1. Aims

Review the literature on the health practices of mental health patients in Malawi in relation to accessing Traditional Healers, and with reference to other parts of Africa.

2. Background

Health care systems, guided by wider society, determine ill health in a population, the consequences of ill health, and how it is managed (Gupta and Bhugra [1]). These factors in turn are influenced by the cultural context, and contribute to the formation of explanatory models of illness formed by patients, carers and healthcare professionals alike.  The ‘medical model’ of healthcare dominates certain cultures, usually Western ones, and focuses on physical aspects of disease. In contrast, traditional medicine tends to be popular in most regions of sub-Saharan Africa, with up to 80% of the African population use traditional medicine as their main source of healthcare, although a meta-analysis by Burns and Tomita reported this to be an exaggerated figure (Burns and Tomita [2]). Traditional healers in Africa far outnumber medical doctors, with one traditional healer per 500 population compared with one medical doctor per 40,000 population (World Health Organization [3]). In some African countries, where the conventional healthcare system is well established, people continue to use traditional medicine, and it is a growing area even in Western healthcare models. Indeed, over 100 million Europeans use traditional and complementary medicines; one fifth using regularly and preferring their treatment to include these practices (European Federation for Complementary and Alternative Medicine [4]).

2.1 Mental illness and Malawi

Mental illness is a significant problem in Malawi, with WHO estimates suggesting that depression is the fourth leading cause of disability in Malawi after HIV, cataracts and malaria (Bowie [5]). Prevalence of mental, neurological and substance use disorders is significant in primary care attendees; usually 15-30% but can be as high as 45% (Kauye, Jenkins and Rahman [6]). Furthermore, the Malawi Health Sector Strategic Plan 2011-2016, indicated that mental illness accounts for 4% of the total burden of disease in Malawi (Government of Malawi [7]). The commonest reasons for admission at Zomba Mental Hospital (the only government-run tertiary psychiatric referral hospital in Malawi), are schizophrenia, bipolar disorders, intellectual disability, epilepsy, substance-related and HIV-related conditions (Kauye and Mafuta [8]). Despite this burden of mental illness, the country has less than 1 psychiatrist and 2.5 psychiatric nurses per 100,000 population, and these professionals are mainly found in urban areas (Jacob [9]).

2.2 Healthcare and psychiatric provision in Malawi

Healthcare in Malawi is provided by Traditional healers, as well as a system more akin to Western healthcare models. The latter is mostly Government-run, and is delivered in primary, secondary and tertiary environments. Further healthcare is provided by the Christian Health Association of Malawi, and a small amount is provided through the private sector. About 85% of Malawi’s population lives in rural areas, served by primary care facilities (United Nations [10]), and so access to mental health provisions is problematic for many Malawians, resulting in high levels of untreated mental illness. The Scotland Malawi Mental Health Education Project (SMMHEP) was established in 2006 and aims to provide sustainable support for psychiatric teaching and training for health care professionals in Malawi and medical students (Beaglehole et al. [11]). The project also involves running outpatient clinics and expanding and improving primary care mental health services.

2.3 Traditional healers in Africa and Malawi

Mental disorder in Malawi, similar to other parts of Africa, is often believed to be attributable to culturally accepted ideas and beliefs about divinity, witchcraft, medicine, disease and the influence of ancestral spirits, and social misconduct Steinford [12]. These culturally specific beliefs have an impact on care-seeking behaviour and expectations about treatment outcome in other parts of Africa (Burns and Tomita [2]), and it may be assumed that this is also the case in Malawi. These studies have shown that Traditional healers are often the first, and sometimes only, service provider consulted for a broad range of health problems, including mental illness.

Other types of healer are also recognised worldwide, as well as in Africa, including faith healer and witch doctor. These terms are complicated by the fact that different African countries may understand these titles differently, and the roles these play is confusing. According to Mokgobi [13] the main difference between Traditional healers and faith healers is that the former tend to receive guidance from ancestral spirits, whereas the latter are guided by God or similar. These terms are further complicated by the fact that both may also use herbs on occasion (Mokgobi [13]).

The practice of medical herbalism is widespread in Malawi (Morris [14]), as is the work of faith healers and witchdoctors. Various explanations for the popularity of these traditional practitioners, have been proposed with the most frequently cited reasons being: the consistency with local cultural values and beliefs, superior healer–patient relationships, as well as proximity and lower cost compared to Western health care facilities (Labhardt, Aboa, Manga, Bensing and Langewitz [15]). Nevertheless, delays in accessing formal mental health services have been found commonly where Traditional healers feature in pathways to care (Sorsdahl, Stein and Flisher [16]). This raises concerns with regard to long-term outcomes and morbidity, and an understanding of the help-seeking behaviours of individuals with mental illness is therefore crucial to the effective planning of health services.

3. Design

This is a discursive paper.

4. Method

An evaluative literature review was completed by means of multiple electronic database search as well as an additional manual search to obtain published works identified through the electronic search. Search terms used were: Africa, Malawi, mental disorder, spirituality, and traditional healers.

5. Pathways to Care in Africa and Malawi

Numerous studies have highlighted that the nature and severity of symptoms alone do not determine when and what type of healthcare is sought. These studies have instead shown age, personality, language, education and prejudice to be important (Gupta and Bhugra [1]). Accessibility (long queues), availability (staff shortages, lack of mental health capacity), cost, family preferences, explanatory models, and choice, have also been repeatedly shown to be relevant to African samples (Burns and Tomita [2]). Less is known about these factors in Malawi, although similar to other parts of Africa, Traditional healers are an important part of this pathway of care. Explanatory models are defined by Kleinman [17] as: “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process.” This is based on the idea that reality is socially constructed and explanatory models often favour one’s own world-view. Traditional and religious explanatory belief systems and practices predominate in many regions in Africa, and it is understandable that causal attributions related to mental health symptoms often lead individuals and their families to Traditional healers on their help-seeking pathway. The use of Traditional healers has been shown to be influenced by a number of factors in African samples: advancing age, black race, unemployment, lower education and having an anxiety or a substance use disorder (Sorsdahl et al, [18]). Stekelenburg et al [19]) found more women visited Traditional healers in Zambia, but that the men who did visit them, did so more frequently. They also found a correlation with increasing age and more frequent visits to both the hospital and Traditional healers.

5.1 Traditional healers and the pathway to care in Malawi

Medical professionals or services are generally the first point of contact for patients with mental illnesses in Western countries, whereas Traditional healers are commonly seen in developing countries. Indeed, a systematic review and meta-analysis of traditional and religious healers in the pathway to care for people with mental disorders in Africa by Burns and Tomita [2] found a weighted mean of 48.1% of individuals first consulted traditional and religious healers in their pathway to care, although posited that this figure of 48.1% may actually be lower, due to the over-representation of Nigerian studies in their analysis. Analysing Traditional healers and their practices in Malawi, Nyirenda [20] found that 43% of inpatients at Queen Elizabeth Central Hospital (QECH), a tertiary hospital in Blantyre, had prior consultation with a traditional healer, although this sample was not limited to those with mental illness. Simwaka, Peltzer and Maluwa-Banda [21] reported as many as 80%; and Crumlish et al [22] reported 38% of people utilized Traditional healers as part of their healthcare pathway, although the latter study was for those people who were seeking initial treatments. Kauye, Udedi and Mafuta [23] studied in depth where treatment was sought before reaching a psychiatric hospital in Malawi, and showed that first care was usually sought from primary care clinicians (41.4%), with only 22.7% attending the traditional healer first. The number approaching the traditional healer fell with a second visit to a health care provider, and 80% of those who attended the traditional healer first tended to see a ‘general clinician’ next. Only 24.1% saw a traditional healer having been seen by a general clinician first. Their findings may be associated with dissatisfaction with the Traditional healers, or because traditional methods have been unhelpful, but highlight that a large proportion of patients choose Traditional healers even when possibly living near to a large psychiatric hospital. However, these differing figures may represent the availability and accessibility of various Traditional healers, and different sample characteristic. It is worth noting that Malawians are a heterogenous population with, e.g. Chewa, Ngoni, Yao, Tumbuka groups, and there may be differing within-group beliefs. These figures may also reflect different numbers of faith healers in the sample areas, or a preference of the services they offer. There may also be bias in the attendees in these samples in those being able to afford the journey, having knowledge of what was available, having family members available to bring them and other unknown variables.

The relevance of seeing a traditional healer as part of ones’ health-seeking pathway is unclear. Delays in accessing formal mental health services are common where Traditional healers feature in the pathway to care (Sorsdahl, et al. [16]), and duration of untreated psychosis is associated with worsening outcomes (Penttila, Jaaskelainen, Hirvonen, Isohanni and Miettunen [24]), but there have been conflicting reports as to whether seeing non-physicians in the pathway to care, results in longer duration of psychosis (Bechard-Evans et al, [25]; Sharifi et al, [26]). Previous studies have also shown that pathways to care can vary across diagnostic categories (Fujisawa et al [27]; Steel et al, [28]).

5.2 Reasons for visiting a traditional healer

In the pathway to improved health, individuals will often seek multiple sources, formal and informal, in parallel and consecutively, and using the traditional healer as an alternative to the psychiatric clinic, may reflect complementary, rather than separate use. Indeed, the use of parallel health systems - consulting with traditional and formal medical professionals simultaneously – is common throughout Africa (Kale [29]). In a study by Adeosun et al in Nigeria (Adeosun, Adegbohun, Adewumi and Jeje [30]) 14.5% sought help from more than one traditional healer. The use of Traditional healers as an alternative to the clinic may also reflect the often long-standing nature of mental illness, with patients seeking a cure, rather than chronic disease management. It may be that those who seek additional help from a witchdoctor or herbalist have more severe mental disorders and also that original treatments had not helped. Availability and cost may be important factors in the decision to use multiple agencies, and had they previously attended a formal psychiatric clinic, it is possible that medications would not be available, leading them to seek multiple sources of help. Most Traditional healers will share the values and beliefs of the population they serve, with obvious advantages. A native Malawian doctor may share some values and beliefs with their patients, but at QECH, there is 1 native consultant psychiatrists available for consultation. Relatives may occasionally recommend seeing Traditional healers instead of/as well as the hospital clinic, and Muela, Mushi and Ribera [31] think this is important, as they found that spiritual causes of illness have implications on patient’s social network, and hence this network may be more inclined to encourage attendance at a traditional healer.

Explanatory models are likely to be the most important factor in determining the reasons for visiting a Traditional healer. According to Crumlish et al [22] spiritual and religious beliefs influence perceptions of mental illness in Malawi, with bewitchment being the traditional explanation for mental illness, leading to Traditional healers frequently being consulted. In a study that assessed stigma of mental illness in Malawi, a large proportion of patients attributed mental illness to spiritual causes (82.8%), with 21.9% believing God’s punishment to be the cause (Crabb, Stewart and Kokota [32]).

In a study by Crabb, Stewart and Kokota [32] only a quarter of patients believed that mental illness could be treated outside of the hospital setting, which may reflect the paucity of community mental health care services available. In Malawi, the onus is on patients and their relatives to be responsible for their own healthcare in the community: if they do not attend follow up appointments, practitioners would be unlikely to know.  This is in contrast to some Western healthcare models, in which community mental health services actively monitor their patients wellbeing, with variable rates of satisfaction (Blenkiron and Hamill [33]) and it’s own challenges (Care Quality Commission, [34]). Health surveillance assistants are available, although may not have expertise in mental illness, but SMMHEP are in the process of training community psychiatric nurses in order to expand community services.

5.3 Traditional healer’s views of mental illness

Explanatory views of mental illness may map onto those beliefs held by Traditional healers in Malawi as Nyirenda [20] found in a study looking at Traditional healers and their practices in the country, not limited to those with mental illness. In that study, Traditional healers attributed the causes of diseases or symptoms to: natural diseases inflicted upon the patient by God/bad luck (35%); bewitchment (30%); diseases caused by demonic spirits or ancestral spirits which have not been honoured (18%); and breaking sexual taboos (17%). Similarly, Agara, Makanjuola and Morakinyo [35] studied religious healers’ knowledge about mental illness in Nigeria, and found that mental illness was attributed to witchcraft (93.3%), punishment for sins (73.3%), and supernatural causes (66.7%), amongst others. Using case vignettes in a South African sample, Sorsdahl, Flisher, Wilson and Stein [36] found that traditional healer’s hold multiple explanatory models for mental illness, with severe behavioural disturbance (violence, undressing, urinating in public) as being associated with mental illness, and representative of a psychotic disorder. They also found that hearing voices (Traditional healers may themselves ‘hear voices’) and social withdrawal were not always indicative of a mental illness. Furthermore, the healers in their study tended to identify those as non-psychotic as suffering from physical illness, e.g. HIV, or as a normal reaction to psychosocial stress.  Taken together, whilst these findings indicate that traditional healer’s recognition of mental illness do not entirely map onto that of Western models, Abbo [37] found a variety of labels are used by Traditional healers to categorise psychotic illnesses, in a Ugandan study.

5.4 Choosing a traditional healer

The different types of Traditional healers visited, and the reasons behind the decision to visit the chosen healer, has not been explored in Malawi. This is dependent on the availability of particular Traditional healers, their expertise, and healers themselves may identify e.g. as diviners. The decision of who to consult appears to match the meaning that individuals, or those close to them, ascribe to their experience and/or their pre-existing spiritual or religious beliefs. Those visiting a faith healer may do so for religious, faith or spiritual reasons. Whereas those visiting a witch doctor may be more likely to believe themselves to be bewitched. This kind of health-seeking behaviour, where the type of help sought follows explanatory models of illness, is seen worldwide. In their meta-analysis of traditional healer use across Africa, Burns and Tomita [2] showed regional differences in the extent to which these providers are chosen first, with people from Ethiopia and Nigeria apparently favouring religious/spiritual healers, and South Africans and Zimbabweans favouring Traditional healers, with pooled proportions of participants making first contact with Traditional healers of 17.0% and religious healers of 26.2%.

5.5 The intervention of the traditional healer

Traditional healers may use different treatment techniques. In a Malawian study by Kauye, Udedi and Mafuta [23] the majority of patients seen by Traditional healers were given herbs, with 12% receiving prayer or spiritual support. Their paper defined the healers as native/religious, and did not differentiate further, so it is possible that this sample contained few faith healers, and more herbalists. Examining Traditional healers and their practices in Malawi, Nyirenda [20] showed that 25% of patients with both physical and psychiatric complaints, would be treated by either herbal drinks, herbal baths, or a herbal solution mixed into porridge or root powder applied to the tongue. In that study, 10% were treated by some other means (which may have included praying and cutting), and 65% were referred to hospital. This is in contrast to information provided in my personal communications with Malawian Traditional healers, who said that they did not need to refer patients with ‘madness’ to the hospital, because all of their treatments were curative. Similar practices are seen in other East African countries e.g. Kenya and Tanzania, with a larger focus being placed on traditional healer led counseling in Kenya in particular (Burns and Tomita, [2]). Practices may be more extensive in other parts of Africa. In a Nigerian sample of spiritual healers, treatments were not mutually exclusive, and included: use of water (66.7%), biblical verses (66.7%), fasting and prayer (96.7%), counseling (90%), beating (40%), and occupational therapy (13.3%) (Agara, Makanjuola and Morakinyo, [35]).

There is clearly a difference between Traditional healers and their practices. These are likely to be influenced by the same factors, outlined above, which influence patient’s beliefs about illness, and societal and personal understanding of mental illness. Malawian health care workers completing a medical degree, will have followed a Western model of disease, whereas the calling to becoming a traditional healer is a different path.  Witch doctors may inherit their skill through ‘the calling,’ which runs in families, and herbalists may learn about herbs through watching their parents. Indeed, Nyirenda [20] reported that 58% of Traditional healers were visited by a spirit, and 28% were taught by parents or relatives.

5.6 Do patients find the intervention provided by the traditional healer helpful?

Patient satisfaction is an important component in health-seeking behavior, and has not been studied in Malawi. A Kuala Lumpan sample found only 7.41% of patients reported beneficial effects from traditional treatments, although they were mainly prayed for (Phang, Marhani and Salina [38]). These findings are in contrast to a study in rural Ethiopia, which showed that satisfaction with care administered by Traditional healers is high in many cases (Shibre, Spangeus, Henriksson, Negash and Jacobsson [39]), and in urban Kenya 95.1% of respondents stated that they were satisfied with the Traditional healers’ services (Mbwayo, Ndetei, Mutiso and Khasakhala [40]). Despite these differences, note is made of the possibility of community and hospital respondents varying in their willingness to open up about their experiences of traditional health care.  Traditional healers may provide causal explanations, as found by Patel, Simunyu and Gwanzura [41] in Zimbabwe, which is often not the case in biomedical consultations, and may provide a more holistic/spiritual concept of mental illness, which is more acceptable to patients and consistent with local cultural values and beliefs (Kua, Chew and Ko [42]). They are also likely to be associated with less stigma. In a systematic review of Traditional healers in treating mental disorders; Nortje, Oladeji, Gureje and Seedat [43] found evidence supporting the idea that Traditional healers can provide effective psychosocial interventions, facilitating social engagement and improving coping strategies. They concluded that their interventions might help to relieve distress and improve mild symptoms in depression and anxiety, but found little evidence to suggest that they can change the course of severe mental illnesses such as bipolar and psychotic disorders.

5.7 Financial costs of seeing the traditional healer

To our knowledge, the cost of visiting the traditional healer has not been assessed previously in Malawi, nor what this might entail, i.e. assessment, one-off treatment, multiple treatments etc. Labhardt, Scheiss, Manga and Langewitz [44] found Traditional healers prices to be higher for treating witchcraft, because of the risks associated with it, e.g. becoming bewitched themselves. Muela, Mushi and Ribera [31] stated that considerable amounts of money are spent on Traditional healers in Africa, and found in a Tanzanian sample that most people believed that Traditional healers charged too much for their services, with debate about whether they deserved this. They found that Traditional healers were more empathic, but much more business orientated who manipulated and exploited their patients to obtain money. Patterson Bakari [45] has noted that the costs associated with Traditional healers are often higher than those associated with costs associated with government run hospitals, and in a comparison with Western health providers in Cameroon, Labhardt et al. [44] found that traditional healer’s treatments were more expensive, took longer and often included inpatient treatment, which argues against the idea that lack of money or geographical area are the main drivers for consulting Traditional healers. They believe that it is the perceived quality of care that drives the choice of healthcare, as opposed to cost or distance. However, other authors have argued that Traditional healers offer treatment at lower cost and are easier to reach (Cook and Zumla [46]). There are no guidelines as to what healers should charge, if at all, but some Traditional healer’s sometimes use outcome-contingent care, expecting those who are poorer to pay less. This implies that the onus is then on the traditional healer to encourage their patients to exert effort in order to improve health outcomes. If this does lead to an improved outcome, this may explain some of the possible increased satisfaction seen in some studies.

5.8 Limitations to the studies

There are limitations to the studies looking at pathways to care including: not being representative of the wider populations, confounding by selection bias, comprising patients who thought they were being ‘helpful’ or those who may have felt pressurised to participate, and social desirability bias, whereby respondents are likely to under report contact with alternative health practitioners and over report a negative experience with these. Particularly in contexts such as these, where formal health resources are often scarce and/or inaccessible, it is likely that a substantial portion of individuals requiring or seeking care for mental health disorders never in fact reach formal health services.

6. Conclusions

There are multiple, non-linear, pathways to healthcare in Malawi, similar to other African countries. Traditional healers play an important part in these pathways, and fostering collaborations with them is crucial in the effective planning of psychiatric services across the country, as has been repeatedly stated in studies in neighbouring countries. There are a number of successful collaborations between Traditional healers and biomedical services in TB and HIV in African countries (Peltzer, Mngqundaniso and Petros [47]; Audet [48]), but there appear to be barriers on both sides preventing the integration of Traditional healers into formal healthcare services. My personal communication with Malawian Traditional healers has indicated a lack of willingness to refer patients to psychiatric services, which is also reflected elsewhere in Africa (Adelekan, Makanjuola and Ndom [49]). This behaviour may reflect a lack of belief in the efficacy of treatments offered by psychiatrists for disorders which are perceived as ‘spiritual in aetiology’, but there are also financial implications, for example: who will pay for transporting the patient, and how will healers be remunerated for the loss of income associated with seeing less patients. Important factors also include lack of supervision of healers, lack of mental health legislation, and stigma making the mistreatment of patients more acceptable at the societal level (Burns and Tomita [2]). There are also reports of unscrupulous individuals claiming to be Traditional healers and exploiting vulnerable populations by sexual abuse or extorting money in Malawi, Zambia, Mozambique and South Africa (Sandlana and Mtewa [50]). Education of formal healthcare services, Traditional healers, and the populace in general, is required to understand beliefs held by each. Indeed, education of Traditional healers has been shown to lead to a reduction in the number of those who beat their patients (Adelekan, Makanjuola and Ndom [51]). The Scotland Malawi Mental Health Education Project has initiated such mental health education programmes and has developed community-based services. Advances have also been made in directly engaging Traditional healers, with a herbalist giving a speech at the yearly Malawian Psychiatric Conference.

7. Relevance for Clinical Practice

Kajawu, Chingarande, Jack, Ward and Taylor [52] found that there were marked similarities in regards to diagnostic and treatment practices amongst practitioners of different traditional medicines. They posited that Traditional healers use a unique form of talking therapy, which may imply that patients with specific problems/diagnoses would, in fact, benefit more appropriately from seeing these healers, especially given the paucity of psychological based interventions in Malawi. This could be examined by ascertaining how those with specific diagnoses are treated by the traditional healer, and what the outcomes were. Further work also needs to determine how Malawian Traditional healers and Western based healthcare systems might best work together, as Kajawu et al [52] also found that some Traditional healers ordered their patients to stop ‘biomedical’ medication, which Patel, Musara, Butua, Maramba and Fuyane [53] have previously stated, may undermine future collaborations. The Scotland Malawi Mental Health Education Project continues to train future Malawian psychiatrists, with the aim that these psychiatrists take over, once sustainable. This training would benefit from incorporating time spent with Traditional healers to share expertise, and educate on bad practice in a bi-directional manner.

Acknowledgments

No external or intramural funding was received. I would like to acknowledge the contributions of Amos Mhango, Patrick Chasauka and Dr Jennifer Mutch who helped to formulate this project.

Disclosure Statement

The author reports no actual or potential conflicts of interest.

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