 1 to 5 (1 = strongly agree; 2 = agree; 3 = not sure; 4 = disagree; 5 = strongly disagree). No item was reverse-scored. High scores indicated more knowledge of traditional healing while low scores indicated less knowledge of traditional healing. For the Knowledge sub-scale, Cronbach's alpha was 0.81.

Experiences with traditional healing were measured on the Experiences sub-scale which consisted of 10 items that were modeled on the Likert-type scale of 1 to 5 (1 = never; 2 = seldom; 3 = often; 4 = regularly; 5 = always). High scores indicated more experience while low scores indicated less experience with traditional healing. No item was reverse-scored. For the Experiences sub-scale, Cronbach's alpha coefficient was moderately high at 0.76. There was only one open-ended question included in the KETHQ - Could you please write down anything that you know about traditional healing?

Statistical analysis

To test for differences between categories of health care practitioners in terms of their knowledge and experiences with traditional African healing, separate Kruskal-Wallis tests were computed. The Mann-Whitney U post-hoc tests were computed to determine where specific differences between groups were for the knowledge and experiences variables. The effect size for each comparison was calculated according to this formula: r = z / square root of N (Pallant, 2010). The Kruskal-Wallis and Mann-Whitney U Tests were further used to determine if there were any biographical differences in terms of health care practitioners’ knowledge and experiences with traditional healing. Further, effect sizes for each comparison were calculated by using the abovementioned formula.

Qualitative data were analysed by using participants’ responses to the qualitative items to form the narratives. In this study, qualitative questions were formulated in a manner that required brief responses from the participants. This was done to supplement the responses obtained from some of the close-ended (quantitative) items. The analysis of qualitative data was relatively simple, but invaluable when combined with the results of the statistical analyses.

Results

Knowledge of traditional healing

The sampled health care practitioners obtained a mean of 3.63 (SD = 0.53) on the Knowledge Scale indicating that knowledge among all four categories of Western-trained health care practitioners about traditional healing was average. Upon further investigation it became evident that healthcare practitioners’ knowledge of traditional healing was generally poor and was different from the published information in the literature. The majority of health care practitioners (79.3 %) did not know that in traditional healing there are illnesses that are believed to be caused by witchcraft/sorcery or the ancestors (70.8%) (Table 1). Just under two-thirds (62.7%) of health care practitioners did not know that ancestral spirits are pillars of traditional healing. A two-thirds majority (66.7%) did not know that there are some Christians who consult traditional healers. In addition, 56.4% did not know that some traditional healers are also Christians. A further 33.3% were not sure if some traditional healers are Christian.

Table 1.

Health care practitioners’ knowledge of traditional healing

Item	Agree/Strongly Agree % n	Not sure % n	Disagree/Strongly Disagree % n
There are some Christians who consult traditional healers	7.2 23	26.1 83	66.7 213
In traditional healing there are illnesses that are believed to be inflicted by ancestors	3.8 12	25.4 81	70.8 226
±80% of Blacks in South Africa use services of traditional healers	6.9 22	42.6 136	51.5 161
Some traditional healers are Christians	10.3 33	33.3 106	56.4 180
Traditional healers uses animal, plant products & mineral substances to treat illnesses	2.1 7	43.3 138	54.6 174
In traditional healing cultural beliefs, physical, social & spiritual data are used to make a diagnosis	8.5 27	49.8 159	41.7 133
Traditional healing is accepted by my community	13.5 43	31.7 101	54.8 175
In traditional healing there are illnesses that are believed to be caused by witchcraft/sorcery	2.5 8	18.2 58	79.3 253
Traditional healing is here to stay	17.9 57	24.7 79	57.4 183
Ancestral spirits are pillars of traditional healing	1.9 6	35.4 113	62.7 200

Contrary to commonly cited research on the use of traditional healing services by Africans in South Africa, only 6.9% of healthcare practitioners knew that approximately 80% of Blacks in South Africa use the services of traditional healers. Over half (51.5%) disagreed with this statement and a further 42.6% were not sure if it is true that approximately 80% of Blacks use traditional healing.

The literature indicated that traditional healing uses animal products, plant products and mineral substances to treat illnesses, and that traditional healers use patients’ cultural beliefs about health and illness along with physical, social and spiritual data to make a diagnosis (Barsh, 1997). However, only 2.1% knew that traditional healing uses animal, plant products as well as mineral substances to treat illnesses. A further 43.3% were not sure if traditional healing uses these products and substances; and almost half (49.8%) were not sure that in traditional healing, patients’ cultural beliefs of health and illness are used along with physical, social and spiritual data to make a diagnosis.

Over half (54.8%) of health care practitioners did not think that traditional healing was accepted in their communities. A further 31.7% did not know or were not sure if it was. Only a relatively small percentage (17.9%) thought that traditional healing will continue to exist.

Analysis of biographical data in relation to health care practitioners’ knowledge of traditional healing revealed significant differences between males (Md = 3.7, n = 88) and females (Md = 3.6, n = 231), U = 8660.5, z = -2.05, p = 0.04, r = 0.12 (small effect size) thereby showing that males had greater knowledge than females with regards to traditional healing. Significant differences were found between Christians (Md = 3.6, n = 226) and those who concurrently believe in both traditional African and Christian religions (Md = 4.0, n = 32), U = 1729, z = -4.79, p = 0.000, r = 0.3 (medium effect size). As such, health care practitioners who believed in both traditional African and Christian religions were more knowledgeable with regards to traditional healing.

Differences between groups in terms of their knowledge of traditional healing

When examining the differences between the four categories of health care practitioners in terms of their knowledge of traditional healing, the results revealed no significant difference in knowledge of traditional healing across the four groups of health care practitioners, X² (3, n = 319) = 5.96, p = 0.113. The qualitative results revealed that health care practitioners’ responses revolved around what traditional healers can and cannot do. Most health care practitioners indicated that traditional healers can effectively treat sexually transmitted infections but not Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) which health care practitioners maintained could not be treated by traditional healers.

The narratives

This section presents the results of participants’ responses to the open-ended items (in the knowledge sub-scale) in the form of narratives. Open-ended items were individually analysed such that each item's responses formed a separate narrative as put forward by the participants.

On training to qualify as a traditional healer

Over half (52.7%; n= 168) of participants agreed with the statement that one has to be trained to qualify as a traditional healer. Participants mentioned a “senior or experienced traditional healer”, commonly called “Kobela”, as being the appropriate person to train prospective traditional healers, with some health care practitioners mentioning the name of a well-known senior traditional healer trainer in the Grobblersdal area in Limpopo province. This healer is well known in Limpopo and in other provinces; for ethical reasons, his name is not mentioned here. Some health care practitioners responded by just stating that they do not know if one has to be trained to qualify as a traditional healer. This, as was the case with descriptive statistics (above), indicated a limited knowledge of traditional healing on the part of some of the Western-trained health care practitioners.

Acceptability of traditional healing in their communities

Only 13.5% (n = 43) of participants agreed with the statement that traditional healing is accepted by their communities. Concerning why they thought that traditional healing was accepted by their communities, some participants responded that, “Traditional healing is part of the community's culture and traditional healers are readily available”; “ the community was taught, as part of their culture, to believe in traditional healing”; “in many cases, people in the community believe that their illnesses are caused by witchcraft or sorcery and therefore traditional healers are the first port of call; “ traditional healing works for them”.

Experiences with traditional healing

The results indicated that health care practitioners had very little experience with traditional healing, with a mean of 1.81 (SD = 0.57) on the Experiences Scale (Table 2). The minimum score obtained was 1.00 and the maximum score was 4.80.

Table 2.

Health care practitioners’ experiences with traditional healing

Item	Never/Seldom % n	Regularly/Often % n	Always % n
I have consulted traditional healers after I qualified as a health care practitioner	90.9 290	8.2 26	0.9 3
I have consulted traditional healers before I qualified as a health care practitioner	88.7 283	9.1 14	2.2 7
I have seen patients who were effectively treated by traditional healers	66.8 213	25.4 81	7.8 25
I do refer patients to traditional healers	95.6 305	3.5 11	0.9 3
I often consult a traditional healer	92.8 296	6.6 21	0.6 2
Some of my friends consult THs	55.2 176	36 115	8.8 28
I have heard of Western-trained health care practitioners who consult THs for reasons other than illness	72.4 231	24.5 78	3.1 10
Traditional healers often share knowledge of health care with me	89.7 286	9.7 31	0.6 2
Have heard of Western-trained health care practitioners who consult traditional healers when ill	73.0 233	24.5 78	2.5 8
I have treated patients referred by traditional healers	56.7 181	34.2 109	9.1 29

Table 2 revealed that 92.8% (n = 296) of health care practitioners never or seldom consult traditional healers. Only 7.1% (n = 23) of health care practitioners said that they often or always consult them. More than ten percent of health care practitioners (11.3%) have often or always consulted traditional healers before they qualified as health care practitioners, while only 0.9% reported that they often or always consulted traditional healers after they qualified. The majority never or seldom consulted traditional healers before they qualified as health care practitioners (88.7%) or after they qualified (90.9%). Most of the health care practitioners (95.6%, n = 305) reported that they seldom or never refer patients to traditional healers. On the other hand, 43.3% of health care practitioners have often or always treated patients who were referred to them by traditional healers. In addition, 66.8% (n= 213) of health care practitioners said that they had seldom or never seen patients who were effectively treated by traditional healers. This means, however, that a third (33.2%) of the health care practitioners did often or always see patients who were effectively treated by traditional healers. Only 10.3% indicated that traditional healers often or always shared knowledge of traditional health care with them, in the form of workshops, one-on-one conversations and so on. This implies that there is very little professional interaction between traditional healers and western-trained health care practitioners. Just over a quarter of health care practitioners (26.9%) have often or always heard of western-trained health care practitioners who consult traditional healers when ill. A similar percentage of health care practitioners (27.6%) have often or always heard of other western-trained health care practitioners who consult traditional healers for reasons other than illness. Although not many health care practitioners indicated that they themselves make use of the services of traditional healers, 44.8% said that they have friends who often or always do so.

In relation to health care practitioners’ experiences with traditional healing, significant differences were found between Christians (Md = 1.65, n = 226) and those who believed in both Christianity and traditional African religion (Md = 1.95, n = 32), U = 2389, z = -3.11, p = 0.002, r = 0.19 (small effect size).

Further analysis revealed significant differences in experiences with traditional healing across the four groups of health care practitioners, X² (3, n = 319) = 17.84, p = 0.000. An inspection of the scores revealed that psychiatric nurses had the highest experiences scores (Md = 1.80), while physicians had the lowest experiences scores (Md = 1.50). The Mann-Whitney U Test revealed a significant difference in experiences levels of psychiatrists (Md = 1.6, n = 25) and general nurses (Md = 1.75, n = 168), U = 1465, z = -2.44, p = 0.02, r = -0.18 (small effect size). This means that general nurses had slightly more experiences with traditional healing than psychiatrists. The Mann-Whitney U Test further indicated significant difference in experience levels of psychiatric nurses (Md = 1.8, n = 89) and psychiatrists (Md = 1.6, n = 25), U = 765.5, z = -2.38, p = 0.02, r = 0.22 (small effect size). This implies that psychiatric nurses had slightly more experiences with traditional healing than psychiatrists. The Mann-Whitney U Test also revealed a significant difference in experiences levels of physicians (Md = 1.5, n = 37) and general nurses (Md = 1.75, n = 168), U = 1981.5, z = -3.456, p = 0.001, r = -0.24 (small effect size) which indicates that general nurses had slightly more experiences with traditional healing than physicians. Yet another significant difference was revealed in experiences levels of physicians (Md = 1.5, n = 37) and psychiatric nurses (Md = 1.8, n = 89), U = 1024, z = -3.344, p = 0.001, r = -0.3 (medium effect size). This indicates that psychiatric nurses had moderately more experiences with traditional healing than physicians.

As hypothesised, there were significant differences between the four categories of health care practitioners in terms of their experiences with traditional healing. Overall, psychiatric nurses and general nurses had more experiences with traditional healing than psychiatrists and physicians.

Discussion

The aim of this study was to investigate health care practitioners’ knowledge of and experiences with traditional healing. Psychiatric nurses emerged as the group with more knowledge and more experiences with traditional healing than psychiatrists, physicians and general nurses. Psychiatrists were found to have more knowledge regarding traditional healing than both physicians and general nurses, while physicians had less experience with traditional healing than other health care practitioners’ categories. Hopa, Simbayi and du Toit (1998) found similar results with physicians going as far as to criticise traditional healers as being illiterate. On the other hand, general nurses’ experiences with traditional healing were surpassed only by psychiatric nurses’ experiences with traditional healing. This could be explained by the fact that most of the general nurses worked in rural areas (where majority of traditional healers are concentrated), with those who worked in rural areas having slightly more experiences with traditional healing than those who worked in urban areas.

Although some categories of health care practitioners were found to be superior in their experiences with traditional healing, it is worth mentioning that the median scores of all four categories of health care practitioners, in relation to experiences with traditional healing, fell far below the midpoint of 3. This indicated that the four groups did not have much experience with traditional healing. These findings are consistent with Madiba's (2010) findings in which 73% of 60 health care practitioners in Botswana have never interacted with traditional healers.

Health care practitioners were reluctant to admit that they (themselves) use the services of traditional healers despite over half of them acknowledging traditional healing as being a good health care system that can effectively treat a variety of physiological conditions. It emerged that the majority of health care practitioners never consulted traditional healers although they seem to suggest that they consider both western medicine and traditional healing when they themselves fall ill. Their reluctance to admit to using the services of traditional healers could be due to the fact that most of them are Christians and Christian teaching frowns upon traditional healing. In many African communities, it is common knowledge that many Christians secretly consult traditional healers and do not want to admit this for fear of being ridiculed by fellow Christians and those who view traditional healing as a backward system (Chavunduka, n.d.). It is quite surprising and interesting that although many health care practitioners said that they do not consult traditional healers, over three quarters of them said that their friends, relatives as well as ‘other’ health care practitioners do consult traditional healers. These findings are consistent with King's (2012) findings in which the majority of Black Christians were found to secretly use the services of traditional healers.

The quantitative and qualitative responses to the health care practitioners’ knowledge regarding traditional healing are contradictory. Health care practitioners’ responses to the quantitative questions suggest that they have a limited knowledge of traditional healing. However, their responses to a qualitative question suggest that health care practitioners are knowledgeable about traditional healing. For example, in answer to quantitative questions, majority of health care practitioners expressed that they did not know that there are illnesses in the African tradition that are inflicted by the ancestors or through witchcraft. The health care practitioners also claimed not to know that ancestral spirits are the pillars of traditional healing.

Contrary to the displayed lack of knowledge of traditional healing based on their responses to the quantitative questions, health care practitioners were informative in their narratives about what traditional healers can and cannot do. The health care practitioners mentioned a long list of medical conditions that they believed cannot be treated by traditional healers. In the same vein, the health care practitioners also mentioned a long list of medical conditions that can be treated by traditional healers. Some of the conditions that according to health care practitioners cannot be treated by traditional healers are tuberculosis (TB), HIV, AIDS, cardiovascular conditions, any surgical condition, any form of cancer, asthma, liver cirrhosis and diabetes mellitus. Those conditions that they thought could be treated by traditional healers included other sexually transmitted infections, infertility in females, diarrhea, constipation, epilepsy and infant rashes and infant fallen fontanel. These findings are consistent with Mngqundaniso and Peltzer's (2008) findings and the World Health Organisation (WHO) which recognises traditional healing in treating some of the sexually transmitted infections (Mills, Cooper & Kanfer, 2005).

Furthermore, health care practitioners indicated that traditional healers can effectively treat psychiatric conditions such as clinical depression and any witchcraft-related psychosis. In this regard, the responses of health care practitioners were summed up by one health care practitioner's response by saying that “my brother-in-law was a deeply religious person who did not want anything to do with ancestors, but became psychotic and was treated for this, he became much better”. Another healthcare practitioner maintained that “most psychiatric patients are bewitched and traditional healers are able to heal them”. For any condition which is considered as witchcraft-related, traditional healers are often preferred over western-trained health care practitioners when medical assistance is sought (Hoff & Shapiro, 1986).

Conclusions

Health care practitioners in this study demonstrated limited knowledge and experiences with traditional healing and need to be encouraged to gain knowledge and experience pertaining to traditional healing.