Understanding the role of traditional healers in the Malawian healthcare system: a qualitative study

Understanding the role of traditional healers in the Malawian healthcare system: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding the role of traditional healers in the Malawian healthcare system: a qualitative study Riya Master, Andrew Mguntha, Kimberly Baltzell, Gama Bandawe, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5975877/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Malawi is a pluralistic health system, where people seek care from both formal (e.g. biomedical) and informal (e.g. traditional medicine) sources. An estimated 80% of the population utilizes traditional healers (TH) for care, particularly in rural areas. Given their strong community presence, TH may be able to bridge gaps in the healthcare system, however, data on barriers and facilitators to this relationship are limited. Understanding TH perspectives on disease processes and their role in the community is critical to integrating TH into the biomedical system. Methods We conducted a qualitative study using semi-structured interviews of TH in Thyolo District, Malawi in May 2024. Participants were identified and recruited using purposive sampling. Interviews were conducted in Chichewa, translated into English, and coded for themes. Results We interviewed a total of 25 TH: 17 male and 8 female, age 25 to 84 years. Time in practice ranged from 8 months to 60 years. Major themes identified included: 1. Relationship-building for diagnosis and treatment; 2. Trust and willingness to collaborate with biomedicine; 3. Compensation for gaps in the biomedical system; 4. Recognition of causes and risk factors for infection; and 5. Leadership role in the community. Conclusions In Malawi, TH demonstrate a strong desire for recognition, training, and integration into the biomedical system. Understanding of disease processes outside of traditional vs. biomedical illnesses is variable, but most TH trust biomedicine and feel comfortable referring clients. Given their respected role in society, TH may provide a useful adjunct to biomedical care in rural Malawi. traditional healers alternative medicine herbal medicine Africa Malawi rural medicine low resource infectious diseases Figures Figure 1 Introduction Malawi is a pluralistic health system, where patients seek care from both formal/biomedical (e.g., public or private hospitals, pharmacies) and informal (e.g., traditional healers, drug shops) sources. According to the World Health Organization (WHO), a traditional healer (TH) is defined as: “a person who is recognized by the community where he or she lives as someone competent to provide health care by using plant, animal, and mineral substances and other methods based on social, cultural, and religious practices ( 1 ).” In Malawi, as in many countries in sub-Saharan Africa (SSA), there is a drastic shortage of biomedical health workers relative to the population ( 2 ), and it is estimated that over 80% of Malawians utilize TH for their care. Some TH consider themselves experts in herbal medications (herbalists), others in spiritual problems and treatments (spiritualists), others as specialists in divination to determine the cause of a problem (Diviners), some serve as informal midwives (traditional birth attendants), and many provide a combination of services or consider themselves general practitioners of traditional medicine. Due to the widespread use of traditional healers in Malawi, these informal providers present a unique opportunity to bridge gaps in healthcare between rural communities and the biomedical sector. Successful examples of collaboration between traditional healers and biomedicine have been demonstrated by other studies in the Global South ( 1 , 3 – 5 ). However, there are numerous barriers to these collaborations, including distrust, negative attitudes, differing ideologies, and a lack of recognition of traditional healers within the biomedical space ( 6 – 10 ). Understanding how these viewpoints and perspectives of traditional healers is critical to establishing joint healthcare initiatives with biomedicine in Malawi. Malawi and other countries in SSA are estimated to have high rates of zoonotic and arthropod-transmitted infections and are at high risk for outbreaks of emerging and re-emerging diseases, however, a lack of diagnostic resources and health infrastructure makes early detection difficult ( 11 ). Laboratory testing capacity and treatment of these infections are concentrated in urban, central hospitals; thus, patients presenting to informal providers in rural areas may face large delays in reaching a biomedical referral center, leading to losses of valuable time and data that could be used to initiate early interventions and curb potential outbreaks ( 11 – 13 ). Detection and surveillance capacity for these diseases in Malawi is behind World Health Organization Standards for the region, and the prevalence of these infections is poorly described. There are currently no established mechanisms for the inclusion or recognition of TH within the biomedical system in Malawi, despite indications that TH are willing to collaborate ( 8 ). Given their ease of access, integration, respected role within their communities, and high rates of utilization by the population, particularly in rural areas and villages, informal providers may have untapped potential for integration into the public health system ( 14 – 18 ). Before TH can be integrated as sentinel providers within the biomedical system, we must first understand how TH view their role and how they interact. The primary goal of this qualitative study is to characterize TH perceptions of their role within the biomedical system and their communities and to assess their knowledge and understanding of infectious diseases as part of a larger study that will ultimately create and refine a structured pipeline for early sample collection and pathogen detection from clients in high-risk, remote areas in Malawi. Methods Study design and Setting This was a qualitative interview study of traditional healers in Thyolo District, Malawi conducted in May 2024. Thyolo District is a primarily rural, geographically diverse, agricultural district in Southern Malawi with a population estimate of almost 460,000. It borders Mozambique, is home to Malawi University of Science and Technology and is less than 20 kilometers from Malawi’s second largest city Blantyre, making it an ideal pilot site for the development of enhanced surveillance systems. Qualitative sampling and recruitment We used anonymous survey data collected by our study team in-person via a convenience sample of adult participants from the general public who were recruited in villages throughout the Thyolo region (e.g. at trading centers, near health facilities) to identify TH for recruitment. These surveys included questions on the healthcare preferences and specific locations of informal provider practices, primarily TH sites, in the region. Based on these survey results, local research team knowledge and familiarity with the region and culture (AM), and engagement of the Traditional Healer Association of Malawi, participants for key informant interviews were then identified and recruited using purposive, maximum variation sampling. Interested TH participants were initially approached via phone or at their place of work, then enrolled and consented in person prior to participation. Data collection We interviewed traditional healers who diagnose and treat patients in Thyolo District in person at a private location of their choosing near their healer practice site. Local members of the study team trained in qualitative interviewing techniques and fluent in both English and Chichewa (the local language) conducted semi-structured, individual interviews lasting approximately 1 hour in length, at the TH clinic sites. Interviews were conducted in Chichewa using a semi-structured interview guide (Supplementary File 1). Interview questions were aimed at understanding TH perceptions of their role in providing health services within their communities, particularly in relation to the diagnosis and management of infectious diseases. We also asked about their relationship with biomedicine and included questions to help identify those who may be good candidates for partner sites to act as sentinel providers for the next phase of the study. Interviews were audio-recorded and then transcribed and translated into English by a bilingual (Chichewa/English) speaking research assistants. Transcription and translation quality were verified by AM and GB, both fluent in English and Chichewa. Analysis Interview content was uploaded to Dedoose (Version 9.2.22, SocioCultural Research Consultants, LLC) and coded by two researchers independently (AH and RM) using thematic analysis methodology to identify major themes. The goals of the larger study were used in the initial organization and generation of codes using a deductive approach, with additional codes generated inductively using an iterative approach. In the case of differing perspectives, discussion between the researchers and verification with interviewers occurred until a consensus was reached. After initial analysis, the themes and subthemes and key codes used to generate them were reviewed further through discussion with the full study team, including two local team members familiar with cultural norms (AM and GB) to generate a conclusive list of themes and sub-themes was generated after discussion with the full team (AH, RM, KB, AM, and GB). Results We surveyed 135 adults across the Thyolo region, with over 100 of these participants providing at least one traditional healer practice site with which they were familiar. From these sites and recommendations from the Traditional Healer Association, we interviewed a total of 25 traditional healers, 17 male and 8 female. Age and length of time in practice ranged from 25 to 84 years, and 8 months to 60 years, respectively, with practice sites located throughout Thyolo District (Figure 1). Most participants identified as a general traditional healer with training obtained from their family members (Table 1). The following major themes were identified: 1. Relationship-building for diagnosis and treatment; 2. Trust and willingness to collaborate with biomedicine; 3. Compensation for gaps in the biomedical system; 4. Recognition of causes and risk factors for infection; and 5. Leadership and role in the community (Table 2). Table 1: Traditional healer participant characteristics. Basic characteristics and practice specialty as identified by traditional healer participants. Characteristic Key informants (N = 25) Age (years), mean (SD) Length of practice (years), mean (SD) Gender, n (%): Male Female Training, n (%): Family members Spiritual calling Informal training Some formal training Healer specialty, n (%): General traditional healer Herbalist Spiritualist Diviner Traditional Birth Attendant 59.8 (13.8) 30 (16) 17 (68) 8 (32) 14 (56) 10 (40) 8 (32) 8 (32) 14 (56) 6 (24) 9 (36) 4 (16) 2 (8) SD= standard deviation Table 2: Themes, subthemes, and illustrative quotations. Themes and subthemes Quotation (Specialty, gender, age in years) Relationship-building for diagnosis and treatment Reliance on history/exam Firstly, I do not have examination tools, as I have already said, I am not a fortune teller, so I depend on patients history on what he or she tells me from there I can decide how to treat the client so from the history if it something I cannot manage, I refer the client to the hospital (Traditional Healer, M, 52) Continuity of care ...we just instruct someone to mix and just take maybe half tumbler ... we tell them to take for 7 days and come back again ... if it did not change, we give them another traditional medication. (Spiritualist/Herbalist, F, 64) Trial and error So, I just try to help … just a trial, am not even guaranteed that the person will get well at all times … the spirits are the ones that do the final part (TBA/Diviner, F, 60) Willingness to collaborate Variation in cooperation with biomedicine [Care of the patients I refer] depends on the heart of the doctor that they meet at the hospital. Some doctors are open to work with others while others are just the ‘know it all’. So, I guess my worry over patients I refer sometimes [doesn’t] get recognized. (Spiritualist, F, 76) Decreased governmental support Yes, at first, they could give us referral cards that after referring them they would be treated fast, the patient was not neglected. But now we are no longer given those referral cards … they would even give us gloves because they know that there are some conditions where even us as traditional healers, we need gloves... So, we know that they respect us. I don’t know about these days when our job of helping women to deliver has been stopped. I don’t know if they still respect traditional healers as before (TH/TBA, F, 59) Similar goals .. The best way that I see biomedicine can be useful to a traditional doctor like myself is when they begin to recognize and support us, maybe with gloves and other needs that can make our work more safe and commendable. They can also help us with civic education/training in some health aspects. We are handling the same patients that they also handle every day. Patients choose both sides, so the best is just to help each other by working together in safer environment (TH, M, 68) Bidirectional referral Some doctors do send some patients to traditional healers when they see that their treatment is not effective. What we all need is for all people to be healthy. Government needs healthy people to help in developing the country. (TH/Diviner, M, 80) Compensation for gaps in the biomedical healthcare system Overcrowding of health facilities The hospital days are usually crowded with people seeking different medical attention. So, I can say the accessibility is limited, those being assisted are also limited because of several problems including limited drug supply and limited government cash flows (TH, M, 54) Transport delays It is the patient that then tells me their problems, like lack of transportation. So, when I have the capacity and resources I do, I even carry them on my motorbike to the hospital. (TH/Spiritualist, 60) Concomitant use with biomedicine Sometimes you wonder even biomedical practitioner (doctors) coming to us seeking medical help. Even though they are well educated they find us here in the village looking for traditional medicine, so they know the difference. (TH, M, 59) Privacy and stigma Women come with problems like [being] infertile or barren. I give them herbs that make them become fertile … Men come with different problems, but some include paralysis and under performance [during sex]. That's common in men. (TH, M, 52) Recognition of causes and risk factors for infections Variable definitions of infection Infectious diseases attacks gradually. You may wonder you stay with it for more days before you realize you are sick, while these non-communicable infections attacks the person instantly and with force… (TH, M, 59) Infections are diseases transmitted from one person to another. These include syphilis, chancroid, and other conditions like spinal bifida and swelling of the umbilical cord area (TH/Spiritualist, F, 70) Understanding of transmission Some [diseases] are from food, others from reckless behavior like not washing hands or in short poor sanitation. Not having refuse pits, untidy homes. But washing hands with soap will make us safe from several diseases. You eat a guava fruit without washing it, you never know what was on it before plucking and eating it.” (TH/Spiritualist, M, 60) [One gets infected by measles through] bewitching each other and borrowing each other clothes, especially with those infected (Spiritualist, F, 50) Treatability I challenge that if I fail to treat an infection then even at hospital they cannot manage. If it's not a normal infection, then I advise them to go to traditional healers instead of wasting their time at the hospital. Particularly those connected with witchcraft. (TH/diviner, M, 80) If the symptoms are new then we know that the infection is unusual, If I know that I have never seen that type of infection based on the patient presenting symptoms; I just tell them I should not waste your time, hurry and go to the hospital and tell them the symptoms, so that they can see what to do. (Spiritualist, M, 52) Leadership and role in the community Financial support/resources Most of the times people come with different health problems. They may come while crying. I help them but what they give me in return sometimes is not enough, meaning that most of my work is for free just to help people ... because I was born with a soft heart. There are healers who send back patients because they do not have enough money, but for me I cannot do that, (TH, M, 59) Community leader I am a citizen of this village, I was born and raised in this village... and just to add more, I am the chief of this village now (TH/TBA, F, 59) Social support There are some women who come with marital problems, some they want a job opportunity or maybe they want a child … (Spiritualist, F, 76) TBA= Traditional birth attendant Theme 1. Relationship-building with clients for diagnosis and treatment Traditional healers rely on taking a good history and performing a physical exam to diagnose and treat their patients. They utilize their proximity to their clients and presence as members of their community, which allows for follow-up visits and a trial-and-error approach to determine if their initial assessment and treatment were accurate. Traditional healers believe biomedicine has better diagnostic ability through access to disease-specific testing and technology that they do not have. Many TH, particularly herbalists, reported lacking diagnostic tools and sending patients to the hospital first for a diagnosis to inform their own management. This TH discusses using the hospital to provide a diagnosis to help them determine which herbal treatment to use: “ I give help according to what they are presenting with, the presenting symptoms, the disease history and the diagnosis from the hospital if they have any; all these help me to know which herbal medication to give. If I know the type of herbs of that particular disease, I give [the medication] but if I do not know I refer the patient to the hospital again.” (Herbalist, M, age 49) Another details the process of follow up and continuity of care with their clients to assess the efficacy of therapy and to guide further management, a luxury that is often not available to patients using biomedical facilities for care given the long travel distances and resources needed to get to a more centralized clinic or hospital for care: “ ...when someone comes, I look at him and I know something went wrong somewhere. I get some herbs, put them on a leaf … Get some that he can be adding to his porridge and give him, and also give him some to boil and be drinking … When he takes those, you will see him coming the following day, [telling me] he is okay. ” (TH/Spiritualist/Diviner, M, age 84) The importance of hearing the patient’s full history is highlighted here. Traditional healers indicated that they often have a strong relationship with their clients and are able to spend time with them to get to the root of their concerns in comparison to some of the biomedical sites with limited staffing. “Through asking questions to the client, that’s our main diagnosis tool, because when you don’t ask, then the patient may be delayed the health aid...” (TH, M, age 54) Theme 2. Trust and willingness to collaborate with biomedicine Most TH believe that biomedicine is necessary and can be trusted, aside from some of the negative effects of staffing and resource limitations and recent fears by the public surrounding COVID-19 and vaccination. Traditional healers indicate that they often refer clients and use biomedical facilities themselves for care when they are ill. They also provided examples of bidirectional referrals and receiving patients sent by biomedical providers for further care. Traditional healers have a desire to formalize this relationship even further and provided examples of previous programs where collaboration with biomedicine was stronger and supported by the Malawi Ministry of Health. They emphasize that current government policies and lack of recognition have made it more difficult for them to earn the respect of biomedical providers. One TH discussed her opinions on biomedicine and doubts in the community that arose during the COVID-19 pandemic: “ My opinion on biomedicine is that they are necessary ... People started having doubts on biomedicine because of coronavirus believing that it was a satanic plot to wipe out communities. To me, I did not believe that ... I saw that there is no reason to fear an injection [of the COVID-19 vaccine] and I just received it. ” (Spiritualist, F, age 64) When unfamiliar with the disease, TH typically refer patients to the hospital. Many remembered having a more formal referral process in the past that has changed in recent years. “ At first, we had referral papers that we would give patients, but it seems that initiative just died a natural death for some reason … Those referral papers were helpful in that when they get to the hospital, they should know that they are been referred from here. And when coming bac,k they would come here first but now all this stopped. So, we just tell [the patient] to go to a biomedical facility and when they are there it is up to them… ” (Spiritualist, F, age 76) However, some TH do not feel respected by biomedical providers and even recommend patients not to tell the hospital they visited a traditional healer due to fear of the patient being treated unfairly. “ We do not understand why traditional healers and biomedical service providers do not find a way to work together because both of us have our interest in the same subject, the patient. The hospitals need the patient, so do we. Both of us, our agenda is the same, to heal. So why can’t we tolerate each other? ... it was discovered that the biomedical practitioners look down on traditional healers because they went to formal colleges and attended training courses in biomedicine.” (Interview with members of Traditional Healers Association of Malawi) Some TH also commented on the decrease in support from the Malawian Government, and their decision to ban the use of traditional birth attendants (TBAs) for deliveries and the requirement that all pregnant people receive services at a biomedical facility. “ Imagine how it happened with Traditional Birth Attendants. They were completely stopped instead of finding a better way to improve their practice through training them, learn their ways and improve their practice. But it just stopped. ” (TH, M, age 52). “ Sometimes the Ministry of Health could invite us [to seminars], especially in the past but now it does not happen. In the past, they would take us for training on how we can receive a patient, but also that time we could communicate and a give us a patient from the hospital and us too could give them patients. ” (Spiritualist, F, age 76) Despite this, there is a strong desire to collaborate with biomedicine and further the care of their patients and the community. Traditional healers feel they share similar goals to biomedical providers and want the public to have access to high-quality health care. “ I am telling you that, we want the government hospitals together with us, we should be working together ... agreement on modalities of how we can work together instead of sidelining each other ... there should be coordination ” (TH, M, age 68) Theme 3. Compensation for gaps in the biomedical system Traditional healers provide care for community members who may have difficulty accessing biomedicine or are afraid of stigma and judgment. Participants provided examples of how TH often provide transportation or accessibility for patients who cannot present to the hospital or do not have the resources to get to a biomedical facility or pay for the treatment they may need. Additionally, TH cite only being called upon by the Ministry of Health during times of public health emergencies like during the COVID-19 pandemic, but then feeling forgotten once the crisis has passed. Traditional healers recognize the lack of resources and biomedical providers as a gap they can fill in the community. Here, THs note the assistance they provide with transportation and more accessible, flexible payment for treatment options, since many hospitals and medications are not easily available to community members both due to distance and financial costs. Despite the government hospitals being free, there are often drug shortages that require patients to visit private pharmacies that are significantly more costly. “If they do not have money, they just use a bicycle to carry the patient, (pushing) the patient slowly until they reach there. Because they don’t have money. It’s terrible to narrate these sad events. This is why we do assist them with what we can before they reach the hospital to help preserve the patient lives on the way.” (TH/Spiritualist/Diviner, M, age 84) “It all depends on government hospitals because they are free. That’s why we want government to recognize the traditional healers so that people can access medicine from traditional healers because herbs are cheaper than biomedicine, but financially you can’t access biomedicine anywhere unless you visit a government facility. Biomedicine is expensive in pharmacies and other outlets and an ordinary villager cannot afford it.” (Herbalist, M, age 64) This TH describes how, during recent measles outbreaks, they were recruited to advise people on precautionary measures but felt TH presence was only acknowledged when biomedical providers needed something from them and the “situations are tough” instead of considering them as important colleagues and collaborators. “Most times us tradition healers we are considered useless by those who provide biomedical healthcare, we are only considered when things are critical, but when there is peace, we are useless people.” (TH, M, age 59) Some healers also describe providing care to clients who may face stigma for sensitive issues such as sexual performance or infertility. One healer describes how some clients prefer his services and feel more comfortable due to facing discrimination at biomedical facilities: “ A poor person and their appearance alone, they are left to die … That is why some people do not trust the hospital, when there is help, but because of profiling .” (TH/Spiritualist, M, age 60) Theme 4. Recognition of causes and risk factors for infections Traditional healers primarily separate illness into either spiritual/traditional vs. biomedical in etiology, thus defining what constitutes an infectious illness and level of understanding of infectious pathophysiology is highly variable. Mechanisms of infectious disease transmission like respiratory and fecal-oral contact were commonly described, but traditional explanations were also frequently used. Specific knowledge of germs, such as bacteria or viruses, and how they differ was much less well understood. There was also a high degree of variation in what is considered “treatable” based on attribution of cause to traditional vs. biomedical cause of illness. This TH describes how they believe many infections are caused by bewitchment and can be treated with traditional medicine. While TH universally believe diseases caused by spiritual or traditional causes, such as bewitchment, cannot be treated by biomedicine, disease states that fall into this categorization vary by provider. This healer describes successfully treating infections being caused by bewitchment: "All I can say is that I treat infections. I have got treatment for different infections. For example, when I give some treatments, the patients purge, then they look like they are drunk, then all infections are gone! Then I command that every (bad thing) that is within the body of the man should go out, whatever it is in his body, the bad omen goes out through defecation ... so I just suggest that he was bewitched.” (TH/Diviner, M, age 52) While this TH reports not knowing what causes infections: “These Infections I should not lie… us as herbalist we don’t know where they come from, but biomedical facility can know because they have examination equipment.” (Spiritualist, M, age 52) While another specifically mentions understanding that microorganisms cause tuberculosis (TB): “The coughs that are spreading all over, it is when I cough out sputum or I have TB and cough there, then that microorganism that cause TB will go and enter someone, that person will also start coughing .” (Spiritualist, F, age 64) Many TH placed emphasis on poor hygiene or risky behavior as key in the transmission of infectious diseases: “Some people are not using condoms … whether it is woman, or a man, they will sleep with many partners without a condom. they will go there, sleep with that one, take a disease and transfer it to another just like that … All sorts of infections are there, through the bad behavior, the promiscuous behavior. ” (TH, M, age 68) While others use traditional explanations: “There has to be a difference because they are some illnesses even if you wash your hands, you still get the infection. For example, traditionally epilepsy when you are at the back of the one having convulsions and they pass flatus; you can get the disease as well. But if you stand at the front, you cannot.” (TH, M, age 78) Perceptions of treatability also varied greatly among TH, with some describing consistent referral of common infections like malaria, tuberculosis, cholera, HIV/AIDs, and COVID-19 to biomedical facilities for treatment, while others endorsed their own ability to treat some of these same illnesses. For example, one healer describes referring a patient to the hospital with suspected malaria for diagnostic testing and biomedicine as standard procedure. “ On malaria we cannot give a person medicine because we do not have the treatment for malaria...he needs to go to the hospital to be told the severity of the malaria and the treatment he will get, either quinine or LA (lumefantrine-artemether). Myself I cannot do that.” (Spiritualist, F, age 64) However, this TH on the other hand says there is a traditional medicine for malaria that can also be used as an alternative, after the patient has been diagnosed at a biomedical facility: “... we just tell them that this could be malaria, and you should go to a biomedical facility to get quinine, but we do have our own traditional medicine that is bitter like quinine, we give the person and the person gets better.” (Spiritualist, F, age 76) Theme 5. Leadership role in the community Traditional healers describe feeling well-respected by their communities and often provide social services like financial support or help with transportation for their clients. They also note the influence they have on the perception of biomedicine by the community and help sensitize people to the importance of public health interventions, like the COVID-19 vaccine. Some even serve as village chiefs or local government leaders and report attending meetings at hospitals to advocate for their community and culture. They report assisting their clients in dealing with a variety of social and familial issues such as marriage and financial struggles, in addition to provision of medical care. This TH discusses giving his clients money to support them: “Some come with unhappy pale faces, as if there is a funeral, or child is sick, so I give them medicine and tell them to bring the patient, I give them money to use, I am not a greedy doctor.” (TH/Diviner, M, age 52) One TH explained how he tries to help community members understand the lack of healthcare resources when they are frustrated that they cannot get the care they need: “But the main problem that people don’t know is that the challenges at the government hospitals are not caused by the doctors but rather government. For me as a group Chief, I have a role to sensitize people on this. For instance, [health center in the area], doesn’t have enough health workers ... when the patient is brought at night and the health worker is not on duty, the people will still demand that the person should work ... [and] he is the only health worker at the institution, and he is supposed to perform all the duties during the day and night which may be exhausting. But the community will be infuriated for feeling being ignored. But our role is to explain to these communities on the shortage of health workers.” (TH, M, age 54) Others provide social support to clients, including those with chronic illnesses, and emphasize their need to take their medications and not purely rely on traditional medicine for disease states that have a known biomedical treatment. “We had a case of a client who had rashes, when he called and explain his symptoms, I asked him if he went to the hospital and get his blood test. But it was found that he had stopped taking ARVs [anti-retrovirals]. We always encourage patients on ARVs to take their drugs because if they stop then drugs cannot work effectively in their bodies.” (TH, M, age 54) Discussion Traditional healers in Malawi acknowledge a reliance and willingness to collaborate with biomedicine while highlighting their ability to fill some of the existing health systems resource gaps given their role as leaders and trusted members of their communities. Understanding of infectious disease states by TH is highly variable and further training is needed to improve recognition of conditions more concerning for emerging or re-emerging pathogens where public health systems may benefit from early detection, or conditions that require antimicrobials or other treatment that can only be obtained at a biomedical facility. Traditional healers indicate a willingness to learn and a desire for more trainings and recognition by the Ministry of Heath so that they can improve their skills and play a larger role in Malawi’s healthcare system. Our findings are consistent with prior studies in SSA demonstrating that TH are open to collaboration and often view their services as separate or adjunctive to biomedical healthcare. While there are some studies arguing that the use of traditional medicine can be dangerous, harmful, or cause delays in care ( 6 , 9 , 19 – 22 ), there are many others describing traditional healers working effectively within the biomedical system or providing support to those undergoing biomedical care. Healers may not only serve as informal providers but often add social support and encouragement for those reluctant or having difficulty with the biomedical healthcare system, particularly for persons living with HIV ( 5 , 23 – 29 ). There are notable social and political barriers to collaboration with the biomedical system, which has led to frustration by TH with the government’s lack of attempt to bridge the divide. This is apparent in the 2007 decision by the Malawian Ministry of Health to ban the use of traditional birth attendants. A unilateral reduction or ban on the use of traditional healers, including TBAs, for care may not result in improved outcomes if biomedical facility access and quality of services are not expanded simultaneously, given the complex dynamics and multiple factors that influence healthcare delivery, particularly to marginalized populations ( 30 – 33 ). As with the use of community health workers or other lay providers within the public health system, requiring some degree of regulation, registration, baseline training, and skills assessments for TH may mitigate some of the harms that stem from use of corrupt, deceptive, or underqualified individuals for care. A prior study in rural Uganda found that TH were successfully engaged in a program to recognize and refer clients with signs of Bubonic plague ( 23 ). Based on this and our current study findings, the inclusion of TH as sentinel providers within the biomedical system is feasible but will require additional training and investment in them by biomedical systems in Malawi. As TH already alluded to being called upon during the COVID-19 and other public health crises, providing advance preparation and training to recognize and assist during other potential threats is imperative to maximize efficacy of their role in these processes. As indicated by the variable responses on how to diagnose and treat potential infections, TH need training on risk factors for emerging or re-emerging infections and assessment of which conditions are more likely to be easily transmitted or require early detection and treatment to prevent sequelae or outbreaks. This will require cooperation and more formalized systems within Malawi’s current healthcare infrastructure, which may be difficult to pursue without additional funding and resources. More studies are needed to pilot this process at a limited number of TH sites and determine how to make this as streamlined and cost-effective as possible, prior to widespread implementation. Our study had several limitations. First, we only included the perspective of traditional healers and did not assess views of biomedical providers or clients, thus, it is likely that TH interpreted their potential role and service to their communities in a more positive light. Second, this study occurred within one region of Malawi where an organized Traditional Healer Association exists, and many participants were members of this group. This may have led to recruitment of more highly trained healers or those with more respect for their integrity versus others who do not participate in this organization. Conclusion Traditional healers in Malawi respect and value biomedicine and are open to collaboration. They view themselves as filling gaps in the public healthcare system caused by financial hardship and lack of accessibility by rural populations, including in times of crisis, such as the COVID-19 pandemic. More training and education on infectious diseases and outbreak detection is needed prior to integration of healers into the biomedical system to serve as sentinel providers for emerging and re-emerging infectious threats. Abbreviations SSA: sub-Saharan Africa; TBA: traditional birth attendant; TH: traditional healer; WHO: World Health Organization Declarations Ethics approval and consent to participate This study was approved by the University of California, San Francisco (UCSF) Internal Review Committee (IRB) and the Malawi University of Science and Technology Research Ethics Committee (MUSTREC). All study procedures conformed to the Declaration of Helsinki for the Protection of Human Subjects of 1964 (revised 2013). Interview participants provided written, informed consent prior to participation. Survey participants were verbally consented to participation on an anonymous basis. Personal information that could identify participants was omitted for recordings, transcriptions, and translations to the maximum possible extent. Consent for publication Not applicable Availability of data and materials The data used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Study funding was provided by a grant from the University of California, San Francisco Institute for Global Health Sciences Center for Pandemic Preparedness and Response (AH, GB) and the UCSF Department of Humanities (RM). Travel grant funding was provided by the UCSF Department of Emergency Medicine Global Health Section (AH). Authors’ Contributions RM was responsible for development of study instruments, data analysis, synthesis of study findings, interpretation of results, and manuscript preparation. AM was responsible for study design, development of study instruments, data collection, data integrity, oversight of study staff, interpretation of results and review for cultural context, and manuscript preparation. KB was responsible for development of study instruments, data analysis, interpretation of results, and manuscript review. GB was responsible for study design, study oversight, data analysis, interpretation of results and review for cultural context, and manuscript review. AH was responsible for study design, development of study instruments, study oversight, data integrity, analysis, interpretation of results, and manuscript review. Acknowledgements We would like to recognize our study staff for their tireless efforts in high quality data collection in difficult to reach settings and to the traditional healers for welcoming us into their clinics and communities. References Kokota D, Stewart RC, Abbo C, Bandawe C. Views and experiences of traditional and Western medicine practitioners on potential collaboration in the care of people living with mental illness in Malawi. Malawi Med J. 2022 Dec 16;34(4):231–8. Bickton FM. Strengthening human resources for health in resource-limited countries: The case of Medic to Medic in Malawi. Malawi Med J. 2019 Mar 31;31(1):99. Audet CM, Ngobeni S, Wagner RG. Traditional healer treatment of HIV persists in the era of ART: a mixed methods study from rural South Africa. BMC Complement Altern Med. 2017 Dec;17(1):434. Sundararajan R, Ponticiello M, Lee MH, Strathdee SA, Muyindike W, Nansera D, et al. Traditional healer-delivered point-of-care HIV testing versus referral to clinical facilities for adults of unknown serostatus in rural Uganda: a mixed-methods, cluster-randomised trial. Lancet Glob Health. 2021 Nov;9(11):e1579–88. Warsame M, Gyapong M, Mpeka B, Rodrigues A, Singlovic J, Babiker A, et al. Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial. Clin Infect Dis. 2016 Dec 15;63(suppl 5):S312–21. Barker RD, Millard FJC, Malatsi J, Mkoana L, Ngoatwana T, Agarawal S, et al. Traditional healers, treatment delay, performance status and death from TB in rural South Africa. Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2006 Jun;10(6):670–5. Hooft A, Nabukalu D, Mwanga-Amumpaire J, Gardiner MA, Sundararajan R. Factors Motivating Traditional Healer versus Biomedical Facility Use for Treatment of Pediatric Febrile Illness: Results from a Qualitative Study in Southwestern Uganda. Am J Trop Med Hyg. 2020 Jul 8;103(1):501–7. Lampiao F, Chisaka J, Clements C. Communication Between Traditional Medical Practitioners and Western Medical Professionals. Front Sociol. 2019 Jun 21;4:37. Teshager NW, Amare AT, Tamirat KS, Zeleke ME, Taddese AA. Traditional herbal medicine use doubled the risk of multi-organ dysfunction syndrome in children: A prospective cohort study. Chen RJ, editor. PLOS ONE. 2024 Feb 23;19(2):e0286233. Van Der Watt ASJ, Nortje G, Kola L, Appiah-Poku J, Othieno C, Harris B, et al. Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qual Health Res. 2017 Dec;27(14):2177–88. Maze MJ, Bassat Q, Feasey NA, Mandomando I, Musicha P, Crump JA. The epidemiology of febrile illness in sub-Saharan Africa: implications for diagnosis and management. Clin Microbiol Infect. 2018 Aug;24(8):808–14. Baltzell K, Kortz T, Scarr E, Blair A, Mguntha A, Bandawe G, et al. “Not all fevers are malaria”: a mixed methods study of non-malarial fever management in rural southern Malawi. Rural Remote Health [Internet]. 2019 Jun 15 [cited 2025 Jan 8]; Available from: https://www.rrh.org.au/journal/article/4818 Kortz TB, Blair A, Scarr E, Mguntha AM, Bandawe G, Schell E, et al. Characterizing Pediatric Non–Malarial Fever and Identifying the At-Risk Child in Rural Malawi. Glob Pediatr Health. 2018 Jan 1;5:2333794X17750415. Aron MB, Mulwafu M, Mailosi B, Kreuels B, Dullie L, Kachimanga C, et al. Experiences and practices of traditional healers on snakebite treatment and prevention in rural Malawi. PLoS Negl Trop Dis. 2023 Oct;17(10):e0011653. Boum Y, Kwedi-Nolna S, Haberer JE, Leke RRG. Traditional healers to improve access to quality health care in Africa. Lancet Glob Health. 2021 Nov;9(11):e1487–8. Healers important tool in preventing AIDS in Malawi. AIDS Wkly. 1994 Nov 21;10. Munthali AC, Mannan H, MacLachlan M, Swartz L, Makupe CM, Chilimampunga C. Non-use of Formal Health Services in Malawi: Perceptions from Non-users. Malawi Med J J Med Assoc Malawi. 2014 Dec;26(4):126–32. Zachariah R. Health seeking and sexual behaviour in patients with sexually transmitted infections: the importance of traditional healers in Thyolo, Malawi. Sex Transm Infect. 2002 Apr 1;78(2):127–9. Burns JK, Tomita A. Traditional and religious healers in the pathway to care for people with mental disorders in Africa: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2015 Jun;50(6):867–77. Gallaher JR, Purcell LN, Banda W, Charles A. The effect of traditional healer intervention prior to allopathic care on pediatric burn mortality in Malawi. Burns J Int Soc Burn Inj. 2020 Dec;46(8):1952–7. Luyckx VA, Steenkamp V, Rubel JR, Stewart MJ. Adverse Effects Associated With The Use Of South African Traditional Folk Remedies. 2004 May 31 [cited 2025 Jan 23]; Available from: https://opendocs.ids.ac.uk/articles/journal_contribution/Adverse_Effects_Associated_With_The_Use_Of_South_African_Traditional_Folk_Remedies/26480974/1 Zamawe C, King C, Jennings HM, Fottrell E. Associations between the use of herbal medicines and adverse pregnancy outcomes in rural Malawi: a secondary analysis of randomised controlled trial data. BMC Complement Altern Med. 2018 May 25;18(1):166. Apangu T, Candini G, Abaru J, Candia B, Okoth FJ, Atiku LA, et al. Engagement with Traditional Healers for Early Detection of Plague in Uganda. Am J Trop Med Hyg. 2023 Nov 1;109(5):1129–36. Audet CM, Pettapiece-Phillips M, Tian Y, Shepherd BE, Vermund SH, Salato J. “If it weren’t for my traditional healer, I would be dead”: Engaging traditional healers to support people living with HIV in rural Mozambique. PloS One. 2022;17(6):e0270565. Audet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci IS. 2017 Apr 13;12(1):50. Baheretibeb Y, Wondimagegn D, Law S. Holy water and biomedicine: a descriptive study of active collaboration between religious traditional healers and biomedical psychiatry in Ethiopia. BJPsych Open. 2021 May 5;7(3):e92. Makundi EA, Malebo HM, Mhame P, Kitua AY, Warsame M. Role of traditional healers in the management of severe malaria among children below five years of age: the case of Kilosa and Handeni Districts, Tanzania. Malar J. 2006 Jul 18;5:58. Sundararajan R, Alakiu R, Ponticiello M, Birch G, Kisigo G, Okello E, et al. Understanding traditional healer utilisation for hypertension care using the Andersen model: A qualitative study in Mwanza, Tanzania. Glob Public Health. 2023 Jan;18(1):2191687. Sundararajan R, Langa PV, Morshed T, Manuel S. Traditional healers as client advocates in the HIV-endemic region of Maputo, Mozambique: results from a qualitative study. SAHARA J J Soc Asp HIVAIDS Res Alliance. 2021 Dec;18(1):77–85. Creanga AA, Gullo S, Kuhlmann AKS, Msiska TW, Galavotti C. Is quality of care a key predictor of perinatal health care utilization and patient satisfaction in Malawi? BMC Pregnancy Childbirth. 2017 May 22;17(1):150. Godlonton S, Okeke EN. Does a ban on informal health providers save lives? Evidence from Malawi. J Dev Econ. 2016 Jan 1;118:112–32. Mselle LT, Moland KM, Mvungi A, Evjen-Olsen B, Kohi TW. Why give birth in health facility? Users’ and providers’ accounts of poor quality of birth care in Tanzania. BMC Health Serv Res. 2013 May 10;13(1):174. Shajarizadeh A, Grépin KA. The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India. BMJ Glob Health. 2022 Jul;7(7):e007926. Additional Declarations No competing interests reported. Supplementary Files SupplementalFile1.docx Supplemental files: Supplemental File 1: Traditional healer interview template Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5975877","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":412556124,"identity":"bdaf1c4e-2a5a-4379-82b1-f9b99e881ac7","order_by":0,"name":"Riya Master","email":"","orcid":"","institution":"University of California San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Riya","middleName":"","lastName":"Master","suffix":""},{"id":412556125,"identity":"dcd8356c-8b12-42c9-a452-fdd0213dbbfd","order_by":1,"name":"Andrew Mguntha","email":"","orcid":"","institution":"ENANDY Research Consultancy","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Mguntha","suffix":""},{"id":412556126,"identity":"3b6a3942-d6cc-4ef6-a1ff-e6253a126845","order_by":2,"name":"Kimberly Baltzell","email":"","orcid":"","institution":"University of California San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Kimberly","middleName":"","lastName":"Baltzell","suffix":""},{"id":412556127,"identity":"a94622f9-a2a6-43da-a4da-7cdc6d07d115","order_by":3,"name":"Gama Bandawe","email":"","orcid":"","institution":"Malawi University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Gama","middleName":"","lastName":"Bandawe","suffix":""},{"id":412556128,"identity":"f286f193-b9e1-4e76-8732-3c9a22417c6d","order_by":4,"name":"Anneka Hooft","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACNiBmbGBgSABSDxg+AHnsQJ4EPi38CC3Mho0zgDyeAwS0SDYgaWnmIUaLwe3egw9n1DDk8bM3sz+2bbOz52FgPnibB5+WO+eSDTccYyiW7DnM2JzblpzYw8CWbI1Xy40cM8kHbAyJG27kHwRqOZBgz8BjJo1Pi/2NHPOfD/6BtCQzNlu2HQA6jP8bXi0gWxg3tkG1MLYdYOxh4GEjpMVYcmafROJMoF9m9pwD+oWZzdhyDn4thh97vtkk9rM3M3z4UQYMMfbmhzfe4NECBcgRwUxY+SgYBaNgFIwCAgAAMixMuHbzW+wAAAAASUVORK5CYII=","orcid":"","institution":"University of California San Francisco","correspondingAuthor":true,"prefix":"","firstName":"Anneka","middleName":"","lastName":"Hooft","suffix":""}],"badges":[],"createdAt":"2025-02-06 18:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5975877/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5975877/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75999603,"identity":"9859917a-fbc0-404c-bfaf-b82eac35e83c","added_by":"auto","created_at":"2025-02-11 10:20:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":370966,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMap of traditional healer study sites within Thyolo District\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMalawi (depicted in bright orange) is show for context within Southeast Africa. Thyolo District is in the southeast of the country bordering Mozambique. Locations of healer practices included in the study within Thyolo District are depicted by navy blue dots.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5975877/v1/ae90d3f4519539ec89597a2c.png"},{"id":76099540,"identity":"31700dd1-3b72-4868-80ad-950d030e9349","added_by":"auto","created_at":"2025-02-12 09:53:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1132447,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5975877/v1/621c5876-2eb7-46db-831c-8c2957f1b0f5.pdf"},{"id":75999605,"identity":"5c9f8d32-f62c-4274-adee-aa6bccbfb632","added_by":"auto","created_at":"2025-02-11 10:20:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17354,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental files:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplemental File 1: Traditional healer interview template\u003c/p\u003e","description":"","filename":"SupplementalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5975877/v1/16ab20b9978fbf4e61496ec6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the role of traditional healers in the Malawian healthcare system: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalawi is a pluralistic health system, where patients seek care from both formal/biomedical (e.g., public or private hospitals, pharmacies) and informal (e.g., traditional healers, drug shops) sources. According to the World Health Organization (WHO), a traditional healer (TH) is defined as: \u0026ldquo;a person who is recognized by the community where he or she lives as someone competent to provide health care by using\u003c/p\u003e \u003cp\u003eplant, animal, and mineral substances and other methods based on social, cultural, and religious practices (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u0026rdquo; In Malawi, as in many countries in sub-Saharan Africa (SSA), there is a drastic shortage of biomedical health workers relative to the population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and it is estimated that over 80% of Malawians utilize TH for their care. Some TH consider themselves experts in herbal medications (herbalists), others in spiritual problems and treatments (spiritualists), others as specialists in divination to determine the cause of a problem (Diviners), some serve as informal midwives (traditional birth attendants), and many provide a combination of services or consider themselves general practitioners of traditional medicine.\u003c/p\u003e \u003cp\u003eDue to the widespread use of traditional healers in Malawi, these informal providers present a unique opportunity to bridge gaps in healthcare between rural communities and the biomedical sector. Successful examples of collaboration between traditional healers and biomedicine have been demonstrated by other studies in the Global South (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, there are numerous barriers to these collaborations, including distrust, negative attitudes, differing ideologies, and a lack of recognition of traditional healers within the biomedical space (\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Understanding how these viewpoints and perspectives of traditional healers is critical to establishing joint healthcare initiatives with biomedicine in Malawi.\u003c/p\u003e \u003cp\u003eMalawi and other countries in SSA are estimated to have high rates of zoonotic and arthropod-transmitted infections and are at high risk for outbreaks of emerging and re-emerging diseases, however, a lack of diagnostic resources and health infrastructure makes early detection difficult (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Laboratory testing capacity and treatment of these infections are concentrated in urban, central hospitals; thus, patients presenting to informal providers in rural areas may face large delays in reaching a biomedical referral center, leading to losses of valuable time and data that could be used to initiate early interventions and curb potential outbreaks (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Detection and surveillance capacity for these diseases in Malawi is behind World Health Organization Standards for the region, and the prevalence of these infections is poorly described.\u003c/p\u003e \u003cp\u003eThere are currently no established mechanisms for the inclusion or recognition of TH within the biomedical system in Malawi, despite indications that TH are willing to collaborate (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Given their ease of access, integration, respected role within their communities, and high rates of utilization by the population, particularly in rural areas and villages, informal providers may have untapped potential for integration into the public health system (\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Before TH can be integrated as sentinel providers within the biomedical system, we must first understand how TH view their role and how they interact. The primary goal of this qualitative study is to characterize TH perceptions of their role within the biomedical system and their communities and to assess their knowledge and understanding of infectious diseases as part of a larger study that will ultimately create and refine a structured pipeline for early sample collection and pathogen detection from clients in high-risk, remote areas in Malawi.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and Setting\u003c/p\u003e \u003cp\u003eThis was a qualitative interview study of traditional healers in Thyolo District, Malawi conducted in May 2024. Thyolo District is a primarily rural, geographically diverse, agricultural district in Southern Malawi with a population estimate of almost 460,000. It borders Mozambique, is home to Malawi University of Science and Technology and is less than 20 kilometers from Malawi\u0026rsquo;s second largest city Blantyre, making it an ideal pilot site for the development of enhanced surveillance systems.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQualitative sampling and recruitment\u003c/h2\u003e \u003cp\u003eWe used anonymous survey data collected by our study team in-person via a convenience sample of adult participants from the general public who were recruited in villages throughout the Thyolo region (e.g. at trading centers, near health facilities) to identify TH for recruitment. These surveys included questions on the healthcare preferences and specific locations of informal provider practices, primarily TH sites, in the region. Based on these survey results, local research team knowledge and familiarity with the region and culture (AM), and engagement of the Traditional Healer Association of Malawi, participants for key informant interviews were then identified and recruited using purposive, maximum variation sampling. Interested TH participants were initially approached via phone or at their place of work, then enrolled and consented in person prior to participation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe interviewed traditional healers who diagnose and treat patients in Thyolo District in person at a private location of their choosing near their healer practice site. Local members of the study team trained in qualitative interviewing techniques and fluent in both English and Chichewa (the local language) conducted semi-structured, individual interviews lasting approximately 1 hour in length, at the TH clinic sites. Interviews were conducted in Chichewa using a semi-structured interview guide (Supplementary File 1). Interview questions were aimed at understanding TH perceptions of their role in providing health services within their communities, particularly in relation to the diagnosis and management of infectious diseases. We also asked about their relationship with biomedicine and included questions to help identify those who may be good candidates for partner sites to act as sentinel providers for the next phase of the study.\u003c/p\u003e \u003cp\u003eInterviews were audio-recorded and then transcribed and translated into English by a bilingual (Chichewa/English) speaking research assistants. Transcription and translation quality were verified by AM and GB, both fluent in English and Chichewa.\u003c/p\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003cp\u003eInterview content was uploaded to Dedoose (Version 9.2.22, SocioCultural Research Consultants, LLC) and coded by two researchers independently (AH and RM) using thematic analysis methodology to identify major themes. The goals of the larger study were used in the initial organization and generation of codes using a deductive approach, with additional codes generated inductively using an iterative approach. In the case of differing perspectives, discussion between the researchers and verification with interviewers occurred until a consensus was reached. After initial analysis, the themes and subthemes and key codes used to generate them were reviewed further through discussion with the full study team, including two local team members familiar with cultural norms (AM and GB) to generate a conclusive list of themes and sub-themes was generated after discussion with the full team (AH, RM, KB, AM, and GB).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe surveyed 135 adults across the Thyolo region, with over 100 of these participants providing at least one traditional healer practice site with which they were familiar. From these sites and recommendations from the Traditional Healer Association, we interviewed a total of 25 traditional healers, 17 male and 8 female. Age and length of time in practice ranged from 25 to 84 years, and 8 months to 60 years, respectively, with practice sites located throughout Thyolo District (Figure 1). Most participants identified as a general traditional healer with training obtained from their family members (Table 1). The following major themes were identified: 1. Relationship-building for diagnosis and treatment; 2. Trust and willingness to collaborate with biomedicine; 3. Compensation for gaps in the biomedical system; 4. Recognition of causes and risk factors for infection; and 5. Leadership and role in the community (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Traditional healer participant characteristics. Basic\u003c/strong\u003e characteristics and practice specialty as identified by traditional healer participants.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey informants (N = 25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 322px;\"\u003e\n \u003cp\u003eAge (years), mean (SD)\u003c/p\u003e\n \u003cp\u003eLength of practice (years), mean (SD)\u003c/p\u003e\n \u003cp\u003eGender, \u003cem\u003en\u003c/em\u003e (%):\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Male\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003cp\u003eTraining, \u003cem\u003en\u003c/em\u003e (%):\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Family members\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Spiritual calling\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Informal training\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Some formal training\u003c/p\u003e\n \u003cp\u003eHealer specialty, \u003cem\u003en\u003c/em\u003e (%):\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; General traditional healer\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Herbalist\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Spiritualist\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Diviner\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Traditional Birth Attendant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e59.8 (13.8)\u003c/p\u003e\n \u003cp\u003e30 (16)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (68)\u003c/p\u003e\n \u003cp\u003e8 (32)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (56)\u003c/p\u003e\n \u003cp\u003e10 (40)\u003c/p\u003e\n \u003cp\u003e8 (32)\u003c/p\u003e\n \u003cp\u003e8 (32)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (56)\u003c/p\u003e\n \u003cp\u003e6 (24)\u003c/p\u003e\n \u003cp\u003e9 (36)\u003c/p\u003e\n \u003cp\u003e4 (16)\u003c/p\u003e\n \u003cp\u003e2 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD= standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Themes, subthemes, and illustrative quotations.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes and subthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuotation (Specialty, gender, age in years)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 684px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship-building for diagnosis and treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eReliance on history/exam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003eFirstly, I do not \u0026nbsp;have examination tools, as I have already said, I am not a fortune teller, so I depend on patients history on what he or she tells me \u0026nbsp;from there I can decide \u0026nbsp;how to \u0026nbsp;treat the client \u0026nbsp;so \u0026nbsp; \u0026nbsp; from the history \u0026nbsp;if it something I cannot manage, \u0026nbsp;I refer the client to the hospital (Traditional Healer, M, 52)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eContinuity of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003e...we just instruct someone to mix and just take maybe half tumbler ... we tell them to take for 7 days and come back again ... if it did not change, we give them another traditional medication. (Spiritualist/Herbalist, F, 64)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eTrial and error\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003eSo, I just try to help \u0026hellip; just a trial, am not even guaranteed that the person will get well at all times \u0026hellip; the spirits are the ones that do the final part\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(TBA/Diviner, F, 60)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 684px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWillingness to collaborate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eVariation in cooperation with biomedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003e[Care of the patients I refer] depends on the heart of the doctor that they meet at the hospital. Some doctors are open to work with others while others are just the \u0026lsquo;know it all\u0026rsquo;. So, I guess my worry over patients I refer sometimes [doesn\u0026rsquo;t] get recognized. (Spiritualist, F, 76)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eDecreased governmental support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes, at first, they could give us referral cards that after referring them they would be treated fast, the patient was not neglected. But now we are no longer given those referral cards \u0026hellip; \u0026nbsp;they would even give us gloves because they know that there are some conditions where even us as traditional healers, we need gloves... So, we know that they respect us. I don\u0026rsquo;t know about these days when our job of helping women to deliver has been stopped. I don\u0026rsquo;t know if they still respect traditional healers as before (TH/TBA, F, 59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eSimilar goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003e.. The best way that I see biomedicine can be useful to a traditional doctor like myself is when they begin to recognize and support us, maybe with gloves and other needs that can make our work more safe and commendable. They can also help us with civic education/training in some health aspects. We are handling the same patients that they also handle every day. Patients choose both sides, so the best is just to help each other by working together in safer environment (TH, M, 68)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eBidirectional referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 507px;\"\u003e\n \u003cp\u003e\u003cem\u003eSome doctors do send some patients to traditional healers when they see that their treatment is not effective. What we all need is for all people to be healthy. Government needs healthy people to help in developing the country. (TH/Diviner, M, 80)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 677px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompensation for gaps in the biomedical healthcare system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 175px;\"\u003e\n \u003cp\u003eOvercrowding of health facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eThe hospital days are usually crowded with people seeking different medical attention. So, I can say the accessibility is limited, those being assisted are also limited because of several problems including limited drug supply and limited government cash flows (TH, M, 54)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 175px;\"\u003e\n \u003cp\u003eTransport delays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eIt is the patient that then tells me their problems, like lack of transportation. So, when I have the capacity and resources I do, I even carry them on my motorbike to the hospital. (TH/Spiritualist, 60)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 175px;\"\u003e\n \u003cp\u003eConcomitant use with biomedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eSometimes you wonder even biomedical practitioner (doctors) coming to us seeking medical help. Even though they are well educated they find us here in the village looking for traditional medicine, so they know the difference.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;(TH, M, 59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 175px;\"\u003e\n \u003cp\u003ePrivacy and stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Women come with problems like [being] infertile or barren. I give them herbs that make them become fertile \u0026hellip; Men come with different problems, but some include paralysis and under performance [during sex]. That\u0026apos;s common in men. (TH, M, 52)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 677px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecognition of causes and risk factors for infections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 175px;\"\u003e\n \u003cp\u003eVariable definitions of infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eInfectious diseases attacks gradually. You may wonder you stay with it for more days before you realize you are sick, while these non-communicable infections attacks the person instantly and with force\u0026hellip; (TH, M, 59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Infections are diseases transmitted from one person to another. These include syphilis, chancroid, and other conditions like spinal bifida and swelling of the umbilical cord area (TH/Spiritualist, F, 70)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 175px;\"\u003e\n \u003cp\u003eUnderstanding of transmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eSome [diseases] are from food, others from reckless behavior like not washing hands or in short poor sanitation. Not having refuse pits, untidy homes. But washing hands with soap will make us safe from several diseases. You eat a guava fruit without washing it, you never know what was on it before plucking and eating it.\u0026rdquo; (TH/Spiritualist, M, 60)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003e[One gets infected by measles through] bewitching each other and borrowing each other clothes, especially with those infected (Spiritualist, F, 50)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 175px;\"\u003e\n \u003cp\u003eTreatability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eI challenge that if I fail to treat an infection then even at hospital they cannot manage. If it\u0026apos;s not a normal infection, then I advise them to go to traditional healers instead of \u0026nbsp; wasting their time at the hospital. Particularly those connected with witchcraft. (TH/diviner, M, 80)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 502px;\"\u003e\n \u003cp\u003e\u003cem\u003eIf the symptoms are new then we know that the infection is unusual, If I know that I have never seen that type of infection based on the patient presenting symptoms; I just tell them I should not waste your time, hurry and go to the hospital and tell them the symptoms, so that they can see what to do. (Spiritualist, M, 52)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"664\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 664px;\"\u003e\n \u003cp\u003eLeadership and role in the community\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eFinancial support/resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003e\u003cem\u003eMost of the times people come with different health problems. They may come while crying. I help them but what they give me in return sometimes is not enough, meaning that most of my work is for free just to help people ... because I was born with a soft heart. There are healers who send back patients because they do not have enough money, but for me I cannot do that, (TH, M, 59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eCommunity leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003e\u003cem\u003eI am a citizen of this village, I was born and raised in this village... \u0026nbsp;and just to add more, I am the chief of this village now (TH/TBA, F, 59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003e\u003cem\u003eThere are some women who come with marital problems, some they want a job opportunity or maybe they want a child \u0026hellip;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(Spiritualist, F, 76)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTBA= Traditional birth attendant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1. Relationship-building with clients for diagnosis and treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional healers rely on taking a good history and performing a physical exam to diagnose and treat their patients. They utilize their proximity to their clients and presence as members of their community, which allows for follow-up visits and a trial-and-error approach to determine if their initial assessment and treatment were accurate. Traditional healers believe biomedicine has better diagnostic ability through access to disease-specific testing and technology that they do not have. Many TH, particularly herbalists, reported lacking diagnostic tools and sending patients to the hospital first for a diagnosis to inform their own management.\u003c/p\u003e\n\u003cp\u003eThis TH discusses using the hospital to provide a diagnosis to help them determine which herbal treatment to use:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI give help according to what they are presenting with, the presenting symptoms, the disease history and the diagnosis from the hospital if they have any; all these help me to know which herbal medication to give. If I know the type of herbs of that particular disease, I give [the medication] but if I do not know I refer the patient to the hospital again.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Herbalist, M, age 49)\u003c/p\u003e\n\u003cp\u003eAnother details the process of follow up and continuity of care with their clients to assess the efficacy of therapy and to guide further management, a luxury that is often not available to patients using biomedical facilities for care given the long travel distances and resources needed to get to a more centralized clinic or hospital for care:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003e...when someone comes, I look at him and I know something went wrong somewhere. I get some herbs, put them on a leaf \u0026hellip; Get some that he can be adding to his porridge and give him, and also give him some to boil and be drinking \u0026hellip; When he takes those, you will see him coming the following day, [telling me] he is okay.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e(TH/Spiritualist/Diviner, M, age 84)\u003c/p\u003e\n\u003cp\u003eThe importance of hearing the patient\u0026rsquo;s full history is highlighted here. Traditional healers indicated that they often have a strong relationship with their clients and are able to spend time with them to get to the root of their concerns in comparison to some of the biomedical sites with limited staffing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Through asking questions to the client, that\u0026rsquo;s our main diagnosis tool, because when you don\u0026rsquo;t ask, then the patient may be delayed the health aid...\u0026rdquo;\u003c/em\u003e (TH, M, age 54)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2. Trust and willingness to collaborate with biomedicine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost TH believe that biomedicine is necessary and can be trusted, aside from some of the negative effects of staffing and resource limitations and recent fears by the public surrounding COVID-19 and vaccination. Traditional healers indicate that they often refer clients and use biomedical facilities themselves for care when they are ill. They also provided examples of bidirectional referrals and receiving patients sent by biomedical providers for further care. Traditional healers have a desire to formalize this relationship even further and provided examples of previous programs where collaboration with biomedicine was stronger and supported by the Malawi Ministry of Health. They emphasize that current government policies and lack of recognition have made it more difficult for them to earn the respect of biomedical providers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne TH discussed her opinions on biomedicine and doubts in the community that arose during the COVID-19 pandemic:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMy opinion on biomedicine is that they are necessary ... People started having doubts on biomedicine because of coronavirus believing that it was a satanic plot to wipe out communities. To me, I did not believe that ... I saw that there is no reason to fear an injection [of the COVID-19 vaccine] and I just received it.\u003c/em\u003e\u0026rdquo; \u0026nbsp; (Spiritualist, F, age 64)\u003c/p\u003e\n\u003cp\u003eWhen unfamiliar with the disease, TH typically refer patients to the hospital. Many remembered having a more formal referral process in the past that has changed in recent years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAt first, we had referral papers that we would give patients, but it seems that initiative just died a natural death for some reason \u0026hellip; Those referral papers were helpful in that when they get to the hospital, they should know that they are been referred from here. And when coming bac,k they would come here first but now all this stopped. So, we just tell [the patient] to go to a biomedical facility and when they are there it is up to them\u0026hellip;\u003c/em\u003e\u0026rdquo; (Spiritualist, F, age 76)\u003c/p\u003e\n\u003cp\u003eHowever, some TH do not feel respected by biomedical providers and even recommend patients not to tell the hospital they visited a traditional healer due to fear of the patient being treated unfairly. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe do not understand why traditional healers and biomedical service providers do not \u0026nbsp;find a way to work together because both of us have our interest in the same subject, the patient. The hospitals need the patient, so do we. Both of us, our agenda is the same, to heal. So why can\u0026rsquo;t we tolerate each other? ... it was discovered that the biomedical practitioners look down on traditional healers because they went to formal colleges and attended training courses in biomedicine.\u0026rdquo; \u0026nbsp;\u003c/em\u003e(Interview with members of Traditional Healers Association of Malawi)\u003c/p\u003e\n\u003cp\u003eSome TH also commented on the decrease in support from the Malawian Government, and their decision to ban the use of traditional birth attendants (TBAs) for deliveries and the requirement that all pregnant people receive services at a biomedical facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eImagine how it happened with Traditional Birth Attendants. They were completely stopped instead of finding a better way to improve their practice through training them, learn their ways and improve their practice. But it just stopped.\u003c/em\u003e\u0026rdquo; (TH, M, age 52).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSometimes the Ministry of Health could invite us [to seminars], especially in the past but now it does not happen. In the past, they would take us for training on how we can receive a patient, but also that time we could communicate and a give us a patient from the hospital and us too could give them patients.\u003c/em\u003e\u0026rdquo; (Spiritualist, F, age 76)\u003c/p\u003e\n\u003cp\u003eDespite this, there is a strong desire to collaborate with biomedicine and further the care of their patients and the community. Traditional healers feel they share similar goals to biomedical providers and want the public to have access to high-quality health care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI am telling you that, we want the government hospitals together with us, we should be working together ... agreement on modalities of how we can work together instead of sidelining each other ... there should be coordination\u003c/em\u003e\u0026rdquo; (TH, M, age 68)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3. Compensation for gaps in the biomedical system\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional healers provide care for community members who may have difficulty accessing biomedicine or are afraid of stigma and judgment. Participants provided examples of how TH often provide transportation or accessibility for patients who cannot present to the hospital or do not have the resources to get to a biomedical facility or pay for the treatment they may need. Additionally, TH cite only being called upon by the Ministry of Health during times of public health emergencies like during the COVID-19 pandemic, but then feeling forgotten once the crisis has passed. Traditional healers recognize the lack of resources and biomedical providers as a gap they can fill in the community.\u003c/p\u003e\n\u003cp\u003eHere, THs note the assistance they provide with transportation and more accessible, flexible payment for treatment options, since many hospitals and medications are not easily available to community members both due to distance and financial costs. Despite the government hospitals being free, there are often drug shortages that require patients to visit private pharmacies that are significantly more costly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If they do not have money, they just use a bicycle to carry the patient, (pushing) the patient slowly until they reach there. Because they don\u0026rsquo;t have money. It\u0026rsquo;s terrible to narrate these sad events. This is why we do assist them with what we can before they reach the hospital to help preserve the patient lives on the way.\u0026rdquo;\u003c/em\u003e (TH/Spiritualist/Diviner, M, age 84)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It all depends on government hospitals because they are free. That\u0026rsquo;s why we want government to recognize the traditional healers so that people can access medicine from traditional healers because herbs are cheaper than biomedicine, but financially you can\u0026rsquo;t access biomedicine anywhere unless you visit a government facility. Biomedicine is expensive in pharmacies and other outlets and an ordinary villager cannot afford it.\u0026rdquo;\u003c/em\u003e (Herbalist, M, age 64)\u003c/p\u003e\n\u003cp\u003eThis TH describes how, during recent measles outbreaks, they were recruited to advise people on precautionary measures but felt TH presence was only acknowledged when biomedical providers needed something from them and the \u0026ldquo;situations are tough\u0026rdquo; instead of considering them as important colleagues and collaborators.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Most times us tradition healers we are considered useless by those who provide biomedical healthcare, we are only considered when things are critical, but when there is peace, we are useless people.\u0026rdquo;\u003c/em\u003e (TH, M, age 59)\u003c/p\u003e\n\u003cp\u003eSome healers also describe providing care to clients who may face stigma for sensitive issues such as sexual performance or infertility. One healer describes how some clients prefer his services and feel more comfortable due to facing discrimination at biomedical facilities:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eA poor person and their appearance alone, they are left to die \u0026hellip; That is why some people do not trust the hospital, when there is help, but because of profiling\u003c/em\u003e.\u0026rdquo; (TH/Spiritualist, M, age 60)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4. Recognition of causes and risk factors for infections\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional healers primarily separate illness into either spiritual/traditional vs. biomedical in etiology, thus defining what constitutes an infectious illness and level of understanding of infectious pathophysiology is highly variable. Mechanisms of infectious disease transmission like respiratory and fecal-oral contact were commonly described, but traditional explanations were also frequently used. Specific knowledge of germs, such as bacteria or viruses, and how they differ was much less well understood. There was also a high degree of variation in what is considered \u0026ldquo;treatable\u0026rdquo; based on attribution of cause to traditional vs. biomedical cause of illness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis TH describes how they believe many infections are caused by bewitchment and can be treated with traditional medicine. While TH universally believe diseases caused by spiritual or traditional causes, such as bewitchment, cannot be treated by biomedicine, disease states that fall into this categorization vary by provider. This healer describes successfully treating infections being caused by bewitchment:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;All I can say is that I treat infections. I have got treatment for different infections. For example, when I give some treatments, the patients purge, then they look like they are drunk, then all infections are gone! Then I command that every (bad thing) that is within the body of the man should go out, whatever it is in his body, the bad omen goes out through defecation ... so I just suggest that he was bewitched.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(TH/Diviner, M, age 52)\u003c/p\u003e\n\u003cp\u003eWhile this TH reports not knowing what causes infections:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;These Infections I should not lie\u0026hellip; us as herbalist we don\u0026rsquo;t know where they come from, but biomedical facility can know because they have examination equipment.\u0026rdquo;\u003c/em\u003e (Spiritualist, M, age 52)\u003c/p\u003e\n\u003cp\u003eWhile another specifically mentions understanding that microorganisms cause tuberculosis (TB):\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The coughs that are spreading all over, it is when I cough out sputum or I have TB and cough there, then that microorganism that cause TB will go and enter someone, that person will also start coughing\u003c/em\u003e.\u0026rdquo; (Spiritualist, F, age 64)\u003c/p\u003e\n\u003cp\u003eMany TH placed emphasis on poor hygiene or risky behavior as key in the transmission of infectious diseases:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some people are not using condoms \u0026hellip; whether it is woman, or a man, they will sleep with many partners without a condom. they will go there, sleep with that one, take a disease and transfer it to another just like that \u0026hellip; All sorts of infections are there, through the bad behavior, the promiscuous behavior.\u003c/em\u003e\u0026rdquo; (TH, M, age 68)\u003c/p\u003e\n\u003cp\u003eWhile others use traditional explanations:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There has to be a difference because they are some illnesses even if you wash your hands, you still get the infection. For example, traditionally epilepsy when you are at the back of the one having convulsions and they pass flatus; you can get the disease as well. But if you stand at the front, you cannot.\u0026rdquo;\u003c/em\u003e (TH, M, age 78)\u003c/p\u003e\n\u003cp\u003ePerceptions of treatability also varied greatly among TH, with some describing consistent referral of common infections like malaria, tuberculosis, cholera, HIV/AIDs, and COVID-19 to biomedical facilities for treatment, while others endorsed their own ability to treat some of these same illnesses. For example, one healer describes referring a patient to the hospital with suspected malaria for diagnostic testing and biomedicine as standard procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eOn malaria we cannot give a person medicine because we do not have the treatment for malaria...he needs to go to the hospital to be told the severity of the malaria and the treatment he will get, either quinine or LA (lumefantrine-artemether). Myself I cannot do that.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(Spiritualist, F, age 64)\u003c/p\u003e\n\u003cp\u003eHowever, this TH on the other hand says there is a traditional medicine for malaria that can also be used as an alternative, after the patient has been diagnosed at a biomedical facility:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;...\u003cem\u003ewe just tell them that this could be malaria, and you should go to a biomedical facility to get quinine, but we do have our own traditional medicine that is bitter like quinine, we give the person and the person gets better.\u0026rdquo;\u003c/em\u003e (Spiritualist, F, age 76)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5. Leadership role in the community\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional healers describe feeling well-respected by their communities and often provide social services like financial support or help with transportation for their clients. They also note the influence they have on the perception of biomedicine by the community and help sensitize people to the importance of public health interventions, like the COVID-19 vaccine. Some even serve as village chiefs or local government leaders and report attending meetings at hospitals to advocate for their community and culture. They report assisting their clients in dealing with a variety of social and familial issues such as marriage and financial struggles, in addition to provision of medical care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis TH discusses giving his clients money to support them:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some come with unhappy pale faces, as if there is a funeral, or child is sick, so I give them medicine and tell them to bring the patient, I give them money to use, I am not a greedy doctor.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(TH/Diviner, M, age 52)\u003c/p\u003e\n\u003cp\u003eOne TH explained how he tries to help community members understand the lack of healthcare resources when they are frustrated that they cannot get the care they need:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But the main problem that people don\u0026rsquo;t know is that the challenges at the government hospitals are not caused by the doctors but rather government. For me as a group Chief, I have a role to sensitize people on this. For instance, [health center in the area], doesn\u0026rsquo;t have enough health workers ... when the patient is brought at night and the health worker is not on duty, the people will still demand that the person should work ... [and] he is the only health worker at the institution, and he is supposed to perform all the duties during the day and night which may be exhausting. But the community will be infuriated for feeling being ignored. But our role is to explain to these communities on the shortage of health workers.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(TH, M, age 54)\u003c/p\u003e\n\u003cp\u003eOthers provide social support to clients, including those with chronic illnesses, and emphasize their need to take their medications and not purely rely on traditional medicine for disease states that have a known biomedical treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We had a case of a client who had rashes, when he called and explain his symptoms, I asked him if he went to the hospital and get his blood test. But it was found that he had stopped taking ARVs [anti-retrovirals]. We always encourage patients on ARVs to take their drugs because if they stop then drugs cannot work effectively in their bodies.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(TH, M, age 54)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTraditional healers in Malawi acknowledge a reliance and willingness to collaborate with biomedicine while highlighting their ability to fill some of the existing health systems resource gaps given their role as leaders and trusted members of their communities.\u003c/p\u003e \u003cp\u003eUnderstanding of infectious disease states by TH is highly variable and further training is needed to improve recognition of conditions more concerning for emerging or re-emerging pathogens where public health systems may benefit from early detection, or conditions that require antimicrobials or other treatment that can only be obtained at a biomedical facility. Traditional healers indicate a willingness to learn and a desire for more trainings and recognition by the Ministry of Heath so that they can improve their skills and play a larger role in Malawi\u0026rsquo;s healthcare system.\u003c/p\u003e \u003cp\u003eOur findings are consistent with prior studies in SSA demonstrating that TH are open to collaboration and often view their services as separate or adjunctive to biomedical healthcare. While there are some studies arguing that the use of traditional medicine can be dangerous, harmful, or cause delays in care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), there are many others describing traditional healers working effectively within the biomedical system or providing support to those undergoing biomedical care. Healers may not only serve as informal providers but often add social support and encouragement for those reluctant or having difficulty with the biomedical healthcare system, particularly for persons living with HIV (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are notable social and political barriers to collaboration with the biomedical system, which has led to frustration by TH with the government\u0026rsquo;s lack of attempt to bridge the divide. This is apparent in the 2007 decision by the Malawian Ministry of Health to ban the use of traditional birth attendants. A unilateral reduction or ban on the use of traditional healers, including TBAs, for care may not result in improved outcomes if biomedical facility access and quality of services are not expanded simultaneously, given the complex dynamics and multiple factors that influence healthcare delivery, particularly to marginalized populations (\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). As with the use of community health workers or other lay providers within the public health system, requiring some degree of regulation, registration, baseline training, and skills assessments for TH may mitigate some of the harms that stem from use of corrupt, deceptive, or underqualified individuals for care.\u003c/p\u003e \u003cp\u003eA prior study in rural Uganda found that TH were successfully engaged in a program to recognize and refer clients with signs of Bubonic plague (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Based on this and our current study findings, the inclusion of TH as sentinel providers within the biomedical system is feasible but will require additional training and investment in them by biomedical systems in Malawi. As TH already alluded to being called upon during the COVID-19 and other public health crises, providing advance preparation and training to recognize and assist during other potential threats is imperative to maximize efficacy of their role in these processes. As indicated by the variable responses on how to diagnose and treat potential infections, TH need training on risk factors for emerging or re-emerging infections and assessment of which conditions are more likely to be easily transmitted or require early detection and treatment to prevent sequelae or outbreaks. This will require cooperation and more formalized systems within Malawi\u0026rsquo;s current healthcare infrastructure, which may be difficult to pursue without additional funding and resources. More studies are needed to pilot this process at a limited number of TH sites and determine how to make this as streamlined and cost-effective as possible, prior to widespread implementation.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, we only included the perspective of traditional healers and did not assess views of biomedical providers or clients, thus, it is likely that TH interpreted their potential role and service to their communities in a more positive light. Second, this study occurred within one region of Malawi where an organized Traditional Healer Association exists, and many participants were members of this group. This may have led to recruitment of more highly trained healers or those with more respect for their integrity versus others who do not participate in this organization.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTraditional healers in Malawi respect and value biomedicine and are open to collaboration. They view themselves as filling gaps in the public healthcare system caused by financial hardship and lack of accessibility by rural populations, including in times of crisis, such as the COVID-19 pandemic. More training and education on infectious diseases and outbreak detection is needed prior to integration of healers into the biomedical system to serve as sentinel providers for emerging and re-emerging infectious threats.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSSA: sub-Saharan Africa; TBA: traditional birth attendant; TH: traditional healer; WHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the University of California, San Francisco (UCSF) Internal Review Committee (IRB) and the Malawi University of Science and Technology Research Ethics Committee (MUSTREC). All study procedures conformed to the Declaration of Helsinki for the Protection of Human Subjects of 1964 (revised 2013). Interview participants provided written, informed consent prior to participation. Survey participants were verbally consented to participation on an anonymous basis. Personal information that could identify participants was omitted for recordings, transcriptions, and translations to the maximum possible extent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudy funding was provided by a grant from the University of California, San Francisco Institute for Global Health Sciences Center for Pandemic Preparedness and Response (AH, GB) and the UCSF Department of Humanities (RM). Travel grant funding was provided by the UCSF Department of Emergency Medicine Global Health Section (AH).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors’ Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRM was responsible for development of study instruments, data analysis, synthesis of study findings, interpretation of results, and manuscript preparation. AM was responsible for study design, development of study instruments, data collection, data integrity, oversight of study staff, interpretation of results and review for cultural context, and manuscript preparation. KB was responsible for development of study instruments, data analysis, interpretation of results, and manuscript review. GB was responsible for study design, study oversight, data analysis, interpretation of results and review for cultural context, and manuscript review. AH was responsible for study design, development of study instruments, study oversight, data integrity, analysis, interpretation of results, and manuscript review.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to recognize our study staff for their tireless efforts in high quality data collection in difficult to reach settings and to the traditional healers for welcoming us into their clinics and communities.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKokota D, Stewart RC, Abbo C, Bandawe C. Views and experiences of traditional and Western medicine practitioners on potential collaboration in the care of people living with mental illness in Malawi. Malawi Med J. 2022 Dec 16;34(4):231\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBickton FM. Strengthening human resources for health in resource-limited countries: The case of Medic to Medic in Malawi. 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Clin Infect Dis. 2016 Dec 15;63(suppl 5):S312\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eBarker RD, Millard FJC, Malatsi J, Mkoana L, Ngoatwana T, Agarawal S, et al. Traditional healers, treatment delay, performance status and death from TB in rural South Africa. Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2006 Jun;10(6):670\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eHooft A, Nabukalu D, Mwanga-Amumpaire J, Gardiner MA, Sundararajan R. Factors Motivating Traditional Healer versus Biomedical Facility Use for Treatment of Pediatric Febrile Illness: Results from a Qualitative Study in Southwestern Uganda. Am J Trop Med Hyg. 2020 Jul 8;103(1):501\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eLampiao F, Chisaka J, Clements C. Communication Between Traditional Medical Practitioners and Western Medical Professionals. Front Sociol. 2019 Jun 21;4:37. \u003c/li\u003e\n\u003cli\u003eTeshager NW, Amare AT, Tamirat KS, Zeleke ME, Taddese AA. Traditional herbal medicine use doubled the risk of multi-organ dysfunction syndrome in children: A prospective cohort study. Chen RJ, editor. PLOS ONE. 2024 Feb 23;19(2):e0286233. \u003c/li\u003e\n\u003cli\u003eVan Der Watt ASJ, Nortje G, Kola L, Appiah-Poku J, Othieno C, Harris B, et al. Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qual Health Res. 2017 Dec;27(14):2177\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eMaze MJ, Bassat Q, Feasey NA, Mandomando I, Musicha P, Crump JA. The epidemiology of febrile illness in sub-Saharan Africa: implications for diagnosis and management. Clin Microbiol Infect. 2018 Aug;24(8):808\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eBaltzell K, Kortz T, Scarr E, Blair A, Mguntha A, Bandawe G, et al. \u0026ldquo;Not all fevers are malaria\u0026rdquo;: a mixed methods study of non-malarial fever management in rural southern Malawi. Rural Remote Health [Internet]. 2019 Jun 15 [cited 2025 Jan 8]; Available from: https://www.rrh.org.au/journal/article/4818\u003c/li\u003e\n\u003cli\u003eKortz TB, Blair A, Scarr E, Mguntha AM, Bandawe G, Schell E, et al. Characterizing Pediatric Non\u0026ndash;Malarial Fever and Identifying the At-Risk Child in Rural Malawi. Glob Pediatr Health. 2018 Jan 1;5:2333794X17750415. \u003c/li\u003e\n\u003cli\u003eAron MB, Mulwafu M, Mailosi B, Kreuels B, Dullie L, Kachimanga C, et al. Experiences and practices of traditional healers on snakebite treatment and prevention in rural Malawi. PLoS Negl Trop Dis. 2023 Oct;17(10):e0011653. \u003c/li\u003e\n\u003cli\u003eBoum Y, Kwedi-Nolna S, Haberer JE, Leke RRG. Traditional healers to improve access to quality health care in Africa. Lancet Glob Health. 2021 Nov;9(11):e1487\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHealers important tool in preventing AIDS in Malawi. AIDS Wkly. 1994 Nov 21;10. \u003c/li\u003e\n\u003cli\u003eMunthali AC, Mannan H, MacLachlan M, Swartz L, Makupe CM, Chilimampunga C. Non-use of Formal Health Services in Malawi: Perceptions from Non-users. Malawi Med J J Med Assoc Malawi. 2014 Dec;26(4):126\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eZachariah R. Health seeking and sexual behaviour in patients with sexually transmitted infections: the importance of traditional healers in Thyolo, Malawi. Sex Transm Infect. 2002 Apr 1;78(2):127\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBurns JK, Tomita A. Traditional and religious healers in the pathway to care for people with mental disorders in Africa: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2015 Jun;50(6):867\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eGallaher JR, Purcell LN, Banda W, Charles A. The effect of traditional healer intervention prior to allopathic care on pediatric burn mortality in Malawi. 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Am J Trop Med Hyg. 2023 Nov 1;109(5):1129\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eAudet CM, Pettapiece-Phillips M, Tian Y, Shepherd BE, Vermund SH, Salato J. \u0026ldquo;If it weren\u0026rsquo;t for my traditional healer, I would be dead\u0026rdquo;: Engaging traditional healers to support people living with HIV in rural Mozambique. PloS One. 2022;17(6):e0270565. \u003c/li\u003e\n\u003cli\u003eAudet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci IS. 2017 Apr 13;12(1):50. \u003c/li\u003e\n\u003cli\u003eBaheretibeb Y, Wondimagegn D, Law S. Holy water and biomedicine: a descriptive study of active collaboration between religious traditional healers and biomedical psychiatry in Ethiopia. BJPsych Open. 2021 May 5;7(3):e92. \u003c/li\u003e\n\u003cli\u003eMakundi EA, Malebo HM, Mhame P, Kitua AY, Warsame M. Role of traditional healers in the management of severe malaria among children below five years of age: the case of Kilosa and Handeni Districts, Tanzania. Malar J. 2006 Jul 18;5:58. \u003c/li\u003e\n\u003cli\u003eSundararajan R, Alakiu R, Ponticiello M, Birch G, Kisigo G, Okello E, et al. Understanding traditional healer utilisation for hypertension care using the Andersen model: A qualitative study in Mwanza, Tanzania. Glob Public Health. 2023 Jan;18(1):2191687. \u003c/li\u003e\n\u003cli\u003eSundararajan R, Langa PV, Morshed T, Manuel S. Traditional healers as client advocates in the HIV-endemic region of Maputo, Mozambique: results from a qualitative study. SAHARA J J Soc Asp HIVAIDS Res Alliance. 2021 Dec;18(1):77\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eCreanga AA, Gullo S, Kuhlmann AKS, Msiska TW, Galavotti C. Is quality of care a key predictor of perinatal health care utilization and patient satisfaction in Malawi? BMC Pregnancy Childbirth. 2017 May 22;17(1):150. \u003c/li\u003e\n\u003cli\u003eGodlonton S, Okeke EN. Does a ban on informal health providers save lives? Evidence from Malawi. J Dev Econ. 2016 Jan 1;118:112\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eMselle LT, Moland KM, Mvungi A, Evjen-Olsen B, Kohi TW. Why give birth in health facility? Users\u0026rsquo; and providers\u0026rsquo; accounts of poor quality of birth care in Tanzania. BMC Health Serv Res. 2013 May 10;13(1):174. \u003c/li\u003e\n\u003cli\u003eShajarizadeh A, Gr\u0026eacute;pin KA. The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India. BMJ Glob Health. 2022 Jul;7(7):e007926.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"traditional healers, alternative medicine, herbal medicine, Africa, Malawi, rural medicine, low resource, infectious diseases","lastPublishedDoi":"10.21203/rs.3.rs-5975877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5975877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eMalawi is a pluralistic health system, where people seek care from both formal (e.g. biomedical) and informal (e.g. traditional medicine) sources. An estimated 80% of the population utilizes traditional healers (TH) for care, particularly in rural areas. Given their strong community presence, TH may be able to bridge gaps in the healthcare system, however, data on barriers and facilitators to this relationship are limited. Understanding TH perspectives on disease processes and their role in the community is critical to integrating TH into the biomedical system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study using semi-structured interviews of TH in Thyolo District, Malawi in May 2024. Participants were identified and recruited using purposive sampling. Interviews were conducted in Chichewa, translated into English, and coded for themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe interviewed a total of 25 TH: 17 male and 8 female, age 25 to 84 years. Time in practice ranged from 8 months to 60 years. Major themes identified included: 1. Relationship-building for diagnosis and treatment; 2. Trust and willingness to collaborate with biomedicine; 3. Compensation for gaps in the biomedical system; 4. Recognition of causes and risk factors for infection; and 5. Leadership role in the community.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn Malawi, TH demonstrate a strong desire for recognition, training, and integration into the biomedical system. Understanding of disease processes outside of traditional vs. biomedical illnesses is variable, but most TH trust biomedicine and feel comfortable referring clients. Given their respected role in society, TH may provide a useful adjunct to biomedical care in rural Malawi.\u003c/p\u003e","manuscriptTitle":"Understanding the role of traditional healers in the Malawian healthcare system: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-11 10:20:40","doi":"10.21203/rs.3.rs-5975877/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55629ef7-48c7-42b6-ac90-edfb61b8f408","owner":[],"postedDate":"February 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-12T09:53:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-11 10:20:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5975877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5975877","identity":"rs-5975877","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}