The literature regarding the prevalence of psychological distress among people attending traditional healing practices in Africa is limited. In this study, the prevalence was 65.1%, which is high compared to 52% in a study by Okello et al in 2006 in four districts of Uganda and 48% by Ngoma et al in Tanzania . In 1997, Patel et al reported a prevalence of 40% in Zimbabwe . Our prevalence is twice as high as the prevalence of psychological distress in primary health care settings, which ranges from 10 to 30% [30–32]. These figures indicate that a majority of the patients who attend healers have psychological distress. In Africa, traditional healers are found within the community and are therefore more accessible than biomedical health workers . In rural Uganda, the ratio of doctors to the population is about 1:30,000, whereas that of traditional healers is 1:100 .
Risk factors for psychological distress among attendees of traditional healing
The association between socio-demographic factors and psychological distress has been demonstrated in previous studies . In this study, the married women who had a co-wife were associated with more psychological distress than those without a co-wife. Among the married men, having more than one wife was not associated with psychological distress. We do not have a clear explanation for this. It could be that women in polygamous relationships are in a more stressful marital arrangement than those in monogamous relationships. In a Turkish study of women's mental health, a comparison of women from polygamous and monogamous families, respectively, found that the former showed more psychological distress than the latter .
Other possible explanations include less access to resources, reduced level of support, possible weak marital bonds, violence and jealousy . All these factors may contribute to psychological distress in women in polygamous relationships. Further research is needed in this area to determine the associated factors.
In this study, we also found that having more than four children was significantly associated with psychological distress. In traditional Africa, having many children has always been considered an asset for a variety of reasons; for example, children would do farm work and other domestic chores. Today, however, children have to attend school; parents have to afford educational materials, school uniforms, meals and other educational needs, medical care, etc. All this makes raising children more of a burden than it used to be. In 2000 the Government of Uganda introduced free primary education for not more than four children from the same family. Parents are still supposed to meet the rest of their children's needs, including educational materials and meals.
This study found that some indicators of socio-economic status (being in debt, sleeping hungry because of lack of food) were significantly associated with psychological distress. The majority of the respondents were peasant farmers who were likely to have less education, less likely to be in gainful employment and earning less than one dollar a day. All these factors are related to poverty. The relationship between poverty and psychological distress, especially depression, is receiving increasing attention by researchers these days. Although no direct causal relationship has been demonstrated, it is widely recognized that extreme poverty causes much distress [36, 37]. A study in northern Uganda found that the absence of basic social goods and services, such as food and clothing, had a significant association with outcomes of distress .
Another study by Ovuga et al in 2005 in the same region as this study found no association between depression, depressed mood and unemployment . However, the majority of Ovuga's respondents were peasant farmers who, although they had no formal employment, were engaged in meaningful activities to sustain their lives and families. Our study suggests that this is no longer the case, as our respondents lacked food and were in debt, which points to both material and monetary poverty. It is also likely that poverty and gender may influence help-seeking differently for those with and without psychological distress . Other factors influencing health-seeking behaviour may include belief systems, accessibility, availability of the provider and flexibility of payment terms .
There were significant associations between going for both treatment and explanations for the illness, having visited the healer as well as a health worker and the duration of symptoms. The distressed group was more likely to visit the shrine for treatment and for seeking explanations regarding their ill health. Much research in medical anthropology has developed the idea of explanatory models, which may include accounts of causality, mechanisms or processes of illness, illness course, appropriate treatment, expected outcome and consequences. Not all this knowledge is directly related to personal experience. Much of it resides in cultural practices transmitted by other people over generations. Hence, understanding the cultural meanings of symptoms and behaviour often requires interviews with other people in the patients' family, entourage or community . In our study, we interviewed the patients about why they went to see the traditional healer but not about the types of explanation they received from the healer.
Those who visited the traditional healer and biomedical health units for the same problems were less likely to be distressed. Again, the mechanism here is not clear since psychological distress is usually not diagnosed at PHC [5, 14, 40]. Literature indicates that biomedical health workers focus more on physical illness than psychosocial problems, whereas traditional healers pay more attention to interpersonal and other psychosocial problems that cause psychological distress [5, 7, 40]. This may explain why people who used both systems seemed to have received more comprehensive care and hence a reduction of psychological distress. Also consultation in traditional healing practices is more likely to produce an illness identity which matches the patient's perceptions, thus making sense of the patient's real world [7, 41, 42]. However, our study is inconclusive regarding whether using of both traditional and modern treatments promotes better mental health. That calls for a study, which systemically charts the chronology of symptoms, pathways to care and treatments received.