Content uploaded by Lazarus Kajawu
Author content
All content in this area was uploaded by Lazarus Kajawu on Nov 09, 2016
Content may be subject to copyright.
Keywords: African traditional medicine, Mental illness,
Health-seeking behaviours.
Introduction
In sub-Saharan Africa, 80% of the population continues to use
African Traditional Medicine (ATM) as a source of primary health
care that includes the treatment of common mental illnesses [1]. To
address the global burden of mental health issues in low-income
countries (LICs), the World Health Organization has called for the
optimization of all available resources to bolster the delivery of
mental health treatment in primary care [2]. The recently launched
mental health Global Action Program also focuses on forging
strategic partnerships to enhance countries’ capacity to combat
stigma, reduce the burden of mental disorders and promote health [3].
Health care in Zimbabwe, like most African countries, is provided
by both biomedical and traditional health care providers [4].
Treatment seeking behaviors in Zimbabwe can be characterized as
a system of alternate treatment paths that intersect and overlap [5].
For patients (though not all), the rst assumption is that an illness
is natural and normal and can be treated with standard remedies,
such as over the counter medications or herbal remedies. When
conventional efforts fail to relieve normal symptoms, patients
might then suspect that their illness is not normal or natural, and
turn to traditional medicine, known as Hun’anga in Zimbabwe, to
identify the underlying cause or culprit for sickness and disease
[6]. In general there is a paucity of research available concerning
health seeking behaviour in traditional healing for mental illness
[7].
Volume 1 | Issue 1 | 1 of 6
Int J Psychiatry, 2016
Why Do People Use Traditional Healers in Mental Health Care in Zimbabwe?
Research Article
1Department of Psychiatry, College of Health Sciences, University
of Zimbabwe
2Department of Sociology, University of Zimbabwe
3BA, Institute of Psychiatry, King’s College London, London, UK
and Harvard Medical School, Boston, USA
4Department of Psychology, University of Cape Town
5Department of Medicine/Special Treatment & Research
Program, SUNY Downstate Medical Center, Brooklyn, USA
Abstract
Introduction: In sub-Saharan Africa, including in Zimbabwe, 80% of the population continues to use African
Traditional Medicine (ATM) as a source of primary health care that includes the treatment of mental illnesses, but
little is known about what motivates their health seeking behaviour. The study aimed at understanding why patients
use ATM treatment of mental disorders.
Methods: Using exploratory qualitative methods in a semi-urban community near Harare, we conducted 30 in-
depth interviews with patients from ATM sites using convenience sampling, and three focus-group discussions
with 18 participants from the community recruited from three food distribution depots in the settlement. Data were
coded and analysed using the constant comparative method to identify key themes.
Results: We found that patients preferred the use of ATM for witchcraft, religious, psychological and psychosocial
conditions and believed the causes of their sickness stemmed from witchcraft. Many patients reported high levels
of condence and satisfaction with the ATM received.
Conclusion: The ndings suggest that supernatural and psychosocial factors play a major role in health seeking
behaviour of the communities. Therefore, ATM is a relevant point of referral and rehabilitation for mental health
patients and ATM should be integrated with BM.
International Journal of Psychiatry
Lazarus Kajawu1*, Sunungurai D Chingarande2, Helen Jack3, Catherine Ward4 and Tonya Taylor5
*Corresponding author
Lazarus Kajawu, Department of Psychiatry, College of Health
Sciences, University of Zimbabwe, P.O. Box A178, Avondale,
Harare, Zimbabwe, Tel: 0772 278 468; E-mail: lkajaw@gmail.com
Submitted: 18 Sep 2016; Accepted: 01 Oct 2016; Published: 05 Oct 2016
Volume 1 | Issue 1 | 2 of 6Int J Psychiatry 2016
Very little is known about why patients continue to use Hun’anga,
in parallel or in conjunction with western psychotherapy [8,9].
The objective of this study was to characterize why patients and
community seek therapy in hun’anga in the treatment of common
mental disorders at community health care. An understanding of
the treatment seeking behaviors of patients who use Hun’anga
will help identify aspects of traditional medicine that need to be
integrated into mainstream therapy, and make traditional medicine
a relevant point of referral and rehabilitation for mental health
patients.
In this paper, we sought to explore, using qualitative research
methods, why some Shona people in Zimbabwe use Hun’anga
for the treatment of common mental disorders. Findings from this
study will be used to develop more culturally appropriate mental
health training for both lay and professional Zimbabwean health
providers.
Methods
Purpose and objectives
This study aimed to explore, using qualitative research methods,
why some Shona people in Zimbabwe use Hun’anga for the
treatment of common mental disorders. The study was conducted
in a settlement located 16km Northeast of Harare. A qualitative
design was selected because this was an exploratory study [10].
Sampling and Measures
We conducted 30 in-depth interviews and three focus group
discussions, using a semi-structured questionnaire to guide the
process. A total of 68 participants from seven wards of the Epworth
community were enrolled in the study. The in-depth interviews
were conducted with the patients of traditional healers and the
three focus group discussions sessions were held with the general
members of the community.
We recruited patients from traditional healers who were
registered with Zimbabwe National Traditional Healing
association (ZINATHA). The traditional healers were recruited
using community health workers. Community Health Workers
approached all eligible healers and explained the study
objectives, procedures and obtained informed consent to use their
healing ofces (matare) to recruit patients. Investigators used a
convenience sampling strategy to recruit eligible patients from the
healers’ ofces. Community members were recruited at general
mass gathering points which were food distribution depots in
the community. The Community Health Workers also explained
the study objectives, procedures and the investigator obtained
informed consent from the participants.
Participants were excluded from the study if they did not speak
the Shona language and if they were: minors, prisoners, mentally
disabled or severely mentally ill individuals who had severe
psychosis, severe depression, or those who were hyper manic.
We excluded the aforementioned special populations because of
their vulnerable status as human subjects. Recruitment continued
until substantive saturation, or the point at which new data did not
produce more ndings.
Data collection
From January of 2013 to December of 2013, we conducted 3
focus group discussions (FGD) with community members and 30
in-depth interviews (IDI) with the patients of traditional healers.
All interviews were conducted in a private room. The investigator
facilitated the discussion. Two research assistants were available;
one was helping with notes taking while the second was helping
with recording of information during focus group discussions and
in-depth interviews. Each FGD discussion lasted about one hour.
We used a semi-structured interview questionnaire to explore
the community’s views about healing practices, about visiting
traditional healing, and the causes of illness among the people
visiting traditional healers, and the reasons for choice of traditional
therapy over conventional medicine.
The in-depth interviews were conducted one-on-one in a private
room and lasted approximately one hour. The investigator
conducted the interviews with the aid of two research assistants.
To guide the interviews we used a semi-structured interview
questionnaire, to explore the patient’s views about what caused
their illness, the treatment strategies used, the changes in health as a
result of therapy, the patients’ attitude toward traditional therapies,
their personal feelings toward the treatment received, the levels of
improvement as a result of therapy, the patient’s satisfaction with
the therapy, and the limits of the approach. Some key questions
were provided in the table. The researcher asked further probing
questions to generate more discussion before closing questions.
A summary of the major points was given in the end. The focus
group discussions and in-depth interviews were audiotaped and
professionally transcribed.
Ethical concerns
Written permission was obtained from Kunaka District Hospital
before the study was started and concern was also obtained from
all participants. Permission was acquired to conduct the interviews
and audio-recording of the interview was allowed. The interviews
took place in the healer’s shrine.
Data analysis
Data were analysed using the constant comparison method [11].
Essential concepts were coded and compared to extract recurrent
themes across data. While the principal investigator was leading the
process in writing, the other members of the research team reviewed
coded transcripts to validate the outcomes. This process of rening
codes and describing the properties of each code continued until
no new concepts emerged. An analysis comparing and contrasting
the themes was made across the two groups of participants. Data
was manually coded and translated into English. It was then back
translated and checked for consistency. Analysis of the interviews
and focus group discussions explored the subjective meaning of
mental illness and treatment seeking behaviours. Quotations used
throughout this paper reect participants’ typical comments unless
otherwise noted.
Volume 1 | Issue 1 | 3 of 6Int J Psychiatry 2016
Results
Sample characteristics of the in-depth interview and focus group
participants.
Table 1 and Figure 1 present selected socio-demographic variables
used to characterize the sample of in-depth and focus group
discussant participants. Women (70%) were the majority and
the men were only 30%. Focus group discussions were held at
3 food distribution depots and each focus group had 7, 6 and 5
participants, respectively. The mean ages for the 3 groups were 43,
28 and 29, 2 respectively, while the mean for the 3 groups was 34,
17 years (SD: 13, 63). The mean number of years of education was
9.28years (SD: 2, 89) for all participants in the 3 groups.
In-depth
interviews N= 30
Focus groups
N= 18
M (SD) or %, N M (SD) or % (N)
Age 40,40 (SD: 13,61) 34,17 (SD:13,63)
Gender Female 68,97% (20) 32% (6)
Male 31,03% (9) 68% (13)
Ethnicity
Muzezuru 33,33% (10) 27,78% (5)
Munyika 3,33% (1) 11,11% (2)
Mukaranga 20% (6) 5,56% (1)
Mundau 13,35% (4) 11,11% (2)
Malawi 23,33% (7) 16,67% (3)
Zambian 3,33% (1) 5,56% (1)
Mozambican 3,33% (1) 16,67% (3)
Education 6,97 (SD: 3,6) 9,28 (SD: 2,89)
Marital
status
Divorced 10,34% (3) 16% (3)
Married 72,4% (21) 74% (14)
Single 3,45% (1) 1% (2)
Windowed 13,79% (4)
Religion
Christian 55,17% (16) 84% (16)
Traditional 13,79% (4) 16% (3)
NR 31,03% (9)
Number of
people living
in household
2 16,67% (5) -
3 16,67% (5) 27,78% (5)
4 16,67% (5) 11,11% (1)
5 16,67 (5) 16,67% (2)
6 16,67 (5) -
7 10,00 (3) 5,56% (1)
8 3,33% (1) 11,11% (2)
11 3,33% (1) -
14 5,56% (1)
Number of
children
1 16,00% (16) 16,67% (3)
2 28,00% (28) 16,67% (3)
3 18,00% (18) 11,11% (2)
4 16,00% (16) 11,11% (2)
5 10,00% (10) 5,56% (1)
Number of
children
6 2,00 (2) 5,56% (1)
9 1,00% (1) -
Number
of people
earning
income
0 60% (18) 27,78% (5)
1 40% (12) 72,22% (13)
Occupation
Employed 2 32% (6)
Self-employed 3 16% (3)
Unemployed 24 48% (9)
Table 1: Characteristics of the in-depth interview and focus group
participants.
Figure 1: Marital status, Demographic Characteristics of Patients of
Traditional Healers.
Emergent topics
From the focus group discussions and in-depth interviews emerged
two topics: patients’ explanatory models for mental illness and
why Zimbabwean patients use Hun’anga (traditional healing) for
common mental health disorders.
Shona Explanatory Models for Mental Illness
The main causes of illnesses that emerged from data analysis of
participants were supernatural factors. This response was further
categorized into illnesses caused by perceived spiritual causes
(zvemweya), or witchcraft (zvouroyi), or culture (zvemagariro),
and illnesses affecting mental health with unidentied causes
(zvisinganzwisisiki kuchipatara).
Description of causes and symptoms of illness
Both groups of participants attributed the causes of mental illness
to spirituality “zvomweya”. Nearly all participants reported
causes due to ancestral spirits (zvemidzimu), or possession by evil
(kusvikirwa nemweya yetsvina) or an aggrieved spirit (kubatwa
nengozi), and people who had been beaten by goblins (vakarohwa
nezvidhoma).
Many of the participants reported cultural issues (zvechivanhu) as
the causes of mental illness. Many patients mentioned the pains
which were perceived to have arisen from unidentied traditional
Volume 1 | Issue 1 | 4 of 6Int J Psychiatry 2016
practices (zvemadzinza). For example, when relatives are believed
to have been inciting ancestral spirits (midzimu) to stop extending
protection and as a result, the sufferer becomes a victim of bad airs
(mamhepo) and become psychotic.
Almost all community members reported the causes of illness as
when people had stopped observing their cultural prescriptions
(tarasa tsika nemagariro) resulting in their ancestors withdrawing
their protection from them (midzimu yafuratira) and thereby,
making them prone to illness. However, some of the community
members believed illness was a form of request from ancestors,
asking the living to perform cultural rituals on their behalf. Many
community members mentioned that mental illness in a family
member was believed to be a sign an ancestral spirit (mudzimu)
was seeking to talk through a host (patient); a 30-year- old
community member whose friend had depression had this to say;
“The healing spirit (mudzimu) rst makes its host ill as a way
of alerting the relatives so that they may nd out what the
problem is all about, you see, my friend doesn’t want to talk
with anyone and looks sad all the time with tears all over the
place” (community member FGD).
Many community members spoke about witchcraft issues as
causing a number of mental health problems. Examples given
were: those who are bewitched (vakaroyiwa) and may become
depressed, patients presenting with psychosis (kupenga) and
confusion (kuvhiringika) through witchcraft (huroyi), some are
struck by witchcraft birds (zvishiri) and become unconscious,
some patients were inserted witchcraft objects (zvipotswa) in their
bodies which would make them suffer from untold pain, and many
similar issues.
Patients’ reasons for the use of Hun’anga
From our data, we identied specicity as the main reason why
Zimbabwean patients use Hun’anga for common mental health
disorders.
Specicity
Most participants reported that they used Hun’anga because mental
illness with a supernatural cause can only be xed by Hun’anga.
This means conditions which were perceived to derive from
culture or witchcraft could be treated only in traditional healing. A
community member observed,
“Those people with bad luck and nding it difcult to get
married (munyama) for them to go to the hospital complaining
that they need to get married, is not possible (Community
member, FGD)”.
The aetiology of mental illness was strongly linked to spiritual
factors by both study groups. Most of the community members
believed that the spiritual problems (matambudziko ezvemweya)
were believed to respond more positively to methods of traditional
medicine rather than in western medicine when, generally, doctors
failed to make a diagnosis. This was noted by a 37-year-old female
community member, who was living with a 42-year old female
patient suffering from mental psychosis,
“When we went to see the doctors, we were told the diagnosis
was not clear, when the person was molested by evil spirits”
(Community member).
Many participants mentioned their choice of treatment was
determined by the perceived causes of illness. Many patients
mentioned they visited traditional healers because they perceived
only traditional medicine (chivanhu) could resolve witchcraft
(huroyi) problems, as one 47 years old female patient suffering
from hysteria (mamhepo) observed;
“Because people thought that my illness was due to black
magic (mishonga yechibhoyi) which could only be treated in
traditional medicine” (Patient).
Nearly all community members reported supernatural causes
for unidentied illnesses (zvisinganzwisisiki) where nobody
understood the illness affecting the patient. A 40-year-old female
community member observed,
“If the illness is arising from (mushonga wechibhoyi)
black magic, or after getting beaten by goblins (varohwa
nezvidhoma), a person may go to a western trained doctor
who may fail to see what happened” (Community member).
Almost all the community members who used traditional medicine
and patients felt they were consulting traditional medicine because
the healers provided holistic care–healing the mind, body and spirit
(kushandirwa zvose nemweya). A 26-year-old female community
member who uses traditional medicine for her anxiety noted,
“Some traditional healers may start by chanting (kudeketera)
to your ancestral spirits (midzimu) for their support in the
treatment before they start healing. This is different from the
hospital set up where ancestors (midzimu) are not recognized
and no nurse will refer to any of your ancestors (kudeketera
kumidzimu) for their protection. It feels good to be connected
with your ancestors and I feel better” (Community member,
FGD).
However in assessing the impact of traditional therapy they had
received, many participants had different feelings. Many patients
reported they derived complete satisfaction, but a few patients
thought they’d only experienced partial satisfaction or even no
satisfaction. However many participants felt traditional healing
was better than no treatment.
Discussion
This was the rst study of why Zimbabwean patients use traditional
healing (Hun’anga) for common mental health disorders. The
ndings in this study are limited by difculties in selection of
traditional healing sites that represent diverse backgrounds and
viewpoints, scheduling interviews with hard to reach respondents
and the study site which was a peri-urban settlement and
Volume 1 | Issue 1 | 5 of 6Int J Psychiatry 2016
commonalities may differ in other areas, particularly in low and
middle income countries. There was also a risk the validity of the
data was (or could have been) compromised because respondents
did not answer the questions openly and honestly. To minimize
biases and sources of error, we took certain precautions and the
steps outlined above regarding the selection of subjects, their
comparability, and a calculation of sample size. In spite of the
above, some important ndings are noteworthy.
Explanatory models for mental health illness were largely
supernatural. Our results supported a Nigerian study which found
supernatural reasons to be the most popular explanations for
mental illness amongst carers and patients, a notable difference
from psychosocial issues found in international ndings [12].
The study showed that witchcraft played a central role in the
causation of mental health problems. Although witchcraft is
outlawed in Zimbabwe, this category continues to be used as an
important way of explaining misfortune and requires attention.
A similar result was established in Sub-Saharan Africa [13-
15]. The problems created by witchcraft were not identiable
to practitioners of conventional medicine, and could only be
identied in Hun’anga. What was surprising from our data was
that traditional healers served both the roles of providing therapy
for those affected as well as being used to cause illness when
requested by their patients to do so, for example, they cast bad
spells on their patient’s enemies. This implies that some traditional
healers (but not all) practise unethical behaviours. There is need to
train traditional healers the ethics of preventing public harm.
In addition, our study showed people who sought Hun’anga were
perceived to have developed mental health problems from their
lack of following their culture or their relatives were perceived
to have incited ancestral spirits to turn against them to either
withdraw their perceived protection from bad spirits, or cause bad
spirits to inict harm on them. Our result corroborated previous
studies [16,17]. Their study found spiritual possession is believed
to inuence the brain directly. What was surprising, however, was
that most of the illnesses that arose, including those with apparent
physical causes, were often attributed to the supernatural factors.
The implication of the ndings is that patient treatments in
Zimbabwe should focus beyond the physical manifestations of
the problems to include the underlying spiritual issues, which
is the mind. It is important to inform clinicians, policy makers
and other stakeholders that the understanding of the aetiology
of mental health illness from a Zimbabwean traditional healing
perspective may inform the management of patients at the primary
care level. This can be tackled by involving both the healers who
are well versed in the traditional approach and training nurses
at the primary health care level. More research should focus on
exploring this possibility. Our ndings corroborate the previous
research ndings.
Our ndings reveal that attending to perceived supernatural factors
should improve motivation of people with mental health issues to
seek therapy. However, further research is required to establish how
to integrate cultural and spiritual context of a patient in therapy.
What was surprising was, while community members mentioned
seeing patients with the more orid psychotic symptoms, the
patients reported benign symptoms of mental illness. This
could probably be a result of the stigma associated with mental
illnesses where people do not open up about their mental illness,
and this implies there should be deliberate effort to ght stigmas
surrounding having a mental illness.
Our study further revealed that participants made a choice to
use Hun’anga because they rated traditional healers’ skills high.
Participants also felt secure traditional healers would refer them to
other healing agents if it was necessary. Our ndings contradicted
results of previous research which found traditional healers
were not willing to refer patients to biomedical practitioners
[18]. Perhaps the difference was because we used a more robust
qualitative design as opposed to the quantitative methods used in
previous research.
Finally, our ndings suggested that people were satised by using
hun’anga. Our results supported previous research [6,19,20]. The
implication is that hun’anga indeed helps in the treatment of some
people (but not all) with mental health problems. Two questions
that remain to be answered are: how Hun’anga works for different
types of patients and how it can complement biomedicine in the
treatment of mental health problems [21,22].
Conclusion
We conclude that in our study location in Zimbabwe (and
potentially in most developing countries) community health
seeking behaviour is motivated mainly by supernatural factors.
Therefore, we are suggesting, in order to plan for a holistic,
culturally appropriate mental health programme, efforts must
be made to address these factors. Specically for the purpose of
incorporating cultural and spiritual needs in order to cater for
physical and spiritual being of a patient. Such an approach could
make traditional medicine more relevant as referral point as well
as rehabilitation and after care. Above all there must be continuous
mental health education for both mental health and mental illness.
Furthermore, research is needed to identify efcacy of traditional
methods and incorporate them into mainstream therapy. These
ndings can be used to optimize the health choices available in
low-income countries (LICs).
Author Contributions
Conceptualized the study: LK; Designed the interview: LK;
Conducted the interviews: LK; Participated in data analysis: LK,
CW, DC, TT, HJ; Drafted the manuscript: LK; Gave manuscript
input: LK, CW, DC, TT, HJ.
Ethical approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the University
of Zimbabwe and Parirenyatwa Joint Research Ethics Committee
Volume 1 | Issue 1 | 6 of 6Int J Psychiatry 2016
Copyright: ©2016 Kajawu L. is is an open-access article distributed
under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
(JREC) and the Medical Research Council of Zimbabwe (MRCZ);
and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
References
1. Organization WH (2001) The World Health Report 2001:
Mental health: new understanding, new hope. World Health
Organization.
2. Organization WH (2002) The world health report 2002:
Reducing risks, promoting healthy life. World Health
Organization.
3. Organization WH & Others (2015) mhGAP intervention
guide for mental, neurological and substance use disorders in
non-specialized health settings. The Lancet.
4. Shoko T (2007) Karanga traditional medicine and healing. Afr
J Tradit Complement Altern Med 4: 501-509.
5. Taylor TN (2010) “Because I was in pain, I just wanted to be
treated”: competing therapeutic goals in the performance of
healing HIV/AIDS in rural Zimbabwe. J Am Folk 123: 304-
328.
6. Patel V, Musara T, Butau T, Maramba P, Fuyane S (1995)
Concepts of mental illness and medical pluralism in Harare.
Psychol Med 25: 485-493.
7. Chikara F, Manley MR (1991a) Psychiatry in Zimbabwe.
Hosp Community Psychiatry 42: 943-947.
8. Dana RH (2012) Mental health services for African Americans:
a cultural/racial perspective. Journal of Human Growth and
Development 9.
9. Mollica RF, Cardozo BL, Osofsky HJ, Raphael B, Ager A, et
al. (2004) Mental health in complex emergencies. Lancet 364:
2058-2067.
10. Pope C, Mays N (2013) Qualitative Research in Health Care.
John Wiley & Sons.
11. Glaser BG, Strauss AL (2009) The discovery of grounded
theory: Strategies for qualitative research. Transaction
Publishers 5.
12. Adebowale TO, Ogunlesi AO (1998) Beliefs and knowledge
about aetiology of mental illness among Nigerian psychiatric
patients and their relatives. African Journal of Medicine and
Medical Sciences 28: 35-41.
13. Chikara F, Manley MR (1991b) Psychiatry in Zimbabwe.
Psychiatric Services 42: 943–947.
14. Gelfand M (1976) A service to the sick. A history of the health
services for Africans in Southern Rhodesia (1890-1953).
A Service to the Sick. A History of the Health Services for
Africans in Southern Rhodesia (1890-1953).
15. Patel V, Simunyu E, Gwanzura F (1997) The pathways to
primary mental health care in high-density suburbs in Harare,
Zimbabwe. Soc Psychiatry Psychiatr Epidemiol 32: 97-103.
16. Mutambirwa J (1989) Health problems in rural communities,
Zimbabwe. Soc Sci Med 29: 927-932.
17. Crabb J, Stewart RC, Kokota D, Masson N, Chabunya S, et
al. (2012) Attitudes towards mental illness in Malawi: a cross-
sectional survey. BMC Public Health 12: 541.
18. Agara AJ, Makanjuola AB, Morakinyo O (2008) Management
of perceived mental health problems by spiritual healers: a
Nigerian study. Afr J Psychiatry (Johannesbg) 11: 113-118.
19. Dana RH (2002) Mental health services for African
Americans: a cultural/racial perspective. Cultur Divers Ethnic
Minor Psychol 8: 3-18.
20. McKenzie K, Patel V, Araya R (2004) Learning from low
income countries: mental health. BMJ 329: 1138-1140.
