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Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review

"Lola Savoy" (2019-11-30)


Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review
Abstract
Background The WHO estimates that a considerable number of people in Sub-Saharan Africa (SSA) rely on traditional, complementary and alternative medicine (TCAM) to meet their primary healthcare needs, yet there remains a dearth of research evidence on the overall picture of TCAM utilisation in the region.

Methods We conducted a literature search of original articles examining TCAM use in SSA between 1 January 2006 and 28 February 2017, employing Medline, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Scopus, ProQuest, PubMed, Embase and African Journals Online databases. A critical appraisal of relevant articles reporting a quantitative or mixed-method design was undertaken.

Results Despite the heterogeneity and general low quality of the identified literature, the review highlights a relatively high use of TCAM alone or in combination with orthodox medicine, in both general population and in specific health conditions in SSA. TCAM users compared with non-TCAM users are more likely to be of low socioeconomic and educational status, while there were inconsistencies in age, sex, spatial location and religious affiliation between TCAM users and non-TCAM users. Most TCAM users (55.8%–100%) in SSA fail to disclose TCAM use to their healthcare providers, with the main reasons for non-disclosure being fear of receiving improper care, healthcare providers’ negative attitude and a lack of enquiry about TCAM use from healthcare providers.

Conclusion TCAM use in SSA is significant, although most studies emerge from a few countries. Factors associated with TCAM use in SSA are similar to those observed in other regions, but further research may be required to further elucidate challenges and opportunities related to TCAM use specific to SSA.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Key questions
What is already known?
There remains a dearth of research evidence in Sub-Saharan Africa (SSA) on the drivers and facilitators of traditional, complementary and alternative medicine (TCAM) use, factors associated with TCAM use, and the impact of TCAM use on broader healthcare.

What are the new findings?
Studies suggest a high use of TCAM (particularly TCAM products) in SSA, although most studies are limited to few countries, and there is a significant heterogeneity and low quality of some of the current scholarship.

TCAM is used due to its perceived low cost, alignment of TCAM with sociocultural, religious and spiritual values, and dissatisfaction with conventional healthcare.

Non-disclosure of TCAM use to healthcare providers is common among TCAM users in SSA, primarily due to the fear of receiving improper care from hospitals, negative attitude of healthcare providers towards TCAM and a lack of enquiry about TCAM use from healthcare providers.

What do the new findings imply?
Widespread TCAM use in SSA necessitates health departments and governments across the region to consider and familiarise themselves with the current role of TCAM and its future possibilities within the wider healthcare system.

Introduction
Traditional, complementary and alternative medicine (TCAM) refers to a set of healthcare practices (indigenous or imported) that are delivered outside of the mainstream healthcare system.1 In the African setting it may encompass local herbal medicines or products, indigenous healthcare practices (traditional bone setting), as well as imported complementary and alternative medicine products and practices (eg, acupuncture or chiropractic). Sub-Saharan Africa is one region of the world in which TCAM has long been held to be widespread, with a considerable number of its population relying on it to maintain their health or prevent and treat communicable and non-communicable diseases.2 3 The economic influence of TCAM is extensive, contributing at least R2.9 billion (US$2.2 million) to the South African economy alone.4

The increasing uptake of TCAM services across the continent in recent decades has attracted the attention of policy makers, researchers and healthcare professionals. In the past 20 years, the WHO regional office for Africa spearheaded the implementation of a regional strategy endorsed by African Heads of State in Lusaka, Zambia5 to promote the role of TCAM in health systems in the African region. The gains experienced since the adoption of the regional plan include policy formation in 36 countries and research promotion, including the establishment of TCAM research centres in some countries like Nigeria, Ghana and South Africa. The regional plan has also promoted the inclusion of TCAM courses into the curricula of healthcare training institutions in countries across the continent. For instance, such plan has seen the inclusion of TCAM courses in some South African6 and Ghanian7 universities. It has also promoted the training of TCAM practitioners and the local production and cultivation of medicinal plants, as well as the establishment of intellectual property rights for traditional medicine knowledge in few nations.5 Despite such progress, African countries continue to grapple with an absence of TCAM policy or its implementation, inadequate TCAM research infrastructure and insufficient regulation of TCAM products and practices.5 8 For instance, by 2005, only 32% and 27% of the African countries who responded to the WHO global survey had a national policy and law or regulation on TCAM.9

A steady rise in the prevalence of chronic non-communicable diseases is significantly contributing to Africa’s disease burden, and is adding burden to healthcare systems already strained due to the high incidence of infectious diseases.10 With high TCAM use for chronic health conditions reported outside of Africa,11 it is postulated that TCAM will play an integral role in the health and well-being of people suffering from chronic diseases in Africa as well.12 13 TCAM’s role in the provision of primary healthcare is recognised in some Sub-Saharan Africa countries’ health policy documents within the context of limited access to essential health services, especially among the rural poor.14 15

Considering the high utilisation of TCAM across Sub-Saharan Africa, it is necessary for policy decision makers, researchers and health professionals to recognise TCAM healthcare practices as integral to the health-seeking of populations and develop an effective response that safeguards their health and well-being. A proper policy and practice response to increasing TCAM use requires an indepth insight into the nature of TCAM use, including the profile of TCAM users as well as the drivers and barriers that facilitate and limit the use of TCAM. In direct response, this paper reports findings from the first comprehensive critical review of the prevalence of TCAM use alone and in combination with conventional medicine, sociodemographic characteristics of TCAM users, motivators of and barriers to TCAM use, safety and cost associated with TCAM use, as well as details around non-disclosure of TCAM use to health providers.

Methodology
Research design
The systematic review analyses the contemporary scholarship using an established approach developed for a number of health research topics.16–18
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Search strategy
Peer-reviewed articles reporting on TCAM use in Sub-Saharan Africa were searched using the following databases: Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Scopus, ProQuest, Medline, PubMed, African Journals Online, Embase and Google Scholar. Hand searching in the bibliography of relevant articles was also employed to help ensure the capture of all relevant peer-reviewed literature. Table 1 shows a summary of the search strategy employed. The definition of TCAM in our review was based on the definitions of traditional medicine and complementary medicine put forward by WHO.1 It encompasses local herbal medicines or products, indigenous healthcare practices (traditional bone setting), as well as imported complementary and alternative medicine products and practices (such as Chinese medicine and chiropractic). Vitamins and mineral supplements were not considered as TCAM products in our study, as these are usually used for general health prevention rather than for specific health purposes.

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Table 1
Search strategy

The results from the databases and hand searches were imported into EndNote V.X8. Duplicates were removed, and the remaining articles were screened based on the title, abstract and full text. Figure 1 gives a detailed algorithm of how papers were excluded and included.
Search outcomes
We initially identified 1916 articles from the database search and from other sources. These papers were further screened using our inclusion criteria. One hundred and eighty papers met the inclusion criteria and were included in the critical review. A summary of the search process and categorical analysis of the reviewed studies are shown in figure 1 and online supplementary file 1, respectively.
Quality appraisal system
We employed an analytical tool adapted from previous critical reviews on complementary and alternative medicine use17 19 to evaluate the quality of the papers that met the review criteria. The tool appraised study methodology, participant characteristics and TCAM use, with 1 point given to each aspect under the three domains (methodology, reporting of participant characteristics and reporting TCAM use). A maximum potential score of 12 was tallied if all aspects of the three domains were met. Two authors separately analysed and allocated scores. Differences in the final score were resolved through discussion among the four authors, with the most senior author having to make the final decision. Only articles using mixed and quantitative designs were considered as they formed the greater part of the reviewed papers. For mixed-method studies, only the quantitative study component was appraised. Table 2 and the online supplementary file 2 provide the details of the quality appraisal tool and the summated score of each paper, respectively. Articles with summated scores ranging from 9 to 12, 6–8 and 0–5 were considered of good, fair and poor quality, respectively.
Results
A total of 180 articles met the criteria for review. The included articles employed mixed-method (n=14), qualitative (n=12) and quantitative (n=154) research designs. Based on our search strategy, we were able to identify studies from 25 out of the total 48 countries which constitute Sub-Saharan Africa. Nearly three-quarters (72.8%) of included papers reported research conducted in just four countries: Nigeria (n=72, 40.0%), South Africa (n=26, 14.4%), Ghana (n=20, 11.1%) and Uganda (n=13, 7.2%). A summary of the included articles is shown in online supplementary file 1. There were very few articles with high methodological quality. Of the 165 articles that met the requirement for critical appraisal, 2 articles from South Africa20 21 had a total score of 11, and 7 papers from different countries had a score of 10.22–28 Less than a quarter (n=30, 18.2%) and close to two-thirds (n=106, 64.2%) of the articles appraised had total scores ranging from 9 to 12 and from 6 to 8, respectively. Methodological flaws were discovered in the selected articles, with only 8 (4.8%) of studies employing a nationally representative sampling strategy. Two-thirds (n=110, 66.7%) of the identified articles reported a sample size less than 500. Also, the tendency for recall bias based on whether TCAM was used within the past 12 months or less was identified in almost half (n=82, 49.7%) of the papers appraised. With regard to the reporting of TCAM use, close to two-thirds (66.1%) of the articles reviewed failed to provide a definition of TCAM. Details of the results of the critical appraisal scoring system are shown in online supplementary file 2. In general, the reviewed articles reported eight major themes: types of TCAM used, prevalence of use of TCAM, prevalence of concurrent use of TCAM and allopathic medicine, and sociodemographic profile of TCAM users, drivers and barriers to TCAM use, non-disclosure of TCAM use to healthcare providers, TCAM costs and reported adverse effects of TCAM use. In reporting the findings of our review, the prevalence of TCAM and the sociodemographic profile of TCAM users were categorised into general population studies (including both adult male and adult female participants and not limited to examining any single specific disease or condition) and subhealth or disease-specific populations. The categorisation was done to highlight the TCAM utilisation in the general population and in diseases or conditions and specific populations that are considered a public health or clinical issue in Sub-Saharan Africa. Disease conditions or populations with single publication were grouped as others.
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Types of TCAM use
Based on the literature reviewed, biological-based therapies such as herbal therapy are the most common TCAM used in Sub-Saharan Africa, followed by faith-based healing methods (prayer/spirituality) and mind-body therapies (massage, traditional bone setting relaxation, mediation and yoga).29–53 A few studies examining TCAM use among university staff, patients with HIV/AIDS and patients with cancer reported homeopathy,54 prayer/spirituality21 55 and massage56 as the most common TCAM modalities used, respectively.

Prevalence of TCAM use in Sub-Saharan Africa
One hundred and twenty-six of the reviewed articles reported the prevalence of TCAM product (self-care and over-the-counter use) and practitioner use. Papers were divided into two main categories: those reporting TCAM use in the general population (including both adult male and adult female participants and not limited to examining any single specific disease or condition) and TCAM use in subpopulations (such as a specific clinical population). For reporting TCAM prevalence, articles were categorised as reporting on large sample studies (n≥500) and small sample studies (n<500). In general, the current literature suggests a varied prevalence but substantial use of TCAM in both general and subhealth populations (despite methodological limitations in many of the articles reviewed, including no formal or standardised definition of timeframe of use).

Prevalence of TCAM use in the general population
Twenty-six articles reported TCAM product use in the general population,12 44 45 48 49 57–77 reporting substantial prevalence rates ranging from 4.6% (urban settlement in Ethiopia)65 to 94% (semiurban settlements in Nigeria and Ethiopia),49 72 with an estimated average of 58.2%. At least half (n=23) of the study population in majority of the studies reported using TCAM products. Similar utilisation rates were observed among large sample size (≥500) studies44 45 57–60 65 68 76 and small sample size (<500) studies.12 48 49 61–64 66 67 69–75
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A varied prevalence was also observed among the 10 articles20 27 28 58 63 78–81 that reported on TCAM practitioner utilisation (1.2%–67% (mean, 28.8%)). Among studies with large samples,20 27 28 58 79 a lower use of TCAM practitioner services was observed (1.2%–44.1% (average, 12.6%)) compared with studies63 78 80 81 with smaller samples (37.5%–67% (mean, 53.0%)).

Prevalence of TCAM use in health subpopulations
Pregnancy, childbirth, abortion and infertility
Eighteen studies reported the prevalence rates of TCAM use during pregnancy,24 82–95 childbirth94–96 and for pregnancy termination.97 Between 12% and 90.3% (mean, 48.4%) of pregnant women were reported to use a TCAM product during pregnancy, a rate consistent across studies drawn from large sample sizes84 85 93–95 (25.5%–67.5% (average, 45.3%)) and from small sample sizes24 83 86–92 (12%–90.3% (average, 50.1%)). There is limited literature concerning TCAM practitioner service utilisation during pregnancy, with only one Zambian82 and Nigerian98 study reporting the proportion of women seeking the service of a traditional medicine practitioner during their pregnancy (Zambia: 21%; Nigerian: 44.6%). A study of Ghanaian women94 (n=611) reported 11.7% used TCAM products during childbirth, while two Nigerian studies reporting large sample sizes identified 24.1% and 42.5% of postpartum women used the services of TCAM practitioners during childbirth, respectively.95 96 Close to a quarter (22%) of urban Tanzanian women seek help from a traditional medicine practitioner for pregnancy termination compared with 16.9% of their rural counterparts.97 There is also a limited literature with regards TCAM use for infertility, with only one Ugandan study reporting high use (76.2%) of herbal medicine among women seeking infertility care99 and a Nigerian study reporting high use (69%) of TCAM practitioner service among infertile couples.100 There is also a dearth of research evidence of TCAM use among menopausal women, with only one Nigerian study reporting a lower use (3.8%) TCAM practitioner service among menopausal women.101

Sexual health conditions
Three papers, of which two were drawn from large sample sizes (≥500), reported Zambian (68%) women used TCAM products to dry up and constrict the vaginal passage prior to sexual intercourse,102 and Ghanaian (56.3%) women used TCAM to manage gynaecological conditions.94 The third study (n=224) reported 54.9% of male and female Ugandans presenting with various types of sexually transmitted infections used TCAM.103
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Hypertension, diabetes, cancer and asthma
Seven articles reported TCAM product utilisation rates among patients with hypertension32 33 39 46 104–106 and indicate a rate of between 19.5% and 67.8% (mean, 27.1%). Only one of the seven studies was drawn from a large sample of patients with hypertension (n=500) and the reported prevalence in this case was 24%.106

TCAM product use by patients with diabetes varied across the four identified studies drawn from smaller samples, with a higher rate reported in Tanzania (77.1%)107 compared with Nigeria (46%),43 Guinea (33%)108 and Kenya (12.4%).109 With regard to cancer, the available literature reports a high use of TCAM among patients with cancer in Sub-Saharan Africa (Nigeria: 65%34; Ethiopia: 79%110; Ghana: 73.5%56), although one Nigerian study did report a lower rate of use specifically for TCAM services.111 A Prospective Urban and Rural Epidemiological (PURE) study in South Africa reported a higher (61%) TCAM product use among general adult population with non-communicable diseases.12 With regard to TCAM use among patients with asthma, the reviewed literature was drawn from smaller sample size studies conducted in Nigeria, and they suggested that slightly over half of adult (50.5%)29 and a quarter of paediatric (25%)47 patients were TCAM product users.

HIV/AIDS
Twenty-four papers reported TCAM product 112 and practitioner113–115 usage among patients with HIV/AIDS. We observed a similar average prevalence of TCAM product (1.8%–96.8% (mean, 45.8%)) and practitioner use (17.6%–62% (mean, 45.0%)), respectively. Only one product-based59 and one practitioner-based113 studies were conducted using a large sample of patients with HIV/AIDS, and both reported utilisation rates of 1.8% and 62%, respectively.

Malaria and febrile illness
A total of eight papers reported TCAM use for malaria and febrile illness, with close to a quarter of children and at least half of adults reported using TCAM.22 116–122 Two studies reporting large sample sizes in Sierra Leone reported 22%121 and 24.7%22 TCAM products use among children, while the rates were higher among adult populations in Sierra Leone (55%)120 and Ghana (50.3%).119 An increased rate of TCAM use for uncomplicated malaria was recorded in Mali117 between 2003 (24%) and 2013 (58%). Another large population study in two rural districts in Mali documented 27% of individuals with uncomplicated malaria used TCAM alone for management of their health compared with 50% for complicated cases.116 On the other hand, a lower proportion (18.2%) of TCAM products was reported among 33 children with complicated malaria122 The only study reporting TCAM practitioner use for malaria was conducted in Nigeria and reported a prevalence of 49.7%.118

Mental and neurological disorders (epilepsy and mental health disorders)
A total of 11 articles reporting small sample sizes (<500) identified rates of TCAM use among patients with epilepsy40 47 123 and mental health conditions.23 124–131 Among children with epilepsy, Lagunju40 reported a high use (56.6%) of TCAM products compared with 38% reported by Oshikoya et al.47 On the other hand, Nwani et al 123 reported a high utilisation of TCAM practitioner service (65.5%) among adult patients with epilepsy. Seventy-six per cent of Nigerian patients with schizophrenia129 and 11.5% of patients with psychosis in South Africa131 used TCAM products. Among psychiatric patients in general, a higher proportion in Nigeria (73.5%)125 and Ethiopia (50.3%)23 used the service of a TCAM practitioner compared with their counterparts (in Ghana (23.3%)127 and Malawi (22.7%)128). Greater than two-thirds (69%–76%) of patients with schizophrenia in Nigeria124 129 seek care from a TCAM practitioner, whereas a lower proportion of patients with psychosis (11.5%–38.5%) in South Africa126 131 visit a TCAM practitioner. On the other hand, a Ugandan study stated that more than 80% of patients with psychosis simultaneously access both orthodox and traditional medicine systems.132 In Sudan, more than one-third (41%) of patients with mental disorders had sought the service of a TCAM practitioner prior to accessing conventional care.130

Musculoskeletal conditions
A total of seven (six Nigerian, one Ghanaian) studies drawn from small samples reported TCAM product and practitioner use for musculoskeletal conditions. Two studies reported 96.8% of peasant farmers41 and 40.2% of occupational drivers133 as using TCAM products for the management of musculoskeletal pain. Another study reported 47.2% of TCAM product use among patients with osteoarthritis.42 On the other hand, 52.3%, 31.6% and 21% of patients with bone fracture from north central134 135 and middle belt136 regions of Nigeria patronises traditional bonesetters (TBS), respectively. In the Ghanaian study, 29 of the 46 patients interviewed had received treatment from a TBS.137
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Diarrhoea
Four studies were identified that reported TCAM product and practitioner use among individuals experiencing diarrhoea.96 121 138 139 A general population study from Kenya139 and a paediatric-based survey in Sierra Leone121 reported 97.45% and 31% of TCAM product use to manage diarrhoea, respectively. In addition to the Kenyan study, similar studies from Mali (57%)138 and Nigeria (11.3%)96 reported rates of TCAM use for diarrhoea management.

Eye diseases
Seven studies,38 140–144 five of which were conducted in Nigeria, reported that the TCAM use for ophthalmic conditions ranged from 1.6% to 83.2% (average, 28.2%). No study presented TCAM practitioner use for the management of ophthalmic conditions.

Surgical care
Two studies from Nigeria and South Africa reported studies on TCAM product use among surgical patients. In the Nigerian study, 40% of 60 patients surveyed used herbal medicine during their preoperative period,145 while in the South African study 7% of 495 surgical patients had used TCAM in the preceding 6 weeks.146

Others (infantile colic, tuberculosis, oral health and mycetoma)
A study in Nigeria reported that 32.8% and 3.1% use TCAM product and visited a traditional birth attendant to manage infantile colic, respectively.147 Also, studies conducted in Nigeria reported that 10% and 19.8% of patients suffering from tuberculosis148 and toothache149 had consulted with a traditional medicine practitioner, respectively. In addition, another Nigerian study reported that 31.9% of mothers with sick children visiting a private primary healthcare clinic used crude oil as traditional medication.150 In Sudan, 42.4% of patients with mycetoma reported using herbal medicines,151 while 57% of deceased patients who were terminally ill in Ethiopia visited a traditional and spiritual healer.152

General inpatients and outpatients
Five studies (three Nigerian, one South African and one Ugandan) assessed TCAM use among inpatients and outpatients. The current review indicates a higher TCAM utilisation rate among outpatients compared with inpatients. For instance, a Nigerian study among inpatient and outpatients reported that 72% of the 200 outpatients are currently using TCAM products, whereas 18.5% of the 65 inpatients are reportedly using TCAM products.153 Similar findings among outpatients were reported in similar studies in Nigeria (89.9%)30 and South Africa (60.9%)154 and among inpatients in Nigeria (14.2%)155 and Uganda(18.3%).156

Student population, healthcare professionals and academic staff
The reviewed literature indicates that 38.4% of high school students in Nigeria used a TCAM product157 compared with 81.8% and 75.1% TCAM product utilisation rates that were reported among Nigerian university students31 and university students and staff,158 respectively. A similar high utilisation rate was reported among university students in Ghana (89.1%).35 This rate was lower among medical students in both countries (Nigeria: 28%159; Ghana: 56.7%160) and among paramedical students in Nigeria (53.9%).161 In Sierra Leone, 59.1% and 55.6% of graduating medical and nursing students37 as well as all pharmacy students36 used TCAM products.

Among healthcare professionals, TCAM use was reported among medical doctors in Nigeria (20.7%)162 and professionals providing HIV/AIDS care in Durban, South Africa (23.5%).163 One study drawn from a large sample reported that 50.3% of the academic and administrative staff in a South African university54 used TCAM.

Prevalence of concurrent use of TCAM and allopathic medicines
Twenty-six papers were identified that reported on the concurrent use of TCAM products and conventional medicines within the general population44 64 164 and subhealth population.21 35 53 55 66 89 91 105 106 109 112 117 153 165–174 The prevalence of concomitant use ranged from 4.3% to 69.4% (mean, 30.5%). There is high prevalence of concurrent use with conventional medicine in the general population (mean, 54.9% (40%–63.7%)). The prevalence of co-use of TCAM and allopathic medicines among patients with HIV/AIDS had a mean of 20.3% (4.3%–47.9%).21 53 55 112 166–170 173 174 With regard to patients with hypertension, the utilisation rate was higher in a study conducted in Nigeria (47.5%)106 than in Uganda (14.3%),105 but a relatively lower utilisation rate (7%) was reported among patients with diabetes in Kenya.109 Among pregnant women, the prevalence of concurrent use was lower in Kenya (20%)89 than Uganda (64.1%)91 and Ghana (45%).172 Among the general outpatients, two studies in Nigeria reported a varied prevalence of 21%153 and 69.4%.165

Sociodemographic profile of TCAM users in the general population
The sociodemographic characteristics of users of TCAM were identified in a number of articles. TCAM users were reported in many studies to be more common in individuals with a lower socioeconomic status20 44 45 62 65 66 71 79 175 176 and who are unemployed and unskilled20 69 74 when compared with non-users. With regard to the link between age and TCAM use, the relevant papers reported variability based on where the study was conducted. Generally, studies conducted in urban or semiurban settings reported TCAM users to be younger (20–50 years),20 58 61 71 74 whereas those conducted in a rural setting reported TCAM users to more likely be older (>55 years).62 177 An inconsistent pattern was observed from the available literature with respect to educational status of TCAM users. While four included studies reported TCAM users to have little or no formal education,20 62 71 177 two other studies provided a contrasting view.61 74 Generally, TCAM users compared with non-TCAM users in the general population were more commonly reported to be married44 45 57 than not married.20 Two studies reported on the link between TCAM use and spatial location of respondents. A national household survey in South Africa identified rural residents as more likely to visit a TCAM practitioner than their urban counterparts,20 while a study among 324 residents of the Ashanti Region of Ghana did not find any significant difference between TCAM users residing in both locations.50 The available literature reports an equivocal relationship between TCAM use and gender. On one hand, two studies from Ethiopia and Nigeria identified women more than men as likely TCAM users,44 65 while another Nigerian study reported men as likely users of TCAM.45 With respect to religion, a community-based study in Enugu, Nigeria reported TCAM users were likely to be Christians than other religions,74 whereas another Nigerian study conducted in Imo State did not observe any significant difference.68 Meanwhile, two Nigerian studies reported no significant correlation between the sociodemographic characteristics of the respondents and TCAM use.60 72

In summary, TCAM users compared with non-TCAM users in the general population across Sub-Saharan Africa are more likely to be of low socioeconomic status, while there were inconsistencies in age, sex, educational status, spatial location and religious affiliation among TCAM users

Sociodemographic profile of TCAM users in health subpopulations
TCAM users in pregnancy, childbirth and abortion
The reviewed literature shows pregnant women who use TCAM were more likely to be of low socioeconomic status84 88 92 93 98 and less educated84 86 88 89 92 98 compared with non-users, although one study reported higher education completion as a predictor of TCAM use.84 TCAM users were also found to be younger (<30 years)84 98 and married84 98 compared with non-TCAM users.24 Meanwhile, three studies from Zambia,82 Mali90 and Ethiopia83 reported no sociodemographic difference between TCAM users and non-users. With regard to TCAM use during childbirth, two studies drawn from a large sample of Nigerian women show TCAM users are likely to be women who are less educated, from low socioeconomic background, Muslim and primiparous.95 96 With respect to pregnancy termination, a Tanzanian study indicates that women with primary education from both rural and urban settings were more likely to use herbs to induce abortion compared with those with at least a high school education.97

TCAM users among patients with HIV/AIDS
Patients with HIV/AIDS who identified as a TCAM user in a number of studies across Sub-Saharan Africa were more likely to be female,21 168 178–180 not married,180 181 of low socioeconomic status,21 180 younger (<39 years),25 179 180 unemployed,180 181 educated,21 25 from a rural area21 53 and of Christian religious denomination.180

TCAM users among patients with hypertension and diabetes
A review of the literature indicates that patients with hypertension who are male,33 39 46 of low income level,33 39 less educated,33 older106 and reside in rural area33 are more likely to be TCAM users. A Ugandan study did not find any significant association between the sociodemographic profile of patients with hypertension and TCAM use.105 A study undertaken in South Africa in 2010 found that TCAM users with hypertension compared with non-hypertensive TCAM users were more likely to be older, without a partner and unemployed.104 With regard to patients with diabetes, two studies from Kenya109 and Nigeria43 show that patients with diabetes who are older and have had at least a formal education were more likely to be TCAM users.

TCAM users among patients with cancer
A Ghanaian study reported that patients with cancer who were female were more likely users of TCAM,56 whereas a similar study in Ethiopia reported that patients who have attained at least secondary education, had monthly income of more than US$125, presented with comorbidity and at the advanced stage of their disease were likely users of TCAM.110 However, there were no statistically significant differences between TCAM users and non-users with regard to the type of cancer. Meanwhile, a Nigerian study did not find any significant difference between users and non-users of TCAM.34

TCAM users among patients with eye diseases
Patients with eye problems who are older (≥50 years),140 142 from a rural settlement,141 143 married141 and uneducated142 are likely to be TCAM users in Sub-Saharan Africa. However, another study from Nigeria identified younger age (<50 years) as a determinant of TCAM use for eye diseases.141 Also, a similar study from Zimbabwe reported traditional medicine users for eye conditions are likely to belong to the Apostolic sect, reside in a periurban area and unemployed.38

TCAM users among surgical patients
The two identified studies from Nigeria and South Africa conducted among presurgical patients found no statistically significant differences exist between TCAM users and non-users.145 146

TCAM users among patients with malaria and febrile illness
Two Sierra Leonean studies reported that TCAM use was associated with being male,120 Muslim121 and living in a rural area.120 In a study conducted among female residents in Nigeria, TCAM users were more likely to be older (≥50 years), and less educated, unemployed or had a blue-collar job.118

TCAM users presenting with sexual health conditions
A Ugandan study among patients with sexually transmitted infection reported that TCAM use was common among those who were married and educated.103 Ghanaian patients visiting gynaecological units and using TCAM were reported to be less educated and unskilled compared with non-users.94 A Zambian study examining the use of TCAM to achieve vaginal dryness prior to sexual intercourse revealed that the practice was common among married women and those who grew up in rural areas.102

TCAM users seeking infertility care
The two identified studies from Nigeria and Uganda indicated that TCAM users were likely to have attained at least secondary education,99 100 of low socioeconomic class,100 married, never conceived and older than 30 years.99 The Ugandan study also reported herbal medicine use was higher among women with less than 3 years of infertility.99

TCAM users with musculoskeletal diseases
With regard to musculoskeletal diseases, only one Nigerian study among patients with osteoarthritis was identified, and it reported no significant difference in respondent demographics between TCAM users and non-users.42 On the other hand, another Nigerian study that assessed the utilisation of services rendered by TBS reported that being young, male, married, having a skilled occupation and of low economic status were associated with visiting a TBS.134

TCAM users with mental illness and neurological disorders
Two Nigerian studies40 129 reported the characteristics of TCAM users with mental health disorders. Caregivers of children with epilepsy who came from low socioeconomic background and had lower levels of education were more likely to use TCAM.40 Patients with schizophrenia who are older (>40 years), less educated, reside in a rural setting and practise African traditional religion were more likely to use the services of a traditional healer.129 This same study further reported that patients with schizophrenia who are Christians were likely to visit a psychiatric hospital and faith healer compared with their counterparts practising African traditional religion.129 Another study from Sudan reported that mental health patients who visit traditional healers were men, with an average age of 31 years, illiterate or with only a primary education, and unemployed.130

TCAM users among students, healthcare professionals, academic staff and thanh moc huong medicinal general outpatient population
A Ghanaian study observed that TCAM users were more likely to be Christians enrolled in non-science-related programmes at the university.35 In Sierra Leone, healthcare students’ gender, age and year of study were not associated with TCAM use,36 37 although being a Christian was associated with the use of spirituality/prayer among pharmacy students.36 With regard to the general outpatient population, a study in Nigeria reported that women who were older, less educated and whose occupation was fishing were more likely to use crude oil as traditional medication.150

Drivers of TCAM use
A handful of papers included in our review identified a number of pull and push factors promoting TCAM use. Key pull factors reported in the literature include relative low cost and flexibility of payment of TCAM products and services,29–31 42 45 49 60 68 72–76 78 86 88 91 98 106 108 110 118 134 139 150 161 181–190accessibility,22 30 31 49 57 60 72 73 76 88 98 108 118 134 175 183 184 186 187 190 191 and the perception of TCAM being natural and therefore safe as well as effective compared with conventional healthcare.20 29–32 42 45 48 49 57 73 74 76 78 85 86 88 91 106 108 118 134 139 141 150 157 175 183 187 188 192 Patients participating in the identified studies were also positively attracted to TCAM for other reasons such as alignment with a patient’s sociocultural, religious and spiritual values with regard to health and disease12 32 33 42 68 72 73 81 91 106 110 118 149 181 183 187 188 190 192 193 and the sense of patient autonomy of their health.183 Other pull factors of TCAM use identified from the literature are patients’ trust and confidence in their traditional medicine practitioner to share their personal secrets and the perceived privacy they enjoyed with their traditional medicine practitioner.187 194 Perceived psychosocial care and support provided by TCAM providers compared with orthodox healthcare providers have also been reported as a pull factor.98 110 183 In addition, recommendation by respected and trusted peers such as TCAM providers, elders, relatives and friends has also been reported as a factor that drives patients into using TCAM.12 54 111 134 135 161 186 Aggressive advertisement of TCAM products and services is another pull factor.54 73 76 186

The push factors mainly centred on dissatisfaction with conventional healthcare, and this includes long distance to health facilities,187 unavailability of drugs,22 91 186 187 difficulty and inequity in accessing care,22 91 106 186 negative attitude of healthcare providers,106 134 187 long waiting time, lengthy procedures and fear of being diagnosed of a serious disease.134 192

Barriers to TCAM use
A number of population and subpopulation studies reported factors limiting the use of TCAM in Sub-Saharan Africa. Studies conducted among Nigerian31 and Sierra Leonean36 undergraduate students and Nigerian medical doctors162 cited an absence of conclusive scientific evidence that supports TCAM practice as a common barrier to the use of TCAM. A similar finding was reported in a population-based study in Ethiopia.49 Also, lack of patient belief in the safety and efficacy of TCAM was identified as a barrier to TCAM use in studies conducted among patients with hypertension,33 pregnant women88 and patients with various health conditions,192 as well as in the general population.49 In addition, two population-based studies48 189 and a subhealth study192 reported that respondents were reluctant to use traditional medical care due to the perceived demonic nature of TCAM. Further, four population-based studies from Ghana183 184 189 and Tanzania73 and subpopulation studies from Nigeria31 and Ghana192 cited perceived lack of an appropriate dose for TCAM products and unhygienic practice in product preparation,31 73 183 184 189 as well as the unregulated TCAM practitioner practice,183 192 as deterrent to using TCAM. Other barriers to TCAM use were an absence of health financing for traditional health care183 and a perceived lack of education and training among TCAM practitioners.36 183 189

Non-disclosure of TCAM use to healthcare providers