Research Article
Health Care Practitioners’ Attitudes towards Traditional African Healing
Maboe Mokgobi1,2*
1Department of Psychology, School of Health Sciences, Monash University, South Africa Campus, South Africa
2HIV/AIDS, STIs and TB division, Human Sciences Research Council, South Africa

ABSTRACT
Background: For decades, if not centuries, the traditional African healing system has been a fundamental but unrecognised component of the general health care system in South Africa. Research has shown that Western trained health care practitioners’ express different views about traditional healing.

Objective: The aim of this study was to explore Western trained health care practitioners’ attitudes towards traditional African healing.

Methods: The study utilized the Attitudes Towards Traditional Healing Questionnaire (ATTHQ) that was designed for the purposes of this study. A convenient sample of 319 doctors and nurses from state hospitals and clinics in both the Gauteng and Limpopo provinces, South Africa, participated in this study.

Results: The main results of the Kruskal-Wallis test indicated that there were significant differences between different groups of health care practitioners’ in terms of their attitudes towards traditional healing. Psychiatric nurses and psychiatrists had more positive attitudes towards traditional healing than did general nurses and general physicians.

Conclusion: By implication, psychiatric health care practitioners’ work with psychiatric issues and that traditional healing is believed to deal better with psychic and psychosomatic diseases, hence their positive attitudes towards traditional healing.
KEYWORDS
Attitudes; Differences; Health care practitioners; Integration; Traditional healing

Introduction
South Africa is experiencing a dearth of qualified health care practitioners, a problem that existed even before the political liberation in 1994. Rural state hospitals and clinics have arguably never had enough health care personnel. As if the scarcity of qualified health care personnel is not enough to put enormous strain on the system, many nurses and highly qualified and experienced doctors, that the country desperately needs, continue to move abroad at an alarming rate. Consequently, state hospitals and clinics are undesirably understaffed, and health care personnel in these facilities execute their duties with limited operational resources.

In South Africa, as in many African countries, the traditional African healing system has, for centuries, been a fundamental but unrecognised component of the general health care system [1,2]. A history of traditional healing methods has not been documented in South Africa except to say that these healing methods have been in existence way before the colonization of the African continent by some European countries. What is known about the history of traditional healing in South Africa, and indeed in other African states, is that the knowledge in traditional African healing has been part of the oral traditional that has been passed on from one generation to another or from the ancestors to the selected few relatives of the ancestors who would gain traditional healing knowledge by undergoing traditional healing initiation or through dreams and visitations by the ancestors [3]. Nyika and Vontress argued that the majority of people who use the services of traditional healers do so because Western medicine is not easily accessible to them and most of them are illiterate. Contrary to Vontress argument, it would appear that for many decades Africans level of education and religious beliefs did not necessarily determine the likelihood of their consulting traditional healers when the need to seek health care arose [4-6]. Many educated and middle class Africans, young and old, still uphold their traditions and customs and continue to consult with both traditional healers and Western trained medical practitioners’ depending on their perception of the conditions they want to consult about [7]. Even the technological advances in Western medicine do not seem to overshadow the popularity of traditional medicine [8].

It is common among Africans to think that those (Africans) who consider themselves ‘Westernized’ and therefore ‘civilized’ tend to consult with Western medical practitioners’ during the day and with African traditional healers at night when people cannot see them. It is also generally thought that people do so to reduce cognitive dissonance that might be caused by, amongst other factors, orthodox and charismatic Christian teachings as well as Westernization that frown upon the use of traditional healing [9]. However, MacLachlan and Carr contended that cognitive dissonance does not exist in many people who make use of both health care systems. There is in fact, according to them, cognitive tolerance because consumers believe that there is nothing wrong with using both systems as both seem to work well for them [10].

Satimia et al., reported different results and advanced different reasons for the choice between traditional healing and Western healing [11]. They found that in rural Tanzania age and education influence the choice of health care, with people aged between 15 years and 34 years leaning more towards Western healing because of Western education whilst those aged 55 years and older lean more towards traditional African healing because many in this age bracket have not been formally schooled and have been brought up using traditional African medicine.

On the question of age, contrary to Satamia et al., and Edginton et al., found that, at one of the rural villages in the Limpopo province, South Africa; people aged 15 and older consulted traditional African healers before and after consultation with medical doctors and clinics [11,12]. This discrepancy might be explained by the level of formal education of the respondents in this study, with most having fewer than four years of formal schooling. In some cases, the education level may play a role in health care choices.

Overall, much of the literature points to a collaborative approach to the complex issue of health care, and shows that traditional healing is in high demand in the rural and urban areas of South Africa and elsewhere on the African continent [13-16]. In several studies mentioned above, age, education level and social standing of African respondents did not play a major role in people’s choice of healing, which seemed to be based on cultural perception of illnesses and the efficacy of traditional healing. Such efficacy is an aspect that continues to be debated and discussed internationally [17,18]. Given the above reviewed literature on traditional healing in mind, it is important to study Western trained health care practitioners’ attitudes towards traditional healing, particularly because traditional healing is in high demand and its consumers tend to use both traditional healing and Western medicine. The present study was part of a larger study that investigated health practitioners’ views on traditional healing. The aim of the present study was to explore Western trained health care practitioners’ attitudes towards traditional African healing.

The assumption was that an understanding of Western trained health care practitioners’ attitudes towards traditional healing could contribute to guiding the proposed integration process (i.e., integrating traditional healing and Western medicine) and its sustainability, in South Africa; and that health care practitioners, traditional healers, medical aid schemes, the South African Department of Health, consumers of traditional African healing and other interested parties would benefit from the findings of the study. It was hypothesized that there would be significant differences between the four categories of health care practitioners’ in terms of their attitudes towards traditional African healing.
Methodology
Participants
The study employed a convenience sampling procedure to sample 319 Western trained health care practitioners’ from state hospitals and clinics in Limpopo and Gauteng provinces, South Africa.
Measuring instrument
The Attitudes Towards Traditional Healing Questionnaire (ATTHQ):
Health care practitioners’ attitudes towards traditional healing were measured on the ATTHQ which comprised 22 items. Items 2, 3, 6, 7, 10, 13, 14, 15, 18, 20 and 22 were reverse scored as they were negatively worded.

The ATTHQ was modeled on the Likert type scale in which participants were asked to tick one box only on the scale of 1 to 5 (1=strongly agree; 2=agree; 3=not sure; 4=disagree; and 5=strongly disagree). The mean of this scale was 2.68 (SD=0.72). High scores indicated positive attitudes while low scores indicated negative attitudes towards traditional healing.

The ATTHQ was designed for the purposes of this study. Before the ATTHQ could be used in this study, it was piloted on 25 Western trained health care practitioners’ and then subjected to the exploratory factor analysis using IBM SPSS version 19 to determine if the items formed a coherent scale. The ATTHQ was found to be suitable for factor analysis and a single component with eigenvalue greater than 2 (eigenvalue>2) was extracted. The Kaiser-Meyer-Olkin measure of sampling adequacy indicated a higher value of 0.928 which far exceeded the recommended value of 0.6 [19]. Bartlett’s test of sphericity revealed a significant value with p <0.001.

The ATTHQ was further subjected to reliability analyses and yielded the following internal reliability values: Cronbach’s alpha coefficient was high at 0.95, Spearman Brown coefficient was also high at 0.94 and Guttman split-half coefficient was almost equally high at 0.93. The 22 items of the ATTHQ showed a positive inter item correlations indicating that the items measured the same construct and therefore the scale was considered valid.

Procedure and ethical considerations: Ethics clearance for the current study was obtained from the Ethics Committee in the Department of Psychology at the University of South Africa. Participation was voluntary and participants were informed that they were allowed to withdraw their participation at any time without giving reasons, if they so decided. Participants were given questionnaires to complete in their own free time so that there would be no disruptions in their daily duties at health care institutions. Because this study involved several hospitals and clinics in two provinces that are far apart, data collection took place from February 2011 and August 2012 depending on when permission was obtained from each healthcare facility. Out of the 500 questionnaires that were distributed, three hundred and nineteen (n=319) were correctly completed and returned to trained research assistants that were stationed at targeted health care institutions. The 319 participants represented a 63.8% return rate. The rest of potential participants (i.e., 36.2%) did not return the questionnaires and were not asked why they did not return the questionnaires because asking them why they did not return the questionnaires would have been a breach of the ethics code governing research with human participants.

Data analyses and statistical procedures: To test for differences between categories of health care practitioners’ (i.e., psychiatrists, general physicians, general nurses and psychiatric nurses) in terms of their attitudes towards traditional African healing, the Kruskal-Wallis test was computed. Additionally, the Mann Whitney U post hoc tests were computed to determine where specific differences between groups were for the ‘attitudes’ variable. The effect size for each comparison was calculated according to the following formula as recommended by Pallant [20]: r=z/square root of N. It was decided to use non parametric tests since the questionnaire was developed by the author and is thus not a standardized questionnaire. However, the general assumptions for computing non-parametric tests such as the Kruskal-Wallis test and Mann-Whitney U test were checked, and both of the assumptions (i.e., random samples as well as independent samples) were not violated.
Results
The participants included general nurses (52.7%, n=168), psychiatric nurses (27.9%, n=89), physicians (11.6%, n=37) and psychiatrists (7.8, n=25). Over two thirds (72.4%, n=231) of the participants worked in rural areas while 27.6% (n=88) worked in urban areas.

Health care practitioners’ expressed moderate attitudes towards traditional healing, with a mean of 2.78 (SD=0.82, N=319) on the ATTHQ which ranged from 1 (negative attitudes) to 5 (positive attitudes). The minimum score obtained was 1.00 and the maximum score was 4.95.
Would Western trained health care practitioners’ personally use traditional healing?
Western trained health care practitioners’ had mixed and often contradictory feelings about traditional healing. Although almost half (49.8%) of participants in the study reported that they would never use traditional healing for any reason whatsoever (Table 1), 55.5% indicated on another question that they would consider consulting traditional healers in the future. A notable 69.3% of Western trained health care practitioners’ would consider using a combination of both traditional healing and Western medicine when they are ill. The majority (66.5%) of them also indicated that they would seek help from traditional healers even when Western medicine was available.
Would Western trained health care practitioners’ refer patients to traditional healers?
In this study, Western trained health care practitioners’ appeared to be tilting in favour of making patient referrals a two way process between traditional healers and Western trained health care practitioners. Just over 47% said that they would collaborate with traditional healers in treating patients, if given an opportunity to do so. The majority (62.1%) would consider referring patients to traditional healers. However, 43.9% would not encourage any use of traditional healing.
Would Western trained health care practitioners’ support the integration of traditional healing and Western medicine?
In light of the above generally favourable attitudes towards traditional healing, one would expect that a relatively large percentage of Western trained health care practitioners’ would favour formal integration of traditional healing and Western medicine. On the contrary, 50.5% felt that although traditional healing is important for maintenance of health, it should continue to be separate from Western medicine. This was corroborated by a further 42.6% who did not think that Western medicine and traditional healing could improve health care if they worked together. On the question of whether the integration of traditional healing and Western medicine would work, 35.1% felt that it would not and 34.5% felt that it would. If traditional healing and Western medicine were to be integrated, 43.6% of Western trained health care practitioners’ would support it while 38.2% would not.
Safety of traditional healing
Just over 40 percent (41.1%) of Western trained health care practitioners’ were of the opinion that traditional healing was dangerous and that it should not be recognised by medical aid schemes. A further 42% thought that traditional healing could not be trusted. However, while many thought that traditional healing could not be trusted, 45.7% thought that traditional healing should not be discarded. Only a relatively small percentage (28.2%) thought that the government was doing well by supporting traditional healing. More than half (53.9%) thought that when people are ill they should see Western trained medical practitioners’ and not traditional healers.
Learning about traditional healing
Just over 45 percent (45.8%) of health care practitioners’ would not want to learn more about traditional healing while 38.2% would. A further 35.4% indicated that traditional healing belonged in the olden days, and they would therefore not be interested in learning about it.
Biographical differences regarding attitudes towards traditional healing
An analysis of the health care practitioners’ biographical data in relation to their attitudes towards traditional healing showed significant differences between males (Md=3.11, n=88) and females (Md=2.64, n=231), U=7459, z=-3.68, p=0.000, r=0.21 (small effect size). Significant differences were also found between Christians (Md=2.64, n=226) and both Christians and traditional African religious believers (Md=3.32, n=32), U=1376, z=-5.67, p=0.000, r=0.35 (medium effect size). Another significant difference was observed between health care practitioners’ working in rural areas (Md=2.64, n=217) and those working in urban areas (Md=3.09, n=102), U=8630.5, z=-3.17, p=0.002, r=0.18 (small effect size). A Kruskal-Wallis test found no significant differences across the six home language groups (p=0.12).
Differences between groups in terms of their attitudes towards traditional healing
To test the hypothesis, a Kruskal-Wallis test was computed to determine if there were significant differences between the four categories of health care practitioners’ in terms of their attitudes towards traditional healing.

It revealed a significant difference in attitudes towards traditional healing across the four groups of health care practitioners’ (Gp1: n=25: Psychiatrists, Gp2: n=37: Physicians, Gp3: n=168: General Nurses, Gp4: n=89: psychiatric nurses), X2 (3, n=319) = 9.07, p=0.028. The results showed that psychiatrists and psychiatric nurses had the highest attitudes scores (both Md=3.00), with general nurses having the lowest attitudes score (Md=2.61). Physicians had slightly more positive attitudes (Md=2.68) towards traditional healing than general nurses.

A Mann-Whitney U test revealed a significant difference in attitude levels of psychiatrists (Md=3, n=25) and general nurses (Md=2.61, n=168), U=1538, z=-2.16, p=0.03, r=-0.16 (small effect size), with psychiatrists having more positive attitudes towards traditional healing than general nurses. A Mann-Whitney U test also revealed a significant difference in attitude levels of general nurses (Md=2.61, n=168) and psychiatric nurses (Md=3, n=89), U=6080.5, z=-2.462, p=0.02, r=-0.154 (small effect size), with psychiatric nurses having more positive attitudes towards traditional healing than general nurses.
Discussion
The study aimed to explore Western trained health care practitioners’ attitudes towards traditional African healing. As hypothesized, there were significant differences between the four categories of health care practitioners’ in terms of their attitudes towards traditional healing. Current results indicate that psychiatric nurses and psychiatrists had more positive attitudes towards traditional healing than general nurses and physicians. Although previous studies have yielded similar results with proffering an explanation for such results, the explanation of these findings could be that psychiatrists and psychiatric nurses work with psychiatric issues and that traditional healing is believed to deal better with psychic and psychosomatic diseases, hence their more positive attitudes towards traditional healing [21,22]. A further explanation could be that in some healthcare facilities, some psychiatrists and psychiatric nurses already show a willingness to collaborate with traditional healers in treating some psychiatric conditions [23]. These findings are consistent with previous findings in which psychiatric nurses and psychiatrists were of the opinion that there should be formal collaborations between Western trained health care practitioners’ and traditional healers [21]. This view is in agreement with the World Health Organization’s support for the integration of traditional healing into the national health care system of the member states [24]. Other researchers also recommended a formal collaboration between traditional African healing and Western medicine [25,26]. However, in the current study, health care practitioners’ generally viewed traditional healing in a positive light yet they indicated their reluctance to support a formal integration of the two health care systems. Just over half of the participants would prefer that traditional healing should continue to be separate from Western medicine despite acknowledging the importance of traditional healing for the maintenance of health.

Health care practitioners’ concurrently practicing both Christian and traditional African religions had more positive attitudes towards traditional healing than any other religious group. This finding may be due to the fact that traditional African healing and traditional African religion go hand in hand and therefore those who subscribe to traditional African religion tend to also be consumers of traditional African healing and tend to have more knowledge and an understanding of how traditional healing works as compared to those who do not subscribe to traditional African religion [27-29].

Health care practitioners’ working in urban areas showed more positive attitudes towards traditional African healing than those working in rural areas, and males had more positive attitudes towards traditional healing than females. This is contrary to Upval who found that health care practitioners’ working in urban areas where either ambivalent towards traditional healing or were showing less positive attitudes towards traditional healing than health care practitioners’ who were working in the rural areas [30].

Overall, majority of health care practitioners’ indicated that they would personally consider using both traditional healing and Western medicine when they are ill. This indicates that Western trained health care practitioners’ in this study were generally in fovour of traditional healing.

In this study, majority of health care practitioners’ indicated that they would consider referring patients to traditional healers, if necessary. These findings are inconsistent with previous findings wherein health care practitioners’ indicated low rates of patient referrals to traditional healers [31]. The low rates of referrals of patients from health care practitioners’ to traditional healers could be attributed to the fact that traditional healing is not formally recognised by the Health Professions Council of South Africa [32]. Referral of patients to traditional healers by Western trained health care practitioners’ has always been a contentious issue; with traditional healers lamenting the fact that referral of patients seems to be a one way process in which traditional healers refers patients to Western trained health care practitioners’ without reciprocation.

Majority of health care practitioners’ indicated that traditional healing is safe to use and that they would want to learn more about traditional healing and that traditional healing should not be discarded.
Limitations of the Study
The number of general nurses in the current study was far greater than that of other groups of health care practitioners’. There was overrepresentation of health care practitioners’ working in rural areas majority of who spoke Sepedi as home language. Therefore, current results should be read with this skewness of participants in mind.
Recommendations for Further Research
It is recommended that future studies should try to balance the number of participants in each group of health care practitioners’ so as to increase the power of the statistical analyses. Future research regarding health care practitioners’ attitudes towards traditional healing should consider including a qualitative technique to collect data. This will enable health care practitioners’ to use their own words to further elaborate on their attitudes towards traditional healing. An addition of a qualitative technique will yield a rich data that will supplement their quantitative responses to closed ended questions.

Furthermore, future studies could investigate the feasibility of training registered traditional African healers in helping to disseminate modern medicines (e.g., antiretroviral drugs and TB drugs) to patients to improve adherence to treatment. Lastly, future studies could include more in depth interviews or focus group discussions consisting of Western trained health care practitioners’ and the general public to determine possible limitations which stop both groups from preferring the services of traditional healers.
Conclusion
This study showed that different groups of health care practitioners’ (i.e., psychiatrists, psychiatric nurses, physicians and general nurses) have different attitudes towards traditional healing. Health care practitioners’ specialized in and dealing with psychic and psychosomatic issues were shown to have more positive attitudes towards traditional healing than did general nurses and general physicians.

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Figures


Figure 1: (a) Chemical structures of PAMPS48-PEG227-PAMPS48 (AEA) and PEG47-PMAPTACm (EMm, m = 27,53, and 106).
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 2: Time-conversion (?) and the first-order kinetic plots (?) for the polymerization of AMPS in the presence of CPD-PEG-CPD in water at 70oC.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 3: GPC elution curves for a sample of HO-PEG-OH (Mn = 9.40 ? 103; Mw/Mn = 1.06) (----) and triblock copolymer of PAMPS48-PEG227-PAMPS48 (AEA, Mn = 2.32 × 104; Mw/Mn = 1.42) (--).
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 4: 1H NMR spectra for (a) EM53, (b) AEA, and (c) AEA/EM53 micelle in D2O containing 0.1 M NaCl at 20°C. Assignments are indicated for the resonance peaks.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 5: (a) Light scattering intensities and (b) Rh for PIC micelles of AEA/EM106 (?), AEA/EM53 (?), and AEA/M27 (?) as a function of fAMPS (= [AMPS]/([AMPS] + [MAPTAC])) in 0.1 M NaCl aqueous solutions. [AMPS] and [MAPTAC] represent the concentrations of the AMPS and MAPTAC units, respectively. The total polymer concentration was kept constant at 1 g/L.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 6: (a) Distributions of Rh for the PIC micelles of AEA/EM106 (?), AEA/EM53 (?), and AEA/EM27 (?) in 0.1 M NaCl aqueous solutions. (b) Relationship between relaxation rate (G) and square of the magnitude of the scattering vector (q2). (c) Plots of Rh as a function of Cp.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 7: A typical example of Zimm plots for AEA/EM106 micelle in 0.1 M NaCl aqueous solution.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 8: TEM images for (a) AEA/EM27, (b) AEA/EM53, and (c) AEA/EM106 micelles.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.

Tables
ItemAgree/Strongly agree Notsure Disagree/strongly disagree 
% N % N % N 
I would support integration of TH & WH43.6 139 18.2 58 38.2 122 
I do not want to learn anything about TH45.814616.05138.2122
I would not encourage anybody to use TH43.9 140 20.3 65 35.8 114 
WH & TH could improve health if worked together35.7 114 21.7 69 42.6 136 
I would collaborate with THs in treating patients47.315116.95435.8114
I would never use TH for any reason49.815921.36828.992
TH should continue to be separate from WH50.516113.44337.1115
If proper regulation of TH, TH would be a good system23.57529.89546.7149
TH is important for maintenance of health50.516121.36828.290
TH cannot be trusted42.013527.38730.798
Government is doing well by supporting TH28.29031.09940.8130
I would consider referring patients to THs62.119821.97016.051
TH should be discarded 22.67231.710145.7146
When people ill, should see Western doctors & not THs53.917218.25827.989
Integration of TH and WH will not work35.111230.49734.5110
I want to learn more about TH38.212216.05145.8146
I would consider consulting THs in the future55.517725.18019.462
TH is dangerous41.113136.011522.973
When ill, I consider both TH and WH69.32216.92223.876
TH belongs in the olden days35.411320.16444.5142
I would seek help from THs even when Western medicine is available66.521215.75017.847
Medical aid schemes should not recognize TH41.113122.57236.4116
Table 1: Attitudes towards traditional healing (N = 319).
Abbreviations: TH: Traditional Healing; WH: Western Healing; THs: Traditional Healers.

Citation: Mokgobi M (2017) Health Care Practitioners’ Attitudes towards Traditional African Healing. J Altern Complement Integr Med 3: 025.