title: Traditional and religious healers in the pathway to care for people with mental disorders in Africa: a systematic review and meta-analysis.
abstract: OBJECTIVE
  In resource-limited contexts in low- and middle-income countries (LMICs), a considerable proportion of individuals seeking care for mental disorders consult traditional and religious healers in their pathway to mental health care. Reports from Africa suggest that early involvement of healers may result in delays in the care pathway; a potential barrier to early identification and intervention.
  
  
  METHODS
  A systematic review was conducted to evaluate the proportion of patients attending formal health services after making first contact for treatment of mental disorders with traditional or religious healers or other informal and formal care providers within published research in Africa. Electronic databases were searched for the period from January 1990 to February 2014. Quality assessment of included studies was conducted the SAQOR tool.
  
  
  RESULTS
  Fourteen papers were identified with data on category of first care provider. Utilizing random effects modelling with inverse variance method, the pooled proportion of participants making first contact for treatment of mental disorders with two broadly categorised providers (informal and formal) was 48.1 % (95 % CI 36.4-60.0 %) and 49.2 % (95 % CI 38.0-60.4 %), respectively. The pooled proportion of participants making first contact with specific providers was: traditional healers (17.0 %, 95 % CI 10.9-24.1 %); religious healers (26.2 %, 95 % CI 18.1-35.1 %); general health services (24.3 %, 95 % CI 16.9-32.5 %); and mental health services (13.0 %, 95 % CI 5.1-23.5 %). Substantial regional variation in patterns of first provider choice was evident.
  
  
  CONCLUSIONS
  Conclusions of this review must be qualified in the light of several limitations. Approximately half of individuals seeking formal health care for mental disorders in Africa, choose traditional and religious healers as their first care provider. Previous reports suggest that this choice is associated with delays in accessing formal mental health services. Strategies to improve pathways to mental health care in Africa must include innovative programmes aimed at fostering collaboration between biomedical mental health services and these key community-based providers.
authors.affiliation: Department of Psychiatry, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa, burns@ukzn.ac.za.
authors.forename: Jonathan K
authors.initials: JK
authors.lastname: Burns
authors.forename: Andrew
authors.initials: A
authors.lastname: Tomita
mesh_terms: D000349:Africa; D029221:Faith Healing; D006297:Health Services Accessibility; D006801:Humans; D016488:Medicine, African Traditional; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services; D011203:Poverty; D061665:Time-to-Treatment