Thursday, 22 November 2018

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

Peter Bai James1,2, Jon Wardle1, Amie Steel1,3, Jon Adams1 Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone Office of Research, Endeavour College of Natural Health, Brisbane, Queensland, Australia Correspondence to Peter Bai James; Peter.B.James{at} 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: Statistics from 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