Article Text

Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review
1. Peter Bai James1,2,
2. Jon Wardle1,
3. Amie Steel1,3,
1. 1 Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
2. 2 Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
3. 3 Office of Research, Endeavour College of Natural Health, Brisbane, Queensland, Australia
1. Correspondence to Peter Bai James; Peter.B.James{at}student.uts.edu.au

## Abstract

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

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

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

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

• complementary therapies
• Sub-Saharan Africa
• systematic review
• Integrative Medicine
• Health System

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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### Key questions

• There remains a dearth of research evidence in Sub-Saharan Africa (SSA) on the drivers and facilitators of traditional, complementary and alternative medicine (TCAM) use, factors associated with TCAM use, and the impact of TCAM use on broader healthcare.

#### What are the new findings?

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

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

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

#### What do the new findings imply?

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

## Introduction

#### TCAM users among patients with eye diseases

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

#### TCAM users among surgical patients

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

#### TCAM users among patients with malaria and febrile illness

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

#### TCAM users presenting with sexual health conditions

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

#### TCAM users seeking infertility care

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

#### TCAM users with musculoskeletal diseases

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

#### TCAM users with mental illness and neurological disorders

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

#### TCAM users among students, healthcare professionals, academic staff and general outpatient population

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

### Drivers of TCAM use

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

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

### Barriers to TCAM use

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

### Non-disclosure of TCAM use to healthcare providers

Twenty-five subhealth population studies reported on patients’ non-disclosure of TCAM use to their conventional healthcare providers.21 26 33 34 39 40 43 51 52 56 66 82 88 89 91 106 110–112 145 153 169 194–196 The non-disclosure rate of TCAM use to healthcare providers ranged from 55.8% to 100%, with an average of 83.0%. With regard to reasons for non-disclosure, four studies conducted among pregnant women in Uganda91 and Zambia,82 patients with hypertension in Ghana39 and patients with HIV/AIDS in South Africa195 cited fear of receiving improper care as a reason for not disclosing their TCAM use status to their healthcare provider. Another reason for non-disclosure of TCAM use was the conventional medicine provider’s negative attitude with perceived lack of support and understanding that lead to mistrust and stigma from conventional providers. Such reasons were put forward by patients with HIV/AIDS in South Africa,194 Uganda196 and Ghana,51 as well as patients with cancer in Nigeria111 and pregnant women in Uganda.91 The perception among Ethiopian patients with cancer110 and Ugandan patients with HIV/AIDS196 that their conventional healthcare providers lack knowledge about TCAM was another reason for not divulging their TCAM use status. Healthcare providers’ lack of enquiry about TCAM use was also cited among patients with cancer,34 epilepsy40 and diabetes43 in Nigeria. A study in Uganda reported that two-thirds of patients were open for discussion on TCAM use if initiated by their healthcare provider, and majority of them were also willing to adhere to their advice on TCAM use.196

### Cost of TCAM use

We identified 15 papers that reported on the cost of TCAM use.20 21 25 27 47 55 71 111 112 117 130 146 167 197 198 The current literature shows a conflicting picture among studies that compared cost incurred between TCAM and conventional care. Some studies suggest that there is relatively low cost involved in using TCAM therapy compared with conventional care, although there is variation on how cost was measured in the two groups. For example, a Ghanaian national survey revealed that the average total household cost in the last 12 months for conventional care was slightly higher (US$33.43) than costs incurred in seeking TCAM treatment (US$30.33).27 Also, a study conducted among patients with cancer in Nigeria indicates cost of TCAM ranged from no cost to US$31.25, compared with the minimum cost of US$250 for conventional care.111 In Mali, half of conventional malaria treatment costs ranged from no cost to US$116, whereas TCAM treatment ranged from no cost for three-quarters of patients to US$100.117 In other studies, the cost of TCAM was higher than conventional care. For example, a Cameroonian study reported that the cost of TCAM treatment per day (US$1.5) was higher than conventional treatment (US$0.77).197 Although cost was not stated, Sorketti and colleagues130 in Sudan reported that more than three-quarters of psychiatric patients reported that the cost of treatment in traditional health centres was not less than conventional psychiatric service. Although no comparison was made with regard to conventional care, cost for TCAM services was relatively high in certain cases. For instance, in Tanzania, the maximum cost of TCAM treatment for epilepsy was US$100.119 A relatively high cost of TCAM practitioner services was also reported among the general population in South Africa, where the median cost for the last visit to a traditional healer was calculated at US$21. TCAM costs can take up a significant part of the household healthcare budget. Sixty-four per cent of households in a South African study spent more than 10% of their monthly spending,20 whereas majority (92.2%) of patients with HIV/AIDS who are TCAM users in Nigeria spent less than 20% of their monthly income on herbal treatment.112 Among surgical patients in South Africa, close to one-third (30%) paid less than US$60 for TCAM services.146 Findings from studies that assessed the cost per month of TCAM use alone reported an average of US$47.5 (US$12.60–US$96.88).21 25 47 55 167 In comparison between self-treatment and TCAM practitioner use, the average financial cost in Burkina Faso for TCAM self-care (US$2.85) was almost half of that for practitioner use (US$4.77).71

### Safety of TCAM (self-reported or observed adverse effects)

Twenty-four papers reported on the perceived adverse effects due to TCAM or in combination with allopathic medicines.33–35 44 47 52 55 59 66 69 76 84–86 88 106 110 145 146 153 156 199 200 Fifteen of the studies33 34 44 47 69 76 84–86 88 110 145 146 153 199 200 reported on the prevalence of respondents’ perceived side effects due to TCAM products use (4%–53.3% (mean, 19.1%)), whereas four35 66 106 153 reported on respondents’ perceived side effects due to concomitant use of TCAM products and conventional medicines (2%–56.5% (mean, 23.5%)). One Nigerian study153 among outpatients reported a relatively high prevalence of TCAM adverse effects when used alone (9%) than when used in combination with conventional medicine (2%). Gastrointestinal disturbances (nausea, vomiting, diarrhoea and abdominal pain) followed by dizziness, headache and malaise were the most common types of adverse effects reported in 1134 44 52 55 76 84–86 145 146 153 201 of the 1234 44 52 55 59 76 84–86 145 146 153 201 studies that reported on the types of respondents’ perceived side effects. A Ugandan study among patients with HIV/AIDS and non-HIV/AIDS individuals reported that TCAM use was independently associated with the occurrence of liver fibrosis,59 while another among general inpatients indicated that 10 adverse effects were associated with the use of herbal products prior to admission.156

## Discussion

This paper reports the first ever systematic review of the available research evidence on the contemporary use of TCAM in Sub-Saharan Africa. While there are assumptions about high use of TCAM (eg, 80%) across the continent that circulate in the literature, there has been no systematic review to date to substantiate that claim. Our review attempts to provide an estimate of TCAM (product and practitioners) prevalence both in the general population and health subpopulations based on the review of the current literature. The reviewed studies report varied TCAM (product and practitioners) use prevalence rates within and across countries in line with previous reviews.202 203 Such variability is possibly attributed to differences in TCAM definition and sample size in different studies and the high tendency for recall bias due to variations in timeframes over which TCAM use was evaluated. For instance, two large Nigerian studies report different prevalence rates of TCAM use during childbirth due to differences in study location, method of sampling and the way TCAM use was assessed.95 96 Despite an apparent conflict between variability in reported TCAM utilisation rates across studies, and the high sample size and response rate of many of these studies, our review highlights a relatively high use of TCAM both in the general population and health subpopulations, which resonate with findings of previous studies conducted in developed nations204 205 and estimates by the WHO.1 The push and pull factors of TCAM use identified in our review also resonate with the drivers of TCAM use reported outside of Africa,206 and appear to be important drivers underpinning the high use of TCAM across the continent. As in countries outside of Africa, the high use of TCAM also underscores the substantial role of TCAM as a source of basic healthcare to populations across Africa. It is imperative for health departments and governments across Sub-Saharan Africa to at least consider and inform themselves regarding TCAM, its current role and future possibilities in wider healthcare systems. This can be in the form of TCAM policy design and implementation, promoting TCAM training, research and development, as well as encouraging consideration of the integration of TCAM into mainstream healthcare system.1 It is worth noting that as a means of advancing TCAM use, some institutions have integrated TCAM into medical education curriculum within and outside of Africa.6 207

Our review also identified a variation in patient non-disclosure rates across studies which resonates with findings from research outside Africa.208 209 The lowest estimate identified in our review is sufficiently large to warrant concern over communication between patients who are TCAM users and their healthcare providers. Insufficient disclosure of TCAM use also highlights the need to have a clear insight into the barriers to disclosure. The available literature outside of Africa indicates that individual and/or contextual factors may influence patients’ decision not to disclose his/her TCAM use status.208 210 However, the reasons for non-disclosure identified in our review are informed by differences in beliefs and attitudes regarding conventional medicine and TCAM between patients and healthcare providers. In order to improve patient–provider communication about TCAM at the health service delivery level, it is important for healthcare professionals to be aware that their patients are likely users of TCAM and to encourage and facilitate an open dialogue about TCAM use as routine in their interaction with patients. Such communication regarding TCAM should imbibe the culture of shared decision making211 about therapeutic options for patients since it promotes patient satisfaction and active patient involvement in their care.212 Also, TCAM policy and practice guidelines should incorporate culturally sensitive patient education about the usefulness of patient disclosure of TCAM use to their conventional healthcare providers. In addition, to leverage communication about TCAM use with patients, conventional healthcare providers are required to be knowledgeable about commonly used TCAM products and practices to better advise their patients and the public on their risks and benefits. The current literature, although scanty, indicates a deficiency in knowledge about TCAM products and practices among healthcare providers in Sub-Saharan Africa213 214 and outside of Africa.215 216 As it has been suggested in studies outside of Africa,217 218 there is a need for the inclusion of common TCAM modalities into the existing curricula of healthcare training institutions and continuous professional education programme of the various healthcare cadres, as well as making reputable TCAM pharmacopoeias available in health facilities across Africa.

The reasons for the high TCAM patronage across the continent were also examined in our review, and they appear to resonate with the push and pull factors reported in studies conducted outside of Africa.219 220 Possible underlying structural factors that help explain the drivers of TCAM use include the fact that Sub-Saharan Africa is host to the largest population of people who are economically disadvantaged,221 and access to conventional care is limited due to cost and distance.222 Therefore, TCAM offers an affordable and easily accessible healthcare option. Also, because TCAM is publicly available and allows active patient involvement in health decision making, it offers users greater freedom and ownership in terms of their healthcare choices compared with conventional care in which health decisions are generally controlled by the healthcare professional.223

Our review also indicates that TCAM was used concurrently with conventional medicine, indicating that TCAM is mostly used as a complementary therapy rather than an alternative to conventional care. This may be linked to a growing paradigm shift among patients towards a holistic attitude in health that aligns with the philosophy of TCAM and acknowledges the insufficiencies of biomedical care.224 Given the complex interplay of factors influencing the pluralistic nature of health service utilisation in Sub-Saharan Africa,225 further research exploring the factors influencing the decision to use TCAM is required. The concurrent use of TCAM and allopathic medicines is known to also potentially undermine patient safety and health outcome due to herb–drug interactions leading to serious adverse effect and therapeutic failure of conventional medications.226–228 It is imperative that clinical studies be conducted to provide evidence of clinical interactions between conventional medicine and commonly used TCAM modalities in Sub-Saharan Africa. Such information is of value to healthcare providers when interacting with their patients as it will help provide an opportunity for well-informed therapeutic choices to be made that will contribute to maximising patient health outcomes.

Our review indicates a relatively low prevalence of self-reported TCAM adverse effects when used alone or in combination with allopathic medicines compared with what has been reported outside of Africa. Although not verified, it shows that TCAM like any conventional medicine is not free of adverse effects.229 The relatively low prevalence may be due to the fact that patient non-disclosure rate across the Sub-Saharan Africa is high and the fact that TCAM is often considered natural and therefore safe. TCAM adverse effects can be due to inherent toxicity or due to quality issues such as poor quality of TCAM products, incorrect or misidentified, or adulterated or contaminated TCAM products. Despite the majority of side effects being reported were gastrointestinal disturbances in our review, serious adverse effects such as liver and kidney toxicities have been cited in the literature.230 231 This has led the WHO to develop guidelines for the safety monitoring of herbal medicine product within the existing WHO pharmacovigilance framework.232 However, TCAM product safety regulation across Africa is still a challenge as many countries across Africa lack adequate regulatory framework to ensure the safety and quality of TCAM.233 Such challenge is compounded by the fact that there are few preclinical and postmarket TCAM safety and quality data as in addition to confusing nomenclature over plant species, varied cultural differences and traditional practices across Africa.234 Despite its limitations, the use of pharmacovigilance principles as part of the overall regulatory framework for TCAM in Africa is urgently needed. The incorporation of pharmacovigilance questions into ethnobotanical or ethnopharmacological studies is worth experimenting.235 Thus, the systematic collection and analysis of TCAM safety data is crucial in order to protect patients and the public at large.

Our review also identifies, among the general population and some health subpopulations, a relatively high level of self-directed TCAM use compared with the levels of practitioner-directed TCAM use. This may be explained by the significant amount of studies that focused on TCAM product use compared with TCAM practitioner use, or that the decision to use TCAM is more often influenced by family, friends and neighbours than traditional medicine practitioners.12 111 National representative studies that specifically look at TCAM practitioner utilisation both in general populations and among health subpopulations will provide further insight into the extent of TCAM practitioners’ contribution to the health delivery system.

In the general population in particular, the available literature indicates that TCAM users are likely to be of low socioeconomic class who are unemployed and unskilled. This suggests that low socioeconomic status in the society influences the decision to use TCAM given the fact that TCAM is a low-cost healthcare option compared with biomedicine. With particular reference to educational status, the result of the majority of the relevant studies reviewed contrasted with studies from high-income countries that show that TCAM users are more likely to have attained a high level of education than non-users,206 236 237 but in line with current scholarship in other low and middle-income nations.238 The low levels of health literacy239 and low access to evidence-based health information across most populations in Sub-Saharan Africa240 may explain such correlation. Our review reports conflicting findings on the relationship between TCAM utilisation and age, gender, religion and spatial location. This is in contrast with reviews that focused on studies outside of Africa, particularly with respect to gender in which women were more likely TCAM users compared with men.206 236 241 Variations in study design, sample size and data analysis may also explain the differences in TCAM user profile across studies, principally where statistical methods employed did not allow for the impact of confounders to be measured,242 thereby affecting the validity of the findings. Well-designed nationwide, or multinational, studies in which data are appropriately analysed are required to understand how sociodemographic factors affect TCAM use in and across Sub-Saharan Africa.

Our review highlights that there has been a disproportionate research focus on TCAM use among HIV/AIDS and obstetric patients in Sub-Saharan Africa. This pattern suggests the current TCAM research priorities in Sub-Saharan Africa and underscores the historic public health policy and research attention dedicated to infectious diseases and maternal child health in Sub-Saharan Africa.243 Areas that have received less attention in the TCAM research agenda in Sub-Saharan Africa include cancer, diabetes, musculoskeletal conditions and surgery. Given the steady rise in non-communicable diseases in the region10 and the high rate of TCAM use by individuals with these conditions,11 12 greater policy attention and research focus are needed to understand TCAM role in non-communicable diseases prevention and treatment in Sub-Saharan Africa. Specifically, well-designed, large-scale studies that look at how TCAM interfaces or interacts with conventional care for non-communicable disease conditions are urgently needed. Also, for both communicable and non-communicable health conditions, the interprofessional dynamics and provider–patient communication with regard to TCAM use need to be further explored.

### Review limitations and future research directions

Our review highlights key research gaps that need to be addressed that currently challenge attempts to provide a comprehensive overview of TCAM use across Sub-Saharan Africa. First, most of the studies in our review were from Nigeria, South Africa and Ghana. Additional data are required from other Sub-Saharan Africa countries where little research has been conducted to know whether findings from less researched countries are in line or in contrast to the current evidence synthesised in our review. Second, of those articles appraised for quality, the majority had critical methodological flaws, such as employing a non-representative sample strategy, reporting a small sample size, incorporating a substantial risk of recall bias and failing to provide a definition of TCAM in their studies, all of which undermine the integrity of research findings and challenge the ability to draw definitive conclusions and conduct proper comparisons across different studies. Similar methodological limitations have been reported elsewhere.236 238 It is of utmost importance that the quality of empirical research into TCAM use in Sub-Saharan Africa is improved by using standardised methodology that follows good research design and practice.244 Third, our review identified the low cost of TCAM as a key driver of TCAM use, and low socioeconomic status was identified as a possible predictor of TCAM use in our review. However, only few studies in our review compared patient-reported cost of TCAM care and conventional healthcare and it shows a conflicting picture. Thus, there is a dearth of research evidence on the actual cost incurred by patients when seeking TCAM care. An economic analysis of TCAM use relative to conventional healthcare in general and subhealth populations is a worthy focus within the future TCAM research agenda in Sub-Saharan Africa. Fourth, the majority of the papers reviewed in our study employed quantitative survey design and analysis, providing a useful snapshot of TCAM utilisation patterns. Such research design, although useful, provides limited information regarding the decision-making process around TCAM use and patient–provider communication about TCAM use. Quantitative survey design also failed to provide an indepth insight with regard to the interface between the lived experience of TCAM use and the user’s religion and culture. As such, it is important that qualitative studies that focused on TCAM use and practice are conducted to help provide cultural and social insights that are useful to healthcare providers, policy makers and patients. Fifth, only studies published in English were considered in our review. We decided to include only English papers because none of us are proficient in French and other languages. Given that the full text of each included article is thoroughly read and understood before data are extracted, it will be unwise to rely on the English abstract of papers written in other languages given our limitation in other languages other than English. It is possible that an inclusion of studies published in other languages would have influenced our results. Finally, there are new publications beyond our search duration which if included may have influenced our findings. It is good for readers to take this and other aforementioned limitations when interpreting our findings.

## Conclusion

TCAM use appears widespread across many countries in Sub-Saharan Africa, although most studies emerge from just a few countries including Nigeria, South Africa, Ghana and Uganda. Stakeholders involved in the healthcare sector in these countries should be mindful of this critical role of TCAM in healthcare service delivery across these countries. Further research in Sub-Saharan Africa should address a number of gaps identified in the current scholarship in order to help inform policy design and practice, as well as contribute to providing safe, efficient and harmonised healthcare for all in Sub-Saharan Africa.

## Acknowledgments

Successful completion of this manuscript was made possible through participation in the Twelve Weeks to Publication Program funded by Faculty of Health, University of Technology Sydney and with the active support and contributions made by the facilitators and other program participants.

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## Footnotes

• Handling editor Dr Stephanie M Topp

• Contributors PBJ and JW conceived of the study. All authors contributed to the study design. PBJ did the database search and data extraction, while JW, AS and JA supervised the process. PBJ wrote the first draft of the manuscript, while JW, AS and JA contributed to the intellectual content and reviewed the subsequent and final drafts of the manuscript.

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests None declared.

• Patient consent Not required.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Data sharing statement There are no additional data available.

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