Providing mental healthcare through faith-based entities in Africa: a systematic review

Eligibility criteria

The inclusion criteria were as follows: empirical, peer-reviewed studies which included information on FBHPs of MHC in Africa. This included evidence from the wide range of faith-based, mental healthcare (biomedical and alternative), and a variety of FBHPs which are including faith healers, traditional healers, religious leaders, herbalists, traditional and faith healing facilities (churches, mosques, prayer camps and prayer forests). Other faith-based entities include faith-based organizations (FBO) (community-based organisations, non-profit organisations, non-government organisations); faith-based hospitals/ facilities and biomedical/ psychiatric facilities, delivering services at community or facility level (see Figure 2). The included articles contained evidence relating to magnitude of FBHPs where frequency of use and availability were included as variables due to the limited evidence on the number of beds and facilities regarding faith-based MHC services. Availability included affordability, accessibility, and acceptability (cultural, social, and religious linkages) of both the alternative and biomedical types of faith-based MHC in Africa. The other articles included in this systematic review were in relation to the types of FBHPs and MHC services, including referral, the quality of services provided, including the impact of MHC on mental-health, and harmful treatments (including training interventions and qualifications of FBHPs). The effectiveness of mental healthcare was assessed based on the mental health outcomes, whether positive or negative, on the mentally ill individuals and those seeking MHC.

Figure 2

Databases searched/search strategy

The databases that were searched included: PubMed, Scopus, EBSCOhost (Cinahl, AfricaWide, PsycArticles, AtlaReligion and PsycInfo), Google and Google Scholar. The search term clusters and variations are shown in Appendix 1. We used Google and Google Scholar to conduct further purposeful searches for material on faith-based, health facilities, such as hospitals and psychiatric care facilities, as this was not retrievable through standard academic search platforms. Additional articles on faith-based, psychiatric hospitals were searched according to their names and country location on databases (mainly Google scholar) to add towards the magnitude (availability and accessibility) to biomedical care. We also scanned the reference lists of included material for further items for inclusion (after the initial phase of exclusion). The search process was checked by Dr Jill Olivier.

Selection process

This review included quantitative, qualitative, and mixed methods studies; journal articles, book chapters, theses, organisational reports, and commentaries. Included studies were limited to English and published. The date range for inclusion was from 2007-2024. The rigour of the systematic review was enhanced by minimising bias in the selection and analysis of documents through the use of a quality appraisal tool for mixed methods studies and transparency shown for the methodological process.⁵⁴ In the full text review, a small cluster of studies which solely focused on collaboration between traditional- or faith-healers and biomedical practitioners (BMPs) were mostly excluded, unless they had other information relating to the above inclusion criteria as well.

Data collection process

The second phase was a systematic review that extracted data, and we conducted a separate analysis dependent on data type (thematic analysis on qualitative data and meta-analysis on quantitative data) followed by data synthesis. Thus, the study was conducted iteratively with search terms and categories established in Phase 1 and refined through a further checking process. This was deemed necessary given the exploratory purpose of this research, the diverse data types and sources included, and the fact that this is a new research terrain. More extensive results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process are indicated in Figure 3.

Figure 3

The main study characteristics and findings were extracted following the Thomas and Harden’s approach to data extraction, drawing relevant findings from the studies into the extraction sheet.⁵⁷ A thematic, narrative synthesis (a qualitative analysis approach to identify common themes or ideas across texts) was applied to the extracted, qualitative data (using the categorisation in Figure 2 above and then inserted into the data extraction sheet).

For the quantitative data, similar statistics were collated and pooled (in a form of a meta-analysis used to synthesize and express the statistics on the various types and magnitude of faith-based, mental health provision and faith-based, mental health services). A random-effects model using Metaprop in STATA was used so that there could be an observed difference amongst the proportions and the distribution and mean (pooling estimates from the meta-analyses), where the mean could not be entirely dependent on sampling error and various other factors.^56,58,59,60 Finally, qualitative and quantitative data was synthesised from the relevant findings.

Types and utilisation of faith-based mental healthcare delivered by FBHPs

There are varied and diverse types of FBHPs mentioned in the included studies, the most prevalent being individual providers (30/53) and the organisational types (12/53). Types included: traditional healers, faith healers, clergy, imams, FBOs, and faith-based, biomedical facilities (using standardised, psychiatric care).

We roughly pooled quantitative data on alternative types of MHC (described above). There was no quantitative data available on the main types of MHC — the only types being prayer only (3/55 studies), prayer and fasting (4/55), fasting only (2/55), rituals (4/55), herbs and fetish practices (4/55), and sacrifices (4/55) (Figure 4) selected from 21/55 studies. The program used to construct the meta-analysis was STATA. This specifically entailed an analysis on the frequency of use of these few types of MHC with studies from in Ghana, Kenya, Nigeria, and Sudan.^62-64

Figure 4

There were qualitative and quantitative studies included showing that prayers and rituals are used as alternatives to or supplements of mental healthcare (as shown in 16/55 studies), for example, prophets and prophetesses within prayer camps, traditional and faith healers, FBOs, and churches across Africa.^17,18,65-77

Prayer is expressed in a myriad of forms across African contexts. Prayer can take the form of consultations with God. This has been reported in a Kenyan study,⁶⁵ or a journey of healing as described in a Ghanaian study,⁷⁴ or as bereavement, preaching, and worship or Quran recitations to ban evil spirits.^{13,72,73,75,77,78} Prayer only was used in three studies where quantitative data was shown among 8/30 (26.7%),⁶⁰ 51/82 (62%),⁷⁹ and 34/66 (52%)⁶³ respondents with mental illness (Figure 4).

Studies included a focus on Individuals with post-traumatic stress disorder (PTSD) who received faith-based, trauma healing.^155,156 This included prophet stories of the Quran and prayer as well as other types of faith-based MHC which helped displaced communities as tailored services.¹⁵⁵ Another study focused on faith-based strategies for traumatised adolescents in schools by using Christian faith.¹⁵⁶

Other types of alternative MHC were fasting and prayer where they were used together as shown in studies from Zimbabwe, South Sudan, Kenya, and Ghana as well as other emergency settings.^64,73,75,82 In three, sub-Saharan, African countries (Ghana, Kenya, and Nigeria) Esan, Appiah-Poku conducted as a series of randomised control trials where direct observations were used as a way of sharing practices, profiles, and mental health treatments of traditional and faith healers.⁶⁸

Types of rituals included in the studies were birthing or death, cleansing rituals, divination, sacrifice, or dancing.^{63,68,81,82,84} Overall, the alternative MHC of ritual was used very generally, and it was not clear enough what that entailed due to limited descriptions. Similarly, herbalists and traditional healers used herbal medicine as a treatment for emotional issues as described in 9/55 included studies.^{68,80-83,85-88} These herbal and fetish practices included eating herbs, drinking herbal infusions, washing and herbal baths, herbal ointments, decoctions, incense, oils, and perfumes (Table 1).^{16,68,73,80,82,85,86,89}

Some FBHPs, such as FBOs, clergy, and faith healers and traditional healers, provided more biomedical MHC.^{16,65,67,73,76,84,90} Traditional and faith healers offered early mental health screening (2/55)^65,91 and in some cases, could recognise suicidal behaviour,⁶⁵ counselling _(10/55),^{13,14,17,60,61,65,67,71,72,73,74,76,82,90,92,94} social support,^76,94,95 and faith-based, home-based care (4/55)^18,19,66,93 were also provided. Ninety percent provided counselling in a Nigerian study reported in Table 1.

Community, mental health education as a type of mental healthcare provided by prophets (neo-prophetic ministers), traditional and faith healers, FBOs, and churches was found in 4/53 articles.^18,65,72,76 This included assistance with jobs, relationships, substance abuse, and addressing stigma and types of neglect.^19,63,72,92 A study mentioned that clergy who provided mental health education programmes imbue patients with life-skills and coping mechanisms improving their mental health.⁷⁶

Faith-based homecare was utilised in 4/55 studies as a type of MHC provided by FBOs. Traditional faith healers and Christian clergy are more accessible because they provide monetary support and gifts, enable communal ties, and possess less stigmatisation within their communities.^{18,19,63,66,72, 77,83,93,96,97} A study from South Africa reported that 86% of traditional healers used their skills and knowledge to treat psychological issues, 90% frequently treated patients in their homes, and a further 98% visited their MH patients often.⁹² Statistics have indicated that 86% of community members with emotional struggles are subjected to this MH stigma; and 26% of individuals with emotional issues became depressed due to being isolated within their communities.^96,97

The literature also revealed that chaplains, mallams (Muslim religious leaders), and pastors located within biomedical, health facilities provided MHC with an alternative or religious lens as shown in 4/55 studies.^98-101 There was evidence to indicate that chaplains also visited their patients daily, prayed for them, and promoted the use of Holy Books to assist them with their psychological well-being.^98,99,101

In Nigerian and Zimbabwean studies, it was indicated that although chaplains had a sensitive nature in their role, they were not always equipped to deal with severe cases of mental illness.^99,101 There were 6/55 studies that mentioned the use of psychiatric care at faith-based, biomedical facilities.^{78,99,102-105} Examples are the Ruharo Mission Hospital and the Kisiijzi Hospital in Uganda and Le Centre Psychothérapeutique Icyizere in Rwanda (providing MHC for PTSD and substance abuse). Additional examples include the Presbyterian Church (a biomedical facility providing palliative care) in Kenya and the Christoffoel Blind Mission Hospital which is an NGO facility in Nigeria.^{78,99,102-105} The Rwandan study mentioned a facility that found that 77% of patients received outpatient services, 95.3% had psychiatric medications prescribed, and 44.7% had either individual or group psychotherapy.¹⁰⁴ During the COVID-19 pandemic, the role of faith-based, mental healthcare evolved, and some individuals and organisations migrated into online recovery groups known as Project Exodus, rooted in Christian beliefs providing both biomedical and alternative, mental healthcare.¹⁰⁵

Magnitude of faith-based mental health provision

Magnitude was operationalised in this study as “footprint,” classified as the number of faith-based facilities, psychiatric beds, and any faith-based organisations providing biomedical, mental health care, and availability of faith-based, organisational providers of MHC (faith-based psychiatric care and faith-based organisations). It was also classified as the utilisation of individual types of FBHPs and the frequency of use based on faith-based MHC (mainly “alternative”) due to a lack of data on faith-based “biomedical” MHC.

Frequency of utilisation

This review found 11/55 studies that discussed the frequency of utilisation of FBHPs (not all of them, only traditional, faith healers, and herbalists, as well as faith-based, biomedical facilities providing psychiatric care) and the various MHC services in Africa.^{10,13,17,20,68,99,108-110} Kisiiki Hospital in Uganda had limited mental health professionals and medicines, but had 28 beds for outpatient, mental healthcare.^106,111 In Rwanda, CARAES-Ndera has over 288 beds and provides psychotherapies and medication to the patients who struggle with their mental health.¹¹² In Ghana, there were 877 spaces for admission of the mentally ill, while in Nigeria there were 677 beds for mentally ill patients within faith-based facilities and in Kenya, there were no beds for the patients.⁶⁸ These studies estimated the ratio of hospital beds to be between 0.14 and 0.27 per 1000 people, which is above the norm for biomedical practices that are usually between 0.01 and 0.1.⁶⁸

Faith-based facilities at the Christoffel Blind Mission Hospital provided community, mental health levels but no primary-care facilities.¹⁰³ In Ghana and Nigeria, between 60% and 90% of traditional and faith healers had inpatient facilities for patients with emotional struggles; however, there were no facilities for involuntary admissions.⁶⁸ In Kenya, sufficient capacity of MHC services is available based on the number of traditional healers providing MHC. In Ethiopia, there were 150 traditional healers and 164 mosques and churches with one imam/ priest each.^17,107,113

A dynamic relationship is apparent between affordability, accessibility, and availability of faith-based, mental health services.^{10,13,16,20,68,99,108-110} Various types of socially acceptable support are provided by individual (clergy and traditional/faith healers) and organisational providers (prayer camps and prayer forests) within African, mental health systems.^18,76 In Egypt, 30.4% of patients and in Ghana, 93% of women, found they preferred faith-based MHC over biomedical MHC.^20,94 Forms of support systems entailed prayer, financial support, positive words, and emotional care provided by family, community-based support, support for suicidal behaviour, and increased engagement of individuals who struggle emotionally in religious groups as shown in Nigerian, Ghanaian, Ethiopian, and Zimbabwean studies.^{14,17-19,65,76,83}

There are cultural rituals provided by traditional and faith healing facilities through providers across Africa.^{13,14,65,67,74,114,115} These include bewitchment, rituals, and ancestorial connections shown across models.^{13,14,65,67,114,115} In South Africa, it was shown that 41% of patients preferred traditional healers because of their cultural, spiritual, and religious beliefs and faith-based, mental healthcare in emergency and conflict settings have been implemented at a community level for the same reason.^75,116 In other settings, there are programs and models delivered that do not have cultural components but are effective in the primary healthcare settings.⁷⁴

Studies in this review discovered that a vast disparity of 11-62% of mentally ill sought MHC from traditional healers as a first point of contact (Table 2).^{10,12,13,20,110} In an Ethiopian study, it was emphasized that the use of traditional healers can be increased through education on types of treatments or referral pathways to FBHPs and from biomedical facilities.¹⁷ Patients at faith-based, mental health facilities indicated that 53% of patients spent 1-2 months and 10 patients stayed over a year at the facilities.⁶⁴

For the footprint of faith-based MHC, it was found that in the included literature of this study, there were 4 faith-based, biomedical facilities available, 3 studies mentioned the use of chaplains, 18 studies used traditional healers, 11 studies used faith-healers, 8 studies mentioned traditional and faith healing care, and 1 study used an FBO for treating the mentally ill in Africa (Table 2). Among these providers, they have used in-depth investigations and referral pathways. For example, of 128 patients seen in faith based, biomedical, MHC facilities in Malawi, 11.7% of patients sought these facilities as their first point of contact, whereas 22.7% had traditional healers as their first point of contact.¹³ A study mentioned that 23.3% of patients lacked accessibility to biomedical MHC and 21.7% of patients preferred seeking faith-based MHC as their first point of contract.¹² (Table 2 expands on the % of providers used in Ghana, Kenya, and Nigeria). The pooled estimate from the meta-analyses of using the various types of FBHPs as their primary point of mental healthcare was 1.93-38.1% (Figure 5).

Figure 5

Studies in Kenya and Malawi indicated that traditional and faith healers were more affordable than biomedical MHC where patients could pay them through gifts and donations, and there were less travel costs due to closer accessibility.^{12,64,66,67,73,80} One study in Egypt estimated that 24.7% and another study estimated that 75% of FBHPs were more affordable than biomedical MHC.^12,19 However, in a Kenyan study, healers were found to be expensive, but overall it is suggested that FBHPs are more accessible as a form of mental healthcare.⁶⁷

In Africa, faith-based, mental healthcare is used more in rural areas, and biomedical care is used more in urban areas.^12,82 However, one example shows that limited access to biomedical services resulted in a higher utilisation of harmful, faith-based practices.⁶⁶ In some studies, the utilisation of prayers delayed seeking biomedical MHC as explained in a Rwandan study.¹¹⁷

Quality of faith-based, mental health care

Quality of care in terms of effectiveness of the mental healthcare was classified as entailing “health service provided by qualified FBHPs who ensure safe and correct treatment for mental illness.”¹⁰⁶

In this review, quality of faith-based MHC was measured according to whether there were improvements in mental health outcomes of individuals (an example would be also when FBHPs were trained and that relationship with mental health outcomes), also if FBHPs enhanced help seeking behaviour.

Improvement in mental health outcomes

Only five of the 55 included studies reported on whether faith-based, mental health services had an impact on mental health outcomes. However, these studies did not use standardised tools to measure mental health. There was a study which assessed 350 patients in comparison to bipolar disorder patients who used traditional healers and found improvements in their symptoms of hallucinations; however, with serious mental illness, patients did not experience any change in mental health outcomes.²⁰ A cross-sectional study in South Africa found that 145/258 (58%) patients reported better mental health as compared to seven who felt worse and 18 (23%) who showed no effect from consulting traditional healers.¹¹⁶ A Rwandan study by Ng (2016) showed improvements in adults who were diagnosed with PTSD, psychosis, depression, and substance use disorders, and 20 of the patients improved at discharge.¹⁰² However, two studies in Kenya found that suicidal ideation and depression increased from being treated by traditional healers.^88,90

A Ugandan, Sudanese, and two Ghanaian studies found that faith-based MHC improved their mental health by 43-58%, and 57% felt completely healed, 9% felt worse, and 23% showed no effect, with overall positive coping mechanisms created.^62,80,87,116 In a Kenyan study, 58-78% patients suffering from mild to severe depression treated by FBHPs showed an improvement over a 12-week period.¹¹⁸

Harmful practices for mental health outcomes

In Africa, harmful treatments in 13/55 studies were implemented by FBHPs (traditional and faith healers, and clergy) which impacted individuals with mental health issues negatively.^{62,64,66-68,74,76,77,82,89,115,119} Examples of these were scarification, restraint, isolation, fasting, chaining, caning, beating, and incarceration.^{66,68,71,76,82,89} Beatings were found to be used among traditional healers, purportedly to get rid of evil spirits, as well as to get a confession for wrongdoing.^66,68 (Table 3 and Figure 6) Other studies suggest some patients experience negative behavioural changes due to evil influences, which might question the quality of the MHC.^67,76,85 A Ghanaian study explained that patients who had PTSD and were exposed to some form of harmful treatments resulted in negatively impacting their mental health.¹⁵

Figure 6

Limitations

This study had research gaps where the faith-based biomedical field was under explored and due to the complexities of this study, search term compilation was tedious despite trial and error. This study only covered examples where data was available especially in the faith-based, biomedical category (commentaries were included due to a lack of data). Future research may benefit from focusing on one type of provider or specific services. This study also only included certain databases when searching for articles which could be expanded in future studies. More studies on magnitude such as availability (accessibility, affordability, and acceptability) are needed as well as more grey literature assessment.