“What about our ways of living?”: Traditional Health practitioners describe the tenets of African Traditional Medicine.

doi:10.21203/rs.3.rs-1604207/v1

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Research Article

“What about our ways of living?”: Traditional Health practitioners describe the tenets of African Traditional Medicine.

https://doi.org/10.21203/rs.3.rs-1604207/v1

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Background:

African Traditional Medicine continues to strive and contribute to health care for many indigenous people in Africa. Within this system, Traditional Health Practitioners are the custodians of traditional health, knowledge and practices and play various roles such as counselling and teaching. There are unique ways to name, diagnose, treat, and manage ill-health in African Traditional Medicine, which makes this system unique. However, most concepts are loosely used or translated literally by researchers and scholar without their proper application and contextualization. This study was undertaken to explore and describe how Traditional Health Practitioners define African Traditional Medicine, in their own accord and understanding.

Methods:

Qualitative, explorative and descriptive design was adopted. Data was collected from eighteen (18) Traditional Health Practitioners who were sampled using snowball technique. Individual semi-structured interviews were done and audio recorded with consent of participants. Data was analysed using qualitative content analysis. Trustworthiness was ensured through principles of credibility, dependability, confirmability and transferability.

Findings:

The findings revealed two themes: 1) The features of African Traditional Medicine and 2) Elements of practice in African Traditional Medicine. The findings revealed that African Traditional Medicine is intertwined with the everyday life for Africans and cannot be detached. It emerged that there are different and unique ways of naming and understanding concepts with African Traditional Medicine. Spirituality, ancestral calling and the language used plays an important role in qualifying as a Traditional Health Practitioner. However, participants raised concerns regarding the quality of training for Traditional Health Practitioners.

Conclusion:

Being a Traditional Health Practitioner is directly linked to ancestral calling. However, spirituality plays and important role in African Traditional Medicine where practitioners undergo rigorous training to learn the craft of traditional healing such as the use of language, connecting with ancestral spirits and harvesting of plants. Dialogue must be facilitated among Traditional Health Practitioners in different specialization, to reach common understanding on the names, concepts and processes in African Traditional Medicine. This will contribute immensely in the efforts to standardize the practice of African Traditional Medicine in line with global standards.

Traditional health practitioner

African traditional medicine

calling

ancestors

spirituality

If you look at the world right now, everyone is doing things the western way. What about our ways of living?

African traditional medicine (ATM) is arguably the oldest health system in the history of mankind. Within this system, there are ways of understanding and interpreting the world through the African lens. The World Health Organisation (WHO) defines Traditional Medicine as “the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness” [1]. Despite the definition of the WHO, Traditional Medicine (TM) is defined in various ways by scholars and researchers globally. For example, TM is also termed traditional indigenous knowledge [2], traditional health practice, traditional healing [3], endogenous health and complimentary medicine[4]. While the WHO definition is all encompassing, definitions from different countries and regions focus on one or more elements within Traditional medicine such as herbal, spiritual and complimentary. In China, Traditional Chinese Medicine refers to a system of healthcare focusing on healing through herbal medicine, acupuncture and massage [5]. In Australia, on the other hand, traditional medicine is referred to as traditional medicine practice [6], which defines health and disease in relation to various causes such as spiritual, witchcraft and physical sources [7]. In Africa, the concept of ATM is used with more focus on spirituality, healing and the use of medicinal plants for healing. The differences in defining concepts within TM demonstrates how broad TM is and requires a more structured approach to compare similarities and differences in defining it. More importantly is the need to determine whether such differences are congruent with the definitions and descriptions provided by Traditional health practitioners (THPs) across the various regions. The focus of this paper is on ATM and how THPs, as the guardians of ATM, define ATM as a system of healthcare.

Within ATM, THPs play important roles ranging from treatment of ailments, mental health problems and divination [7]. Collaboration between THPs and allopathic practitioners demonstrate that ATM has a place in the modern health system and should be acknowledged for its contribution. But, the challenge has been that scholars are directly translating traditional health knowledge and concepts into medical and academic language, which is misleading as it may distort meaning and facts [8]. People’s understanding of health and illness relies on their culture and traditional practices, therefore the language used in interpreting concepts of ATM should consider the context within which it is practiced. THPs are better placed to share this knowledge and provide proper interpretations where needed .

ATM is structured in terms of the type of service rendered, however falls within the specialties of herbalism, spiritualism, divination, surgery and traditional midwifery [8]. THPs are commonly referred to as traditional healers and most used categories in literature include Isangoma, diviner, Inyanga and herbalist [7]. Within each specialty, THPs typically render health care services that include consultation, assessment of physical and spiritual well-being as well as prescribing oral and topical herbs [9]. Notably ancestral calling play an important role in qualifying one as a THP. Although different terminology is used to describe various aspects of the healing processes in ATM, way of defining things or objects and naming people makes this system of healthcare unique. The names and definitions bear deep meaning and serve cultural values [10], so the question to answer is, to what extent did THPs participate in their own naming or the translation of their names as reported in literature. Therefore, strategies to align and streamline how the concept of ATM is defined must consider the input of THPs as the guardians in the practice of ATM.

The voices of THPs must be heard without prejudice in the discourse for conceptualising and formalising concepts used in ATM. Especially because in Africa, THPs are respected within their communities and often consulted when people need counsel or advice on matters that require wisdom from a traditional and spiritual realm[8]. Therefore, they are considered to be knowledge holders, guardians and custodians of the religion, customs and practices within ATM [8]. Having said that, THPs face a challenge of overcoming the continued undermining of their knowledge and expertise [11], which is often put on a scale with western medicine. It can be argued that decades of assimilating of the western culture and practices has to a large extent influenced many aspects of life among Africans. Among important fundamentals that has been affected are the traditional and cultural practices in most communities [12]. African culture has over the years been passed from generation to generation and includes language which has been used to name, define and explain objects, events and practices [9]. Many African names and concepts that were used in the past, including for naming and communicating certain cultural practices are becoming extinct due to acculturation [13]. Within ATM, symbolic and spoken language plays an important role for THPs in transmitting knowledge either during training or while practicing as a THP and explaining meaning. The extent to which the translation of symbols and language represent the contextual and indigenous meaning must be determined and THPs are better placed to provide that clarity.

Indeed, the lack of documentation and formalisation has threatened the existence of ATM, partly worsened by prohibition of practising ATM during colonial years [14]. As such THPs have in most cases only contributed to the development of ATM knowledge, as study subjects as opposed to being co-authors, where their voice is heard as owners of the knowledge. Standardizing the definition of concepts in ATM will ensure that THPs can comfortably document and streamline their practices, using African languages, so as to reach a common understanding between themselves and other health practitioners or scholars [15]. This becomes an important point of departure in understanding the plight of THPs to be recognised and to be allowed the space to function. Unfortunately, THPs have been spectators in their own game, where they have not been given the platform to explain what ATM represent and entails, from their perspectives.

Therefore, THPs must be given platforms and opportunities to share their knowledge and understanding, using participatory methods that gives them ownership of the knowledge that is being generated and shared by them [16]. Accordingly, the naming and description of concepts in ATM, represents the worldview of indigenous populations served by those THPs. An endeavour must be made by researchers and scholars to understand knowledge and practices in a way that interpreting and communicating that information is factually verified by THPs before publication [17]. For example, in terms of how health is defined, diagnostic concepts and linguistic connotations used in ATM. Scholars have to attempt to provide indigenous meaning without directly translating it to other languages. Good working relationships between THPs, scholars and allopathic health workers must be maintained, based on respect for ATM as a legitimate system of healthcare [18]. As such programmes to manage modern health problems should also consider areas of common understanding between THPs and allopathic practitioners and target areas where both can learn from each other. The modern dominance of allopathic practice over ATM however overshadows the fact that THPs contribute in health knowledge development [19]. It can be argued that most reasons for exclusion of THPs in mainstream health system is based on religious objections and competition point of view as opposed to scientific merits [20]. However, the worldview in traditional health is influenced by indigenous lens within which THPs practice.

Purpose and objective of the study

The purpose of this study was to explore and describe how THPs define African Traditional Medicine.

Design

This study adopted a qualitative, explorative and descriptive design to interview 18 THPs. This qualitative design explored how THPs define ATM within their work setting as there is still no consensus on what the concept of ATM entails from their perspective.

Research setting

This study was conducted in City of Tshwane Metropolitan Municipality of Gauteng Province. The province of Gauteng has rural, urban and semi-urban areas with diverse cultural and traditional practices. There are about 11 district municipalities in Gauteng Province, City of Tshwane included, with a land size of 6,298 km². The total population of residents in the City of Tshwane Metropolitan Municipality is estimated to be at 3, 555,741 million people. Most THPs are located in rural areas and townships where the dominant residents are black Africans. However, there are THPs who are also located in the urban areas of the province and therefore accessing THPs was possible because people who use their services commonly reside within the surrounding communities, be it rural or urban.

Study population

Participants in this study were THPs residing in City of Tshwane Metropolitan Municipality of Gauteng Province. The researcher approached the Traditional Health Practitioner’s Council to get the initial reference and to determine how to contact potential participants. However, the process was challenging as the roll for THPs is at this point, not streamlined as most practitioners are not yet registered. While some THPs belong to their local traditional healers’ organization, many still practice independently. Traditional healers’ organizations are community-based organizations in which THPs are affiliated to share experiences and have a sense of belonging. All THPs that participated were over the age of 18. Snowball sampling method was used to access the participants. The researcher requested the participants to provide a network connection for other THPs that they know within their organization. eighteen (18) THPs were interviewed in this study.

Data collection

Data was collected through individual semi-structured interviews with THPs. While fifteen interviews were conducted at the homes of THPs, three were done telephonically due to the level 4 Covid-19 restrictions in South Africa at the time of data collection. An interview guide was used to elicit information from THPs regarding how they define African Traditional Health Knowledge and Practices. The interviews lasted up to 45 minutes with the following question being asked to THPs: How would you define African Traditional Medicine?. Semi-structured interviews assisted the researcher in eliciting important in-depth information as described by participants.

Probing questions were asked in between to clarify responses of participants. Data was collected by the researcher in English as most THPs were conversant in the language, however participants could respond in the language of their choice. The researcher is conversant with the local languages. Interviews were recorded and field notes taken during the interviews. Data saturation was reached after eighteen interviews when no new data was coming through.

Data analysis

Interviews were transcribed into English and translated where an African language was used by participants. Qualitative inductive content analysis process was undertaken [21] where prominent ideas that came out of the interviews and discussions were identified, openly coded and categorised in order to group common themes that emanated. The service of an independent coder was also used, who together with researchers reached consensus on the themes and subthemes. After all the data was captured and transcribed, participants were still approached to validate the transcription and results [22]. Participants therefore also served as co-coders to ensure consistency and to reduce biasness [23].

The THPs that were interviewed are eighteen, with seven females (39%) and eleven males (61%). In their specializations as THPs, nine identified themselves as sangomas, five as herbalists and four as diviners. However, four THPs practiced in more than one specialization, while three others identified themselves as Gobela ( certified trainer of the THPs). Three of the participants are in dual practice, where they practice as professional nurses and THPs at the same time. Two themes that reflect the perspectives of THPs on their definition of African Traditional Medicine emerged as follows: 1)The features of African Traditional Medicine; 2) Elements of African Traditional Medicine (see Table 1).

Table 1

Themes and subthemes
Themes	Subtheme
The features of African Traditional Medicine	• African Traditional Medicine is a way of life for Africans • Traditional Health Practitioners are called by ancestors • Ability to connect and maintain the spiritual connection with the ancestors
Elements of practice in African Traditional Medicine	• Training of Traditional Health Practitioners on African Traditional Medicine • Language as a medium in African Traditional Medicine

The features of African Traditional Medicine

Participants voiced their different views regarding how best to define African Traditional Medicine. The nature and origin of ATM was described by participants, regarding what it entails and its founding principles. The views expressed depended on their background and experiences. For example, a THP who is herbalist viewed treating illness with herbs as a starting point in his practice, whereas a diviner would explore spiritual causes to the problems being presented. Participants used the concepts traditional health, African traditional health practice and traditional healing interchangeably to describe ATM. Three subthemes emerged defining the nature of ATM; ATM is a way of life for Africans and spiritual connection with the ancestors.

African Traditional Medicine is a way of life for Africans

From the interviews it emerged that participants define ATM as a system representing the traditions and lifestyle lived by Africans. ATM involves every aspect of life and is relevant throughout the stages of life. It emerged that ATM encompasses the roles and responsibilities of African people within their cultural and social context. Participants indicated that ATM has existed over long periods of time and was passed down from their ancestors. The following expressions were made:

“Traditional health is about how we live our health as Africans, not just about giving people muthi [herbs]. It is how we grow up and learn the ways of our ancestors”. (Thp1, Sangoma)

“African traditional health practice is a very old system that relies on using umuthi [herbs] and throwing of bones to connect with the ancestral spirits.” (Thp3, Herbalist)

Another participant defined ATM further based on its roles in society as part of an education system. These roles include how Africans should conduct themselves through the stages of life. Participants highlight their plight for Africans to trust and respect ATM as a legitimate health system from which people can learn.

The participant said:

“If you look at the world right now, everyone is doing things the western way. What about our ways of living? Even us as Africans, we had schools even back then, but our schools in the past were about how to live as a man who is a Venda, how to live as a woman who is a Venda. How to live as a girl who has reached puberty as a Venda, as a man that has reached puberty as a Venda... how to live as an old person who is gogo [healer] in Venda. And today we are saying everybody can live the same, that is why we are failing.” (Thp17, Diviner)

It further emerged that ATM encompasses all elements of life including the physical and spiritual realms. According to one participant, in ATM, treatment is given to patients so that the problem they have can be eliminated and for life to resume like before the consultation.

“So, in African traditional healing, we institute treatment so that everything can go back to normal... spiritually, physically and preventing ubuthakathi (witchcraft).” (Thp7, Sangoma)

(Thp1, Sangoma) said:

“It is a holistic approach in terms of therapy. What type of therapy, maybe spiritual therapy of some sort, you know…giving advices.”

Traditional Health Practitioners are called by ancestors

The definition of ATM by the academic scholars do not consider the calling by the ancestors. The definition is not complete without considering the calling of the THPS by their ancestors. A participant highlighted this in the statement below:

“You do not just wake up and decide to be a healer. There must be a link that connects you with the calling. Sometimes people ignore it and it manifest as a disease or ailment. That’s how different it is.” (Thp8, Sangoma)

All participants described a calling by ancestors as a prerequisite for becoming a THP. You cannot choose which type of THP you want to be. The participants described the process of their THP calling. It was reported that in some cases, the ancestral spirits may choose a person to be a THP before they are even born. There is no specific age on which the calling can present itself. Participants had this to say about the calling:

“But as you grow there are these spirits that have already decided on choosing you to say you must follow the calling...” (Thp5, Diviner)

“But to be a traditional healer, maybe as a child o nyaka go bina malopo [you want to perform a dance of ancestral possessed individual] and say I want to be a traditional healer, but when you grow up, you are a different person.” (Thp16, Herbalist)

Participants reported different ways of diagnosing if one has a calling such as being ill, or having difficulties in your life, which are only diagnosed as a calling when you seek counsel with THPs. Another participant went further describing the preceding events to becoming a traditional healer and said:

“For a person to be a traditional healer, they can tell you a very difficult story. Maybe they started by being sick, went for operations, doctors suspected this. Their history is very painful for them to be a traditional healer. Because at times there is denial, especially if you can look these days, the trend of people becoming traditional healers, you find that this person has a PhD degree, this person is definitely learned, and being told that you need to go for initiation cannot be easily acceptable to them.” (Thp10, Herbalist)

It was also reported that sometimes ancestors can bring about minor ailments to warn a person who denies the calling. Should the person not cede to the call, there will be more serious consequences which may be life-threatening. The figurative use of language in describing anatomical structures was also noted when participants made described body organs according to their importance.

The participant said:

“At a hospital they amputate his finger, saying he is diabetic, o na le swikiri [he is diabetic] and if not careful they will cut this hand. So, whilst he is still in denial, they keep amputating him slowly but surely. These are warning shots. Then when they start saying they need to now take out one of the members of the royal family meaning…heart to insert screws, it is the time he realizes that he has to go for initiation. He goes for initiation when he is now sick, but the particular person becomes better and powerful traditional healer.” (Thp1, Sangoma)

According to another participant, signs of a calling may also include having dreams that sometimes may or may not make sense until you get clarity from a THP. The participant also cited connection between a calling and history of traditional healing in the family. The Participant said:

“People experience their calling in different ways. Like with me, I started with dreams about me wearing izangoma [beads] and ingubo ezinye [other garments]. But when I started dreaming about abantu abanga sekho [people who have passed on] na manzi [and water], I realized ukuthi [that] ngine isipho [I have a gift]. Ugogo wami [my grandmother] was Isangoma.” (Thp 13, Sangoma/ Gobela).

It is evident that for most THPS, a conceding calling in various forms was the first important step that they took to become THPs. not accepting the calling is reported to have caused many problems for THPs who have the gift of being a THP.

Ability to Connect and maintain spiritual connection with the ancestors

According to most participants, the nature of ATM is such that there is always spiritual connection with the ancestors. ATM cannot be defined without considering the constant spiritual connection with the ancestors, the ancestors of the patient and that of the THP. Defining ATM is not just about the physical healing but also the spiritual healing. Some participants reported that spiritual healing forms an important component in the treatment of many ailments that brings the patients to consult with the THPs. Therefore, it is important that a THP is spiritually connected with the ancestors in order to help efficiently the patients. Participants said:

“Here we connect with clients at their spiritual level. So, when you connect with clients you have to reassure them that there will be a connection even if they use their spiritual approach. Here what is more important is the spiritual healing. The spiritual healing goes a long way.” (Thp5, Diviner)

“Traditional health helps people in aligning properly with their spiritual sphere. Some people you find that they are in the Roman Catholic, but their spirit is that of a Zionist. When they are in the Zionist is like you being given fat cakes when your body can actually not stand fat cakes, then you will have stunted growth.” (Thp2, diviner)

“This is what I normally do in terms of my healing… I do mainly diagnosis, how is your genetic make-up, spiritually, your ancestors, we call them ancestors and so on, so that’s what I normally do. Before we come to what can treat you. What can we now do for you, but this is where we start.” (Thp18, Diviner).

“It is therefore important that as a THP you must be able to connect with your ancestors to give the best healing” (Thp2, diviner)

Another participant, emphasized the importance of connecting with the spiritual world in ATM.

The participant said:

“In traditional healing, there are people who really it has got nothing to do with being ill, but it manifests itself as spiritual and you have to help them to connect with their spiritual world…” (Thp10, Diviner)

Most THPs emphasized the importance of spirituality which is strongly entrenched in ATM and facilitate the connection with the ancestors. Spirituality therefore should be regarded as a one basis for defining ATM.

Elements of practice in ATM

The second theme that emerged strongly from the interviews is about the elements of practice and process to undertake to become a THP. According to THPs, the initial step of being a THP requires one to be chosen by their ancestors for the particular calling. Similar to other systems of health care, ATM involves training in a variety of disciplines, which are not exclusively permanent areas of specialization or practice for THPs. Hence, the type of calling and the training the THP undergoes shapes the definition of ATM. Two subthemes to be discussed in this theme are;, training of Traditional Health Practitioners and language as a medium in traditional health practice.

Training of Traditional Health Practitioners on ATM

In addition to the ways of life, ancestral calling and maintenance of the connection to the spiritual world, participants described training as a significant step towards being a THP. However, there seems to be challenges that must be overcome during training, which may interfere with the initiation process translated as ukuthwasa/ho thwasa. It was reported that training of THPs depends on the nature of their calling. Most of the training may even happen in the family, where parents who are THPs may teach their children. This was reported:

“One has to go through the process of observing and slowly be shown how to do certain things such as interpreting visions, identifying plants, performing cleansing ceremonies and others. It is like an internship where students follow their mentor and learn by observing what is being done by their Gobela.” (Thp17, Sangoma/Gobela)

Another participant said

“It also depends on the nature of your calling. For example, the initial training will be tailored to assist the initiate to be, for example a herbalist. Many people these days do shortcuts as they believe you can just know the herbs or plants for certain diseases and then you are qualified, no... you must learn how to do these things properly and know that you remain answerable to your ancestors and the Gobela.” (Thp4, Herbalist)

Participants reported that the training of THPs involves shadowing and mentoring of the initiate at the home of the trainer (Gobela). Accordingly, to qualify to train other THPs takes a lot of experience and requires the extensive knowledge and skills. Some participants raised their concerns regarding the nature of training and increasing number of dishonest THPs who are not properly trained. The challenges raised by participants are on the duration of training and incompetence of initiates after completing the training.

“They say someone went for initiation but is not successful. It is because the quality type of the people who were in charge of the genuine way of doing things, they have passed on. I tend to question people who would say, no I can train you and ka o thwasisa [you can graduate] within 3 months to be a doctor. So, the lifespan of being a traditional healer is decreasing.” (Thp1, Sangoma)

“There are many bogus healers, that if you may ask them where they have been trained, for example as an herbalist, they may not be able to answer you because to them everything is trial and error because most are not answerable to anybody so they may not have been trained properly.” (Thp15, Herbalist)

Other participants supported the importance of proper training of THPs by saying:

“Ho thwasa [initiation] is not about the dancing, automatically… [you become a healer]. you start learning by showing them gradually how to mix medications and how to perform certain interventions such as ho phalaza [induced vomiting], it is the practical at home, so when I die, the child knows almost everything, so… the handover of the practice.” (Thp7, Sangoma)

“I was telling my students that you can’t tell me that you graduated in 2019 and already you are telling me that you are having students. You may have those that are potential students, but you are not at a level where you may say you are ready to start training. What experience do you have? Because when you train them you must also share some experience. At least 4 years to 5 years of practicing so that you have more knowledge to share with your students as well.” (Thp17, Sangoma/Gobela)

It appears that training plays an important role in the development and competence of a THP. Evidently participants were concerned of the fake initiation schools and trainers who promise vulnerable THPs that they will be competent without following proper processes of training for THPs. Lack of standards and regulation for training of THPs are identified in this study as key determinants to emergence of bogus practices.

Language as a medium in traditional health practice

Some participants described the influence and importance of language in ATM. According to participants language serves as a medium for communicating with the ancestors and a tool used in the training of initiates. The use of different language may create interferences when the THP is communicating with the ancestors. Participants said:

“Remember when we talk about the ancestors, the composition of the language of the person who will participate in initiation, Nka se thwasise ke morafi o mongwe [I cannot be trained by another ethnic group] easily. Badimo ba hao [your ancestors] they always have confidence in themselves.” (Thp1, Sangoma).

Another THP said:

“It is difficult to learn the language of someone else when you are still alive, now if I say I will teach you, three months you are a doctor… it goes with the language.” (THP13, Sangoma, Gobela).

It emerged that within ATM, language is not only important for communication, but also for naming, defining and explaining the traditional health concepts, anatomical structures and illness.

“You get ngaka ya setso [a traditional healer], who cannot elaborate in depth the signs and symptoms tsa [of] stroke, but he can diagnose using his concept. like if I want to explain myself in English, I may lose some of the meaning. But if I express myself on something that I do in my language then I will get it right. (Thp 18, Sangoma/herbalist).

“We unpack the body from an environmental perspective, we give a scope where in meriri [hair] replaces the grass, madi [blood] replaces water, marapo [bones] replace matlapa [Rocks] and the skin replace the soil. So, we unpack around that.” (Thp1, Sangoma)

Thp1, (Sangoma) went further and said:

“It’s just like when you change the plant or medicine itself, the herb… let’s say this is a “licorice”. Surely, I might not be explaining the qualities and the ingredients and the usage, but the moment I say sehlare se [this herb] ke maphakoro, you will find that I have a longer list of conditions that may be treated than that of a well-trained doctor from western medicine.”

The language and names used to categorize practitioners in ATM was seen as a problem area by one participant:

“I have a problem with this whole thing of trying to classify us as traditional healers. It is not like the western system, where nurses and doctors have their classification and categories. In African traditional health, one can fall within any of the areas of practice and that may happen over time. (Thp17, Sangoma/Gobela)”

Surely the descriptions and use of language in ATM is important in clarifying health, diseases and their causes. Participants shared examples to indicate that more must be done to understand ATM from the perspectives of THPs, with more focus put on similarities and differences in identifying, defining and understanding health related issues.

Within this exploratory study, a meaningful understanding and clarity is provided on how the THPs defined ATM as a unique system of health. More insight was provided in this study on what the features of ATM are as defined by the custodians of such practice (THPs). Modern definition of ATM restricted the practice of ATM to the use of herbal medicines for healing, it excluded the spiritual aspect and focused more on the physical and physiological process of healing [1–5]. This study however, demonstrated that ATM is a way of life for Africans in the sense that it cannot be separated from the everyday life and cultural practices of the African people. THPs reported that Africans still see their ancestral ways of living as primitive and in extreme cases, perceives the knowledge and practices of ATM as the practise of witchcraft. This may have been fuelled by the western schooling system and indoctrination on a large scale, which vilifies the practice of ATM [24]. For example, the type of food a pregnant woman eats is entrenched in the beliefs and culture. What came out strongly from the study was that the unique circumstances and conditions that every individual or group endure determines how ATM is used.

THPs emphasized that spirituality is one of the bases for defining ATM. Hence this study has endeavored to provide clarity on the role of spirituality and connection with ancestors within the practice of ATM. THPs described ATM as a system heavily influenced by the spirituality and customs within the particular African group. Those customs would then dictate how individuals should behave and conduct themselves in different phases of their life from childhood until old age. Our study findings indicate that ATM encompasses spiritual, physical and mental interventions as elements of the healing process. Spiritual alignment was recognized as an essential element of life that contributes to growth, prosperity and good health. Additionally, it emerged that spirituality within ATM may manifest as illness which requires an inquiry into the genetic make-up of a person to determine ancestral linkage with the presenting problem. Indeed, spiritualty and connection with the ancestral spirits requires a balance between the body, the mind and the soul [25]. This is a founding principle for ATM because spirituality and religion in African contexts are inseparable. Having said that most spiritual practices in Africa as still referred to as cults or myths. Spirituality in ATM is being practiced throughout Africa in written and unwritten forms as seen in cultural and religious practices such as dancing, singing and rituals [26]. Therefore, connecting with the spiritual realm is an important element of the THP. From this study it is apparent that THPs consider spiritual connection with ancestors essential for good health and healing in ATM.

It was reported that to be eligible to practice as a THP, an individual has to meet specific criteria and comply with certain elements in preparation for their role as a THP. According to THPs in this study, the initial criteria for qualifying as a THP is ancestral calling which may present in various ways such as an illness or life difficulties. The initial calling does not necessarily specify the category or nature of specialization one will embark on. Kubeka and Blokland [27] reported occurrences that precede a calling such as being led through dreams to the person who must train the healer for their specific calling. Another study also mentions mental illness which can only be lessened by conceding to the call, known as ukuthwasa [28]. This study affirmed that a person may be chosen by ancestors even before they are born to become a THP. Regardless of the circumstances that led one to be a THP, ceding to ancestral calling is a difficult decision for many as it disrupts many aspects of life including work, school and family relations [29]. This is associated with demands of doing ancestral work which demands a lot of commitment and dedication to helping people in need. Therefore, different people experience their calling in unique but different ways [30]. However, THPs reported that that there is a strong correlation between ancestral calling and history of traditional healing in their family, fulfilling a common Sepedi proverb says rutang bana ditaola le se ye le tsona badimong loosely translated as teach children knowledge and wisdom before you depart.

Another element that influences the definition of ATM according to the participants is the training received by the THPs. The training should be considered when defining ATM because THPs are not complete without the training and initiations. In the Thai culture traditional healers go through trainings on identification of illness and how it can be treated [31]. The training the THPs undergo is in the form of apprenticeship, mentee and mentor relationship. This is similar to the training of the THPs in Africa except that in Africa, there is the spiritual aspect which involves initiation. THPs are led in different ways to a more experienced THP, known as Gobela, for their training. Potential initiates may be directed by ancestors in dreams, or be informed of their gift during a consultation with a THP. However, Most THPs can also learn the craft of practice within their family, where they are taught by their parents. Accordingly, the process of training for THPs involves shadowing where they learn to perform various skills and roles of the THP. As part of their training, THPs learn to identify and harvest plants, analyze and interpret dreams and perform cleansing ceremonies. However, it was reported that there are also challenges about the time it takes to train THPs, which has been reduced drastically by bogus trainers. Although the training of THPs differ from region to region, there are similarities in terms of the process such as staying with the trainer during the period of training [32], learning to conduct consultations, diagnosis and prescribing treatment [33]. Eventually the trainee has to graduate, where a big ceremony is held in the presence of family and the community at large, to confirm that the initiate has been found competent. THPs reported that there are times wherein a THP can fail their training and may need further training. This finding is also reported by Mokgobi [31]. Nevertheless, the THP even after ho thwasa, remains answerable to their trainer, who must ensure their competence prior to their independent practice.

One of the profound elements of ATM is the language within health is defined and interpreted among Africans. The unique language used in ATM to clarify names, illness and processes provides a good basis for communication and knowledge exchange among African people. More insight was provided by THPs on the value of language in naming plants or herbs, labelling anatomic structures and making correlations between the body and the environment. THPs indicated that their inability to elaborate on medical terms does not mean that they are not knowledgeable about illness such as stroke and diabetes. The extent to researchers translated the language used in ATM as understood by THPs must be further explored, especially in relation to the categories used such as herbalist, diviner and Sangoma. Efforts must be made to determine if this concepts in reality represent the views of THPs on the ground. Hence, language is an important medium in communicating with ancestors and for purposes of training for THPs. Cultural and spiritual meaning of certain practices within ATM must be interpreted literally as they are to provide contextual and meaningful explanations [34]. Within ATM, language provides a sense of belonging and pride in ancestors [9], which can therefore facilitate a gravitation towards ATM among people who uses such a service [35]. Using an indigenous language that people understand is essential in the development and maintenance of the particular language.

This study have demonstrated that ATM is a unique system with its own way of defining, naming and explaining concepts and processes. Eligibility for being a THP is determined by ancestral connection and history of having a THP in the family. It is also clear that ATM is a complex system that requires consideration of the cultural and social practices and background within the different societies where it is being practiced. Efforts should be made to understand the use of language in naming and defining concepts and illness from a perspective of THPs. There must be a concerted effort to bring together THPs, to facilitate dialogue on how concepts can be used consistently within ATM. Further research is recommended to explore significance of language in defining and naming in ATM.

ATM-African Traditional Medicine, THP-Traditional Health Practice, TM- Traditional Medicine, WHO-World Health Organisation

a. Ethics approval and consent to participate

Permission to conduct the study was granted by the Faculty of Health Sciences Human Research Ethics Committee at the University of Pretoria ( protocol 812/2019). All methods were carried out in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all participants.

b. Consent for publication

Not applicable

c. Availability of Data and Material (ADM)

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

d. Competing interests

All authors have no competing interests and no declarations to make.

e. Funding

The study was part of the bigger National Research Fund project, and therefore received funding to undertake the study.

f. Authors' contributions

MEM contributed to the conception, design, analysis, interpretation and drafted the manuscript. MFM contributed to the analysis, interpretation and drafted the manuscript. AR contributed to the analysis, interpretation and drafted the manuscript.

g. Acknowledgment

All the traditional health practitioners and their organizations who participated in the study are thanked by the authors. Without your contribution, there would have been no data to report.

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No competing interests reported.

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“What about our ways of living?”: Traditional Health practitioners describe the tenets of African Traditional Medicine.

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