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Understanding Cancer Patients’ Motivations and Experiences in using

Traditional Healers in Ghana, a Constructivist Grounded Theory Approach

By

Isaac Badu Appiah

A thesis submitted for the degree of Doctor of Philosophy

School of Health Science

Faculty of Health and Medical Science

University of Surrey

December 2019

Supervisors: Dr Anne Arber & Dr Afrodita Marcu

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ACKNOWLEDGEMENTS

My first and foremost thanks and gratitude go to the almighty God for His grace that has

enabled me to complete this journey successfully. I also thank Him for the opportunity to

meet people who have thought me many lessons along the way. I would like to acknowledge

my wife, Esther Appiah and our two sons Janaya and Jayden Appiah. Thank you so much for

your support, love and understanding that you have shown to me over the years. I also want

to acknowledge my late parents, who unfortunately did not live to see me complete this

study. I will miss you both always.

I also want to thank my family, who offered me the emotional and material support in

Ghana. Special thanks to my cousins, Prof. Asabere Ameyaw, Dr Addai Darko and my

brother Rev Ampofo Twumasi.

Many thanks go to my supervisors, Dr Anne Arber and Dr Afrodita Marcu, for their

expertise, patience, empathy and friendship. Thank you for making me feel that you were

always there for my success and encouraging me all the way. Thank you for the

understanding, support and flexibility that you showed me when I lost both my parents in the

last couple of years. I could not have done this without the two of you. I am very grateful. I

want to thank Dr Carin Magnusson, who was part of the supervisory team in the first two

years of the course and has continued to encourage me since leaving the team.

I also want to thank the hospitals and herbal clinics staffs who allowed me access to their

settings and supported me in many ways. A special thanks to the participants who spent their

time to share their views with me.

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ABSTRACT

Traditional Medicine is embedded in the socio-cultural traditions of most Ghanaian

communities, with about 70-80% of the population using it alone or in parallel with

Conventional Medicine. Some studies have shown that people living with cancer and other

chronic diseases use Traditional Healers more than the ordinary population. However, studies

that have investigated the reason behind such behaviour of people living with cancer are few.

Thus, this study explores and conceptualises people living with cancers’ motivations and

experiences of using Traditional Healers in the Brong-Ahafo region of Ghana. The region is

rich in cultural traditions and has an abundance of Traditional Healers. The methodological

approach for the study was Constructivist Grounded Theory (CGT) in which semi-structured

interviews were conducted in two hospitals and five herbal clinics (n=35). The interviews

backed by a background observation of participants’ interaction with staff at the study sites.

The main categories from the analysis were: “Placing trust in one’s community”, “Finding

solace in the therapeutic hospitality and conviviality”, and “Aiming to avoid upset and

manage emotions”. These categories underpin the theory “Community of Us” which provides

a conceptualised understanding of the subtleties of the trusting and identity relations between

people living with cancer and Traditional Healers. The theory shows how these identities

influence people living with cancer’ help-seeking behaviour for their illnesses and symptoms

and therapeutic interaction. The “Us” exclude Conventional doctors as people living with

cancer did not trust them because they were detached from the local communities’ identities.

Conventional doctors represented “Whiteness” which symbolises colonial power, inequality,

and elitism. The study shows that people living with cancer use of Traditional Healers in

Ghana are more profound than mere socio-economic factors identified in previous studies.

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DECLARATION

I declare that this thesis is the product of my work. Any ideas, data, text and images form

others were acknowledged and referenced. The thesis has not been submitted partly or in

whole to any other institution for any qualification. I accept that the University has the right

to submit this work to the plagiarism detection service to check the originality. The

University has the right to request an electronic copy or version of this document for any

verification.

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TABLE OF CONTENTS

ACKNOWLEDGEMENTS ................................................................................................................. 2

ABSTRACT ........................................................................................................................................... 3

DECLARATION ......................................................................................................................................... 4

LIST OF FIGURES ............................................................................................................................ 10

LIST OF TABLES .............................................................................................................................. 11

GLOSSARY OF ABBREVIATIONS ................................................................................................ 12

CHAPTER ONE: BACKGROUND AND INTRODUCTION ....................................................... 13

1.1 Chapter Overview ................................................................................ 13

1.2 Cultural Values, and Conceptualisations of Illness in Ghana ................ 14

1.3 Pluralistic Health Care Approaches in Ghana .................................... 17

1.4 Traditional Medicine and Traditional Healers in Ghana .................... 18

1.4.1 The Profile of Traditional Healers in Ghana ...................................... 22

1.4.2 Apprenticeship and Training of Traditional Healers in Ghana ........... 24

1.5 The Approach of Conventional Medicine ............................................. 27

1.6 Overview of Ghana ................................................................................. 31

1.6.1 Ghana’s Health Service Delivery System .......................................... 32

1.6.2 Access to Conventional Health Services in Ghana ............................ 34

1.6.3 Cancer Incident Statistics in Ghana ................................................... 36

1.7 Pre-Field Reflexivity: Researcher’s Background and Biography ......... 38

1.8 Summary of Chapter One ........................................................................ 40

CHAPTER TWO: LITERATURE REVIEW .................................................................................. 43

2.1. Chapter Overview .................................................................................. 43

2.2 Search Strategy and Critical Appraisal ................................................... 45

2.2.1 Databases and Search Terms ............................................................. 45

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2.2.2 Inclusion Criteria and Exclusion Criteria .......................................... 46

2.2.3 Critical Appraisal of the Literature .................................................... 49

2. 3 Factors Influencing the Use of Traditional Healers in Ghana ................ 50

2.3.1 Socioeconomic Factors ..................................................................... 50

2.3.2 Sociocultural Factors ........................................................................ 56

2.3.3 Spiritual Belief System ..................................................................... 61

2.3.4. Psychological and Emotional Motivations for Using Traditional

Medicine……………………….. ............................................................... 63

2.4. People Living with cancer’ Silence about Their Use of Various

Traditional Healers ...................................................................................... 66

2.4.1. Prevalence of People Living with cancer’ Use of Traditional Healers

in Ghana…………………. ........................................................................ 67

2.4.2. Different Forms of Traditional Medicine used by People living with

cancer……………….. ...................................................................................... 68

2.4.3 Lack of Doctor-Patient Communication about Traditional Medicine 69

2.5 Cancer Awareness and Help-Seeking for Cancer Symptom .................... 71

2.6 Summary of the chapter and Research Question ..................................... 75

2.7 Research Aims ........................................................................................ 76

2.7.1 Research Questions ........................................................................... 77

2.8 Overview of theoretical literature on trust .............................................. 77

2.9 General Understanding of Trust ............................................................. 78

2.10 Conceptualising Trust as Interconnected Self-Interests ......................... 81

2.11 Trust as Deference to Authority ............................................................ 82

2.12 Trust in Reputational and Good Behaviour Characteristics .................. 84

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2.13 Endurance of Community Norms and a Generalised Culture of Trust ... 85

2.14 Trust as a System of Language and Communication ............................. 87

2.15 Trust as Familiarity and Habits of Communities ................................... 88

2.16 Summary ............................................................................................... 89

CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGICAL CHOICES ............. 90

3.1 Chapter Overview ................................................................................... 90

3.2 Choosing Interpretivism Approach over Positivism ................................ 90

3.3 The Influence of Constructivism, Social Constructionism and Symbolic

Interactionism on Constructivist Grounded Theory (CGT) ........................... 92

3.4 Choosing Grounded Theory (GT) Methodology ...................................... 95

3.5 Choosing the Constructivist Grounded Theory (CGT) ............................ 99

3.5.1, Brief History of Divisions in Grounded Theory (GT) ...................... 99

3.5.2 Classic Grounded Theory: The Glaserian Approach ....................... 100

3.5.3 Straussian Grounded Theory ........................................................... 101

3.5.4 Constructivist Grounded Theory (CGT) .......................................... 102

3.6 Summary of the Methodological and Philosophical Standpoint in This

Study ........................................................................................................... 104

3.7 Overview of Study Sites and Region ...................................................... 106

3.8 Recruitment and Sampling (Selective to Theoretical Sampling) ............ 107

3.9 Negotiating Access to the Study Sites: Hospitals and Herbal Clinics .... 110

3.10 Data Collection: Interviews ................................................................ 114

3.11 Theoretical Saturation ........................................................................ 117

3.12 Theoretical Sensitivity ......................................................................... 118

3.13 Iteration and Constant Comparison .................................................... 120

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3.14 Seeking Relevant Ethics Approval in UK and Ghana .......................... 121

3.15 Obtaining Informed Consent (IC) and the Challenges around Cultural

Consent ....................................................................................................... 122

3.16 Observations: The Dynamics of Doctor-Patient versus Herbalist-Patient

Relationships .............................................................................................. 124

3.17 Confidentiality and Sensitivity to Participants and Their Data ........... 129

3.18 Researcher’s Safety and Risk minimisation ......................................... 131

3.19 In-field reflexivity and Emotional Labour ........................................... 131

3.20 Data Analysis ...................................................................................... 134

3.21 Transcribing the Interviews ................................................................ 135

3.22 Open, Focused and Theoretical Coding of the Data............................ 136

3.23 Memo Writing ..................................................................................... 145

3.24 Developing Categories ........................................................................ 146

3.25 Theory Development ........................................................................... 148

3.26 Post field Reflexivity ........................................................................... 149

3.27 Considerations for Rigour and Credibility .......................................... 150

3.28 Summary of Chapter ........................................................................... 154

CHAPTER FOUR: FINDINGS ...................................................................................................... 155

4.1 Chapter Overview ................................................................................. 155

4.2. Power Disparity and Lack of Trust ...................................................... 156

4.3 Placing Trust in One’s Community and Identity ................................... 162

4.3.1 Tradition: Participants shared Ancestral and Cultural Connection with

Traditional Healers .................................................................................. 162

4.3.2 Participants Shared Language with the Traditional Healers ............ 165

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4.3.3 Perception of Familiarity, Goodwill and Accountability ................. 169

4.3.4 Participants Perceptions of the Traditional Healers Reputable Virtues

……………………………………………………………………………………………174

4.4 Finding Solace in Therapeutic Hospitality and Conviviality ................. 180

4.4.1. Being Reassured by the Friendly and Jovial Manner of the Traditional

Healers …………………………………………………………………………………………….180

4.4.2 Participants perception of Traditional Healers interest in them ....... 182

4.4.3 Being Listen to and Giving Attention .............................................. 186

4.4.4 Feeling Relaxed .............................................................................. 189

4.4.5 Feeling of Lifting the Spirit and Boosting Hope .............................. 191

4.5. Aiming to Avoid Upset and Manage Emotions ..................................... 194

4.5.1 Euphemising: Softening and Placating Participants Situation .......... 194

4.5.2 Concealing: A Non-Disclosure of Participants Illness ..................... 196

4.6 Chapter Summary ................................................................................. 201

4.7 The theory of “Community of Us.” ....................................................... 202

CHAPTER FIVE: DISCUSSION ....................................................................... 204

5.1 Chapter Overview ................................................................................. 204

5.2 Trusting Identities: People Living with cancer’ Relationships and

Motivations for Using Traditional Healers ................................................. 210

5.2.1 Whiteness: Power, Inequality and Lack of Trust ............................. 214

5.2.2 Trust as a Traditional Identity and Shared Sensitivity ..................... 217

5.2.3 Trust as a Shared Language and Identity ......................................... 223

5.2.4 Trust in the Familiar and Habits in Communities ............................ 226

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5.2.5 Reputational Trust: Reputable Characteristics of the Traditional

Healers …………………………………………………………………………………………230

5.3 Conviviality Interaction and Convivial Therapeutic Landscape ............. 237

5.4 Holistic Support and Quality Human Time ........................................... 242

5.5 Protecting Feelings and Avoiding Distress ........................................... 246

5.5.1 Cultural Telling and Disclosure....................................................... 247

5.5.2 Keeping It to Oneself and Not Washing One’s Clothes in Public .... 253

5.6 Summary of Chapter ............................................................................. 254

CHAPTER SIX: CRITIQUE OF STUDY AND CONTRIBUTION TO KNOWLEDGE ......... 256

6.1 The Study Contributions to Knowledge ................................................. 256

6.2 Strength of the Study ............................................................................. 259

6.3 Limitations and Requirement for Future Research ................................ 260

6.4 Recommendations for practice policy and education ........................... 262

6.4.1 Recommendations for Practice ...................................................... 262

6.4.2 Recommendation for Policy ............................................................ 264

6.4.3 Recommendation for Education ..................................................... 266

6.4.4 Recommendation for Research ....................................................... 268

6.5 Conclusion ......................................................................................... 268

6.6 Dissemination of Findings .................................................................... 270

REFERENCE .......................................................................................................................................... 271

APPENDIXES ........................................................................................................................................ 328

LIST OF FIGURES

Figure 1 Traditional Healers Profile Summary ...................................................................................... 27

Figure 2 Map of Ghana and bordering nations ..................................................................................... 32

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Figure 3 Ghana Health Delivery Structure ............................................................................................ 34

Figure 4 Summary of chapters to Thesis .............................................................................................. 42

Figure 5 PRISMA Flow Chart ................................................................................................................. 48

Figure 6 Researcher's Multiple Identity .............................................................................................. 113

Figure 7 example of Open line-by-line codes..................................................................................... 140

Figure 8 Sample of analytical core category and subcategory ........................................................... 148

Figure 9 The Developed Substantial Theory ...................................................................................... 202

Figure 10: Participants model of placing Trust in their communities ................................................ 214

LIST OF TABLES

Table 1 Summary of studies on people living with cancer’ use of Traditional Healers ....................... 66

Table 2 Methodological Relevance to Theory Development................................................................ 97

Table 3 Summary of GT Methodologies and the Choice for CGT Approach ....................................... 106

Table 4 Participants demographics (Phase 1 visit).............................................................................. 116

Table 5 Participants demographics (Phase 2 visit).............................................................................. 117

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GLOSSARY OF ABBREVIATIONS

CASP: Critical Appraisal Skills Programme

CCG: Constructivist Grounded Theory

CP: Conventional Practice or Hospital

HC: Herbal Clinic

GT: Grounded Theory

NHIS: National Health Insurance Scheme

OFN: Observation Field notes

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SRH: Sunyani Regional Hospital

KHRCIEC: Kintampo Health Research Centre Institutional Ethics Committee

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CHAPTER ONE: BACKGROUND AND INTRODUCTION

1.1 Chapter Overview

The study aims to explore the experiences of people living with cancer in using Traditional

Healers and why they use them in the Brong- Ahafo region of Ghana. The thesis develops a

new theory of the use of Traditional Healers for patients with cancer. In this first chapter,

there is a discussion of the background social and economic context of Ghana, general

cultural beliefs, practices and values. A demonstration on the elements influencing health-

seeking behaviours and use of Traditional and Conventional Medicine is also present. I also

highlight how existing theories of lay use of Traditional Medicine in Ghana or sub-Saharan

West Africa more broadly provide only a partial explanation for peoples ’behaviour and use

of Traditional Healers.

The chapter considers cultural values and practices and how they influence the

conceptualisation of health and illnesses in Ghana. I also discuss medical pluralism and the

different health care approaches dominant in Ghana. These are primarily the lay networks (

local health beliefs and practices), Traditional Medicine and the Conventional Health

Systems. Additionally, the chapter discusses the concept of Traditional Healers in Ghana,

their profile and the impact of their training within the community to become accepted as

established Traditional Healers. Also, the chapter discusses the Conventional Medical System

and how it conflicts with Traditional Medicine in peoples’ experiences and some of the

common criticism against it. Moreover, this chapter provides a general overview of Ghana,

its health delivery system, access to Conventional Health Services, and cancer incidents and

statistics. Furthermore, the chapter outlines my formative background and how that

influenced my development of personal interest into Traditional Healers and to this research.

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1.2 Cultural Values, and Conceptualisations of Illness in Ghana

Culture is a set of shared ideas, concepts, practices and their underlying

meanings, and how they are expressed in human behaviours and interactions

(Keesing, Strathern 1998, Tylor 2010). This shared knowledge, concepts and practices

include belief systems, moral frameworks, laws, customs and norms, symbols, art,

language and even habits and behaviours that people acquire or inherit as members of

a society (Helman 2007, Geertz 2017, Tylor 2010, Kleinman 1980). Both culture and

its influence on people or societies’ worldview and way of life is sophisticated and

can be overt or implied (Helman 2007, Geertz 2017), outsider and insider knowledge,

tertiary and deeper, secondary or primary and superficial or profound in layers (Hall.

1989, Hofstede 1991, Helman 2007).

The belief in spirituality, ancestors and supernatural beings are dominant in

most Ghanaian communities (Utley 2016, Darko 2009). Most Ghanaians highly

revere their ancestors and believe the ancestors have established certain moral

traditions and values which strengthens character development, community

interactions and behaviours towards the sick and vulnerable (Utley 2016). These

moral values include community coherence, consideration for others wellbeing in

society and respect for elders and people with traditional statuses such as chiefs,

Traditional Healers and priests (Utley 2016). Ghanaian communities generally

perceive those in traditional positions such as Traditional Healers, traditional kings

and queens, fetish priests and family heads to be in harmony with the ancestors and

have the necessary wisdom and experience. Ghanaians generally consider such elders

to have Traditional Knowledge to offer advice and insight on important issues such as

illnesses and misfortunes (Utley 2016).

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Ghanaians also inherently believe that the ancestors and other supernatural beings

have the powers to influence or intervene in individual situations, for example, issuing

punishments and rewards to people. Stories of occasions when ancestral spirits have visited

people as sick or weak to test peoples’ behaviours are often told to emphasise the importance

of ethical and moral values. Furthermore, most Ghanaians believe in the importance of

virtues such as kindness, friendliness hospitality, compassion, generosity, faithfulness and

trustworthiness (Utley,2016). Most Ghanaians usually endorse and advocate the idea of

oneness “Yeye Nipa Baako’’, meaning we are one people. The notion of “one people’’ is

pivotal for the collective and reciprocal responsibilities amongst most Ghanaians. What

affects one person affect everyone or the entire community in which almost everyone knows

each other.

In most indigenous Ghanaian communities, people usually knock their neighbours’

door in the morning and the evening to share welfare greetings and to ascertain that the

neighbours’ are feeling well. There is a tradition that we must always help others and greet

them since we do not know when we would need their help. Spiritual and cultural beliefs

influence the understanding and interpretation of health and illnesses, health-seeking

behaviours and preferred treatment methods in most Ghanaian communities (Kleinman 1980,

Helman 2007, Nettleton 2013, Douglas 2003, Landy 1977). These beliefs highlight the

importance of situating, interpreting and discussing health practices in Ghana and other

African countries from the perspective of a broader cultural context (Landy 1977, Helman

2007, Kleinman 1980). Most Ghanaians communities perceive illness as a complex

interaction of physical, psychological, and spiritual factors (Tabi et al. 2006, Kleinman 1980).

Primarily, most Ghanaians consider illness as a misfortune which is sacred (Spiritual),

secular (natural) or both in their origin, which influences the kind of treatment they may seek

(Kleinman 1980, Helman 2007). Most Ghanaians consider illness to be natural if they

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perceive the disease as part of God's predestined plan (destiny) (Abel, Busia 2005,

Neba 2011). The concept “Oyame’’ (almighty God), permeates in all thoughts of the

Akan tribe (the largest tribe in Ghana) and generally all the tribes in Ghana as a

supreme being who controls life and sustains the universe (Bruce, 2002, Abel, Busia

2005, Neba 2011). Many Ghanaians believe that God assigns a destiny or fate to

every person and that fate eventually take its course or God fulfils that fate at a point

in one's lifetime (Abel, Busia 2005, Hevi 1989, Neba 2011).

Apart from the vertical human relationship with a supreme God in the

Ghanaian belief system is the notion of other lesser supernatural beings such as

ancestral spirits and lesser gods or idols who may cause diseases and misfortunes to

humanity. Such misfortunes may demonstrate their anger and dissatisfaction to certain

behaviours and practices (Abel, Busia 2005, Hevi 1989, Bonsi 1980, Tabi et al. 2006,

Bruce, 2005). In the case of evil spirits and witchcraft, the invocation of illnesses and

misfortunes to a person or entire community may be the result of mere dislike or

doing of evil and not necessarily in response to certain behaviours.

However, culture and spirituality are not the only elements that influence

health-related beliefs, actions and practices in Ghana. Other factors that influence the

populations’ beliefs about health include political, socioeconomics, education, age,

historical and environmental determinants which impinge on the local health care

system (Helman 2007, Kleinman 1980). The health-seeking behaviours and beliefs in

Ghana are very complex, usually influenced by more than one factor and the existence

of different therapeutic approaches.

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1.3 Pluralistic Health Care Approaches in Ghana

The concept of medical pluralism is seen as using more than one Medical

System or resorting to diverse kinds of therapies even in cases where the various

therapeutic methods have different conceptualisation and explanatory models of

illness (Moshabela et al. 2016, Moshabela et al. 2017, Hsu 2008). In Ghana and most sub-

Saharan African countries, medical pluralism involves ‘shopping and switching’ between

multiple modalities or therapies of care. There are three primary overlapping and

interconnected approaches to health care in Ghana, which are accessible, including lay health

beliefs and practices (lay networks), Traditional Medicine, and the professional health care

system or Conventional Medicine (Helman 2007, Kleinman 1980).

The popular or lay network of health beliefs and practices constitute the most

extensive health care approach in Ghana but challenging to study because of the vast

complexities and lack of any defined or organised structure (Helman 2007, Kleinman 1980).

The activities and the knowledge of the popular or lay health beliefs are informally

interspersed and disseminated amongst ordinary community members (Helman 2007,

Kleinman 1980). The popular sector of health care is described as a matrix containing

several layers of individuals, families, social networks, lay community beliefs, values and

activities (Kleinman 1980).

The popular culture of beliefs, values, local and family definitions of illnesses and

normality influence patients decisions to pursue treatment or not. These elements also affect

what treatment would be sought (Helman, 2007, Kleinman, 1980). Hence, the lay health

network is the starting point of health-seeking or maintenance behaviours for most Ghanaians

before proceeding to interact with both the Traditional and Conventional Medicine.

As part of this interaction, the ill-person may move freely between modalities or use

them simultaneously (Helman, 2007, Kleinman, 1980). The lay network of health practices in

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Ghana includes self-treatment, pieces of advice and recommendations from society

members such as families, relatives and neighbours. The lay health networks treat

general or specific ailments and allow people to share their experiences of illnesses or

treatments of a condition to support others (de-Graft Aikins, 2005, Aikins et al., 2010,

Gyasi., et al., 2017). For example, older women in Ghana with the experience of

giving birth or having multiple pregnancies are considered able to offer advice on safe

pregnancy and delivery to young women. Also, older men and women in the families

or communities act as health advisors and offer minor treatments to people who

sustain cuts, snake bites, burns, chronic cough and other health issues.

1.4 Traditional Medicine and Traditional Healers in Ghana

An estimated 75% of the global population and between 70% and 80% of the

African population use Traditional Medicine or the services of Traditional Healers

either alone or alongside Conventional Medicine (Oreagba et al. 2011). Furthermore,

people living with cancer and other chronic illnesses have been shown to use

Traditional Medicine or Complementary Alternative Medicine more than the general

population across the globe (Mao et al. 2011, Patterson et al. 2002, Richardson et al.

2000). Many authors pinpoint poverty, lack of available and accessible Conventional

Medicine as the main reasons for the use of Traditional Healers in Ghana (Dove 2008,

Yarney et al. 2013). However, this is not always the case as some people who have

access to Conventional Medicine or have the financial power to afford Conventional

Medicine may continue to use the Traditional Healers services (Chen et al. 2008).

Nonetheless, there is a general understanding that the inadequate and ineffective

provision of Conventional Medicine in Africa, Asia and other developing countries

influence the continuing vivacity of Traditional Medicine (Last, Chavunduka, 2018).

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Although Traditional Medicine is an active part of most indigenous communities,

their role in modern states is a subject of much debate due to the insufficient evidence for its

safety and efficacy. Equally, there is a lack of a standard definition of Traditional Medicine

and what is included or excluded as Traditional Medicine (Last, Chavunduka, 2018,

Kleinman, 1980, Helman, 2007). A shared definition of Traditional Medicine is contested

across countries and different communities within a country (Kleinman, 1980, Last,

Chavunduka, 2018, Helman, 2007). The heterogeneity, ambiguity and the lack of consensus

on definition and components of Traditional Medicine are indications of divergent views,

assumption and the need to view Traditional Medicine within their specific contexts both

nationally and internationally (Last, Chavunduka, 2018, WHO, 2002).

The World Health Organisation (WHO) is the main body at the forefront in

standardising Traditional Medicine through regulation, safety and gathering of information

on efficacy at the global level and more especially in countries where Traditional Medicine is

popular and widely used. As part of this endeavour, WHO has provided a standard definition

of Traditional Medicine as “the sum total of the knowledge, skills, 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” (WHO, 2013, page 15), WHO acknowledges that

Traditional Medicine evades a precise definition or description and contains diverse and

sometimes conflicting characteristics and viewpoints (WHO, 2013). The WHO definition is

considered a working definition and not necessarily comprehensive or inclusive of all

contexts (WHO, 2013, WHO, 2002).

Respectively, there is no clarity in the literature about who is responsible for deciding

what is included or excluded as Traditional Medicine. While the WHO broadly provides

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some information on the components of Traditional Medicine, it leaves the ultimate

responsibility for Traditional Medicine to individual countries and communities (WHO,

2002, Last, Chavunduka, 2018). Traditional Medicine generally includes therapies in

the form of herbs or herbal products, animal parts, minerals and other therapies such

as acupuncture, manual, mental and spiritual therapies or a combination of these to

maintain wellbeing, and to diagnose, prevent and treat illnesses (WHO, 2002).

Although Traditional Medicine has many variations, there seems to be a

consensus that it is opposite to Conventional Medicine, generally part of the cultural

heritage of a nation or community and has evolved as part of their lifestyle (WHO,

2012). Traditional Medicine defers from Conventional Medicine in philosophy,

education, practice and emphasis on current scientific evidence.

In some countries, especially in Europe and America or other developed

countries, Traditional Medicine is often described as Alternative or Complementary

Medicine (WHO, 2002). Herbal Medicine or treatments are the most popular form of

Traditional Medicine and used by 70-80% of the world’s population for therapeutic or

health promotion reasons (WHO, 2012, WHO, 2004). Herbal medicines include herbs

(raw or processed), herbal materials, herbal preparations and finished herbal products

and in some countries may contain additives such as natural organic or inorganic

active ingredients that are not from plants (WHO, 2004).

In General, the concept of Traditional Medicine refers to the use of culturally

embedded health beliefs and practices by indigenous communities for treatment and

therapeutic purposes or general health maintenance (Struthers et al. 2004, Warren et

al. 1995, Berkes 1993, Debas et al. 2006, Zhang 1999, Kincheloe, Steinberg 2008).

Traditional healers are those who are recognised in Ghanaian communities to have the

relevant knowledge and skills entrenched in culture to treat illnesses (Struthers et al.

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2004, Girardet, Robertson Winn 1994, Reyes-García 2010, Zhang 1999). In Ghana, the

mainstream Traditional Medicine is Traditional Herbal Medicine (Bodeker, Ong 2005,

Shukla, Sinclair 2009), which constitute about 65% of all Traditional Medicines in the

country (Bodeker, Ong 2005).

Traditional Herbal Medicine usually involves the use of medicinal plants or herbs in a

raw or refined form for health purposes (Bodeker, Ong 2005, Girardet, Robertson Winn

1994, Tsey 1997). Hence, Traditional Medicine is sometimes used interchangeably or

synonymously with Traditional Herbal Medicine in the literature. Traditional healing in

Ghana may involve treating the physical and the spiritual components of diseases

simultaneously and perceived to adopt a more holistic approach of restoring the mind, body

and spirit (Nettleton 2013, Kolcaba. 1997, Bierlich 1995, Abel, Busia 2005, Neba 2011).

Also, Traditional Healers regularly involve the family and take their concerns and feelings

into consideration. In this sense, the healing process is the responsibility of patients, their

families and the Traditional Healer (Martin, 1981, Helman 2007, Kleinman 1980).

Moreover, a shared worldview or culture, the warmth of patients’ familiarity to

healers and settings, informality and use of everyday language in consultation give

Traditional Healers an edge over their Conventional counterpart (Helman 2007).

Furthermore, the notion that the Traditional healer is part of the broader socio-cultural

community and will act for the benefits of patients and the total community welfare makes

the Traditional sectors sometimes more attractive to indigenous societies (Helman 2007,

Kleinman 1980).

Specific criticisms and judgments passed on Traditional Healers usually relate to the

conceptual and operational explanations and the lack of parity of evidence with Conventional

Medicine (Darko 2009). However, continuously judging all medicines and treatments by the

scientific objective evidence-based standard inherently underpinning conventional Medicine

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undermines the sociocultural importance of Traditional Healers in most indigenous

societies (Darko 2009, Helman 2007, Kleinman 1980).

Traditional Healers meet the healthcare and economic needs of some people in

the African and Asian communities who use them or engage in them commercially

for their livelihood (Kleinman 1980, Cunningham 2001, Yeboah 2000, Zhang 1999).

Also, Traditional Medicine serves as a revenue generation to governments (Yeboah

2000, Cunningham 2001), especially in countries like China and India, where they are

better regulated and formalised (Helman 2007). Although the diversity and the lack of

regulation of Traditional Medicine and Traditional Healers make it challenging to

assess the amount of revenue generated from its market activities, available data

suggest an active and substantial fiscal activity with Traditional Medicine. For

example, the revenue output in China in 2012 was US$ 83.1 billion. The annual

expenditure in the Republic of Korea was US$7.4 billion in 2009. In the United

States, the out of pocket spending on natural and medicinal products was US$14.8

billion in 2008 (WHO 2013).

Furthermore, Traditional Herbal Medicine has the potential for future drug

discovery and development through appropriate investment and research (Reyes-

García 2010, Patwardhan, Mashelkar 2009, Bhat 2012, Fabricant, Farnsworth 2001).

These highlight the necessity to preserve Traditional Healers and ensure the

transmission of their depository of knowledge and practices to the younger

generations to prevent extinction (Ohmagari, Berkes 1997, Brundtland 1987).

1.4.1 The Profile of Traditional Healers in Ghana

The family constitutes a primary level depository of individual skills and

traditions of society and equally a mode of training Traditional Healers (Tsey 1997,

Helman 2007). In Ghana, Traditional healing is considered a family asset and

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reputation (Ryan 1998, Abel, Busia 2005, Osujih 1993, Shukla, Sinclair 2009). Consequently,

the practice is safeguarded and transferred to other family members for perpetuation

(Ndubani, Höjer 1999, Osujih 1993, Tsey 1997). People from a family background of healing

traditions or healers usually inherit or learn the practice of Traditional healing from an

experienced relative or a family member (Tsey 1997, Vandebroek et al. 2004, Shukla,

Sinclair 2009, Abel, Busia 2005, Gessler et al. 1995, Hampshire, Owusu 2012).

Also, some people claimed to have become traditional healers through a divine or

supernatural call and received a revelation from the ancestors or a deity through a dream,

vision, a sign or a direct voice (Hampshire, Owusu 2012, Tsey 1997, Gessler et al. 1995,

Twumasi 2005, Evans-Anfom 1986). Sometimes, the instruction may be conveyed through

the wisdom of the elders who are closely aligned with their ancestors. Usually, those who

become Traditional Healers through this pathway perceive Traditional healing as a higher

“call” which one does not merit and cannot partake without a divine invitation and

authorisation (Tsey 1997, Gessler et al. 1995, Abel, Busia 2005). There are various

experiences, indications or signs of confirmation that an individual has been ‘called’ to the

healing profession by a supernatural power. The individual will usually be possessed by a

spirit which could cause them to exhibit hallucination, hysteria, tremors and ecstatic

behaviours (Lewis 2002, Twumasi 2005, Helman 2007).

In some cases, the “call’’ may be preceded by the potential healer or family

encountering a severe or traumatic emotional encounter (Helman 2007), or a painful

experience or misfortune such as sickness, extreme poverty or family death as a way of

making them sober, but also active and ready for their ‘call’ (Tabuti et al. 2003). These

groups of healers usually claim to have had no choice but to respond to the spirits to avoid

severe repercussions (Gessler et al. 1995, Swantz 1990).

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Additionally, an individual could come to the Traditional healing profession

through a personal decision (Tsey 1997, Helman 2007). People may develop the

interest to become Traditional Healers during a time they are receiving treatment from

a Traditional Healer or when the Traditional Healer has successfully treated them

(Gessler et al. 1995). Under these circumstances, the request to be trained by an

individual serve as a kind gesticulation to propagate the good work of traditional

healing and give back to the community (Gessler et al. 1995).

1.4.2 Apprenticeship and Training of Traditional Healers in Ghana

In general, regardless of which path or combination of ways people take to

become traditional healers, they must be thought through apprenticeship until they

gain the right medicinal or healing knowledge and cultural skills to practice

(Ohmagari, Berkes 1997, Shukla, Sinclair 2009). Even those children from a family

of healers continue to undergo training until they are old enough and have acquired

enough knowledge to practice independently or take over the family healing tradition

(Ohmagari, Berkes 1997, Zarger, Stepp 2004, Shukla, Sinclair 2009, Tsey 1997, Abel,

Busia 2005, Ndubani, Höjer 1999). Although those who receive divine calling

undergo apprentice training, some claim to have gained insights into medicinal plants

and their purposes through supernatural means (Tsey 1997, Abel, Busia 2005, Evans-

Anfom 1986, Twumasi 2005, Neba 2011). This method of acquiring and transmitting

healing knowledge is contentious on the grounds of subjectivity and verification.

Most Conventional Health Professionals see these groups of healers who have

the divine “calling” as the most difficult to have any meaningful role in the effort to

integrate Herbal Medicine with Conventional Medicine in some recommended

settings (Tsey 1997, Bonsi 1980, Osujih 1993). However, in the context of Ghana

and most African communities, such mode of acquiring healing knowledge is

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compatible with the inherent worldview of the powers of the ancestors and spirit beings.

The apprenticeship or training of a Traditional Healer in Ghana can be very extensive

and last for many years (Girardet, Robertson Winn 1994, Shukla, Sinclair 2009). The

Traditional Healers’ training could start between 5-7yrs of age and continue until adulthood

(Shukla, Sinclair 2009, Girardet, Robertson Winn 1994, Gessler et al. 1995, Tsey 1997,

Hampshire, Owusu 2012).

Although the training of adult Traditional Healers can take an average of three years

(Abel, Busia 2005), it can also last for about twelve to fourteen years depending on the

learners’ ability (Ohmagari, Berkes 1997, Girardet, Robertson Winn 1994). During the

training period, the apprentice assumes the position of a servant to the trainer and spend most

of their time with him (Tabuti et al. 2003). Usually, the training is an active process of

collaboration between the trainer and trainee (Rogoff 1990) and takes place in an informal

setting in the community, a sacred bush or a forest (Tsey 1997, Zarger, Stepp 2004, Twumasi

2005). The trainer and trainee often travel to the forest together for the trainee to acquire

extensive knowledge in herbs or plants, preparation of treatments and acquisition of practical

skills in harvesting medicinal plants (Tsey 1997, Shukla, Sinclair 2009, Twumasi 2005).

Extensive knowledge in medicinal plants is essential to Traditional Healers in Ghana

and most African countries (Tsey 1997, Shukla, Sinclair 2009, Zarger, Stepp 2004). The

herbal knowledge benefits Traditional Healers and their trainees to avoid the use of

poisonous or harmful plants while at the same time providing a range of plant medicine

option available as a healer (Shukla, Sinclair 2009, Tabuti et al. 2003). For trainees who are

spiritually based, the training involves learning to tune their senses to recognise, understand

and communicate with the spirits (Twumasi 2005).

Fundamentally, the trainer aims to develop the trainee as a ‘whole person’ by

demonstrating and teaching traditional normative values such as discipline, respect, sharing,

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self-reliance, independence and corporation. It enables the trainee to become a

virtuous member of society, Sendell 1997). Likewise, the trainer tends to be patient to

allow for trial and error and continuous learning and practising by the trainee. Even

when the trainee makes a mistake, the trainer continues to support them if they

continue to show interest and diligence in the endeavour (Ohmagari, Berkes 1997).

The behaviour of the trainer shows the trainees the importance of patience, tolerance

and persistence or resilience in dealing with people, as well as stressful situations. In

Ghana, Traditional Healers are known to have reputation and character, part of which

is due to people’s perception about the nature of their training which strengthens their

understanding and compliance with the socio-cultural traditions and values of their

communities.

Overall, the way an individual becomes a Traditional Healer affects their

practice orientation. Classifying Traditional Healers into spiritual and non-spiritual

practitioners provides a practical and concise working framework to explore the

differences in their worldview. Usually, those who claim to have become Traditional

Healers through spiritual means have explicit spirituality or practices in conjunction

to their herbal or physical treatments of illnesses (Hampshire, Owusu 2012, Tsey

1997, Abel, Busia 2005, Neba 2011). These categories of practitioners offer spiritual

explanations to the causes and treatment of diseases. They are usually required to

consult the spirits for guidance to resolve the perceived spiritual underlie of illnesses

(Ngokwey 1994, Bierlich 1995).

On the other hand, the non-spiritually based practitioners offer a lucid and

physical explanation to illnesses, and their main emphasis is on the use of herbal

medicinal products to treat illnesses (Tsey 1997, Tabuti et al. 2003, Ngokwey 1994,

Bonsi 1980). However, in Ghana, the distinction between the two types of Traditional

27 | P a g e

Healers is a continuum and sometimes blurred with nuances. Although the non-spiritual

practitioners do not overtly make an inference to supernatural powers in their practice, they

inherently recognise the influence of supernatural powers on human endeavours and tend to

look for spiritual explanations, especially for illnesses that come about suddenly or are

difficult to explain or treat. (Tsey 1997, Abel, Busia 2005, Tabi et al. 2006).

Figure 1 Traditional Healers Profile Summary

1.5 The Approach of Conventional Medicine

Conventional Medicine, underpinned by the modern scientific paradigm (Nettleton

2013, Helman 2007, Rose 2001, Kleinman 1980) appears to dominate as the benchmark for

all health discussions. Perhaps, Conventional Medicine is the most organised,

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professionalised, and well-regulated form of health care or treatment modality across

the globe (Janes 1999, Helman 2007, Kleinman 1980). The Conventional Health Care

System offers a biomedical or scientific explanation for the causes and treatments of

diseases (Hewson 1998, Dick 2010). In principle, Conventional Medicine adheres to

the use of objective evidence and rational patterns of conditions (Wade, Halligan

2004). In the perspective of Conventional Medicine, sicknesses and diseases are

caused by an underlying organ pathology that requires treatment or intervention

targeted to the affected organ (Wade, Halligan 2004).

In Ghana and most countries across the world, Conventional Medicine usually

has statutory ascent and receives funding from the government and external donors

(Helman 2007, Hampshire, Owusu 2012, Nettleton 2013). However, Traditional

Medical Systems in some countries, e.g. Ayurveda in India and Chinese Medicine, are

well established or professionalised to some extent. They also receive some level of

governments’ finance and legal support (Helman 2007, Kleinman 1980).

Most indigenous population criticise Conventional Medicine for alluding to a

single scientific view or conceptualisation of health which segregate the sick body

from the person (Nettleton 2013, Helman 2007). Also, many criticise Conventional

Medicine for its generic approach and lack of consideration to the dynamics of the

sociocultural context and subjective interpretations of causes of illnesses and healing

(Helman 2007, Nettleton 2013, Kleinman 1980, Geertz 2017). The quote below from

Atkinson (2012) summarises the criticisms that many people often argue against

Conventional Medicine :

“It is reductionist in form, seeking explanations of dysfunction in invariant biological

structures and processes; it privileges such explanation at the expense of social, cultural, and

biographical explanations. In its clinical mode, this dominant model of medical reasoning

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implies: that diseases exist as distinct entities; that those entities are revealed through the

inspection of ‘signs’ and ‘symptoms’ that the individual patient is a more or less passive site

of the disease manifestation; that diseases are to be understood as categorical departures or

deviations from “normality’’ (Atkinson in Lock and Gordon, 2012, page 180).

The quote alludes to the failure of Conventional Medicine to recognise people as

social beings who are dynamically affected by their socio-cultural and historical context and

background and how all these factors interact to affect a person’s biological function and the

concept of illnesses. The quote highlights the importance of a comprehensive approach to the

treatment of illnesses that would encompass all the social, cultural and emotional or

psychological aspects of human life and avoid a body-mind dualism. Nettleton (2013),

identified five fundamental assumptions that underlie Conventional Medicine and how these

assumptions influence the behaviours of its professionals such as doctors, nurses and

pharmacists. These fundamental tenets are body and mind dualism: the notion that the body

and mind can be segregated or treated as different entities instead of focusing holistically on

the entirety of the person. Conventional Medicine also acts as treating a body that requires

repairs, in which case the Conventional Medicine and its professionals' function either as

engineers or mechanics who are qualified enough to mend any dysfunctions or malfunctions

of the body machine. The adoption of a technological imperative or advancement to health to

the extent of downplaying their potential consequences or overplaying their benefits. The

adoption of a reductionist approach or view in which Medicine focuses on explaining

diseases concerning biological, physiological and physical changes and neglecting the

psycho-spiritual and socio-cultural elements impinging on health. Conventional Medicine

also adheres to the doctrine of specific disease causation which assumes that every disease or

illness has a specific identifiable causative organism or explanation.

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Despite the considerable criticism against Conventional Medicine, it is

essential to acknowledge that Conventional Medical Systems across the globe have

recently evolved and have made improvements in adopting some of the softer skills

which are often associated with Traditional Medicine (King, Hoppe, 2013, Saha, et

al. 2008). Governments across the continents, and regulatory and patients’ advocacy

organisations have implemented several initiatives which have led to improvements in

clinician-patient relationships, patient communications, engagements, empowerment

and involvement in healthcare in recent times (Colombo et al., 2012). The nature of

the relationships between Conventional Medical Practitioners and patients has

dramatically changed, and the once characterised as the experts-lay relationship is

now appropriately described as collaborative or partnership (Nettleton, 2013).

Arguably, there has been massive progress in the education and practice of medical

and other clinical staffs to encompass excellent communications skills, honesty,

openness, respect for patients and their views, confidentiality, autonomy and showing

of interest in other aspects of patients’ lives (King, Hoppe, 2013).

Also, in most countries across the globe, there is a commitment and initiatives

to shift healthcare from institutions to non-institutional environments, encourage

people to take control of their health and involve them in shaping health care policies

and systems (Nettleton, 2013). For example, there has been a considerable

momentum within the UK health service about the patient and public involvement

which has been reflected in various policy initiatives to drive patient empowerment,

participatory approach to care, safety and open culture (Ocloo, Fulop, 2012, Bravo et

al., 2015). Moreover, Conventional Healthcare approaches have now moved from

focusing on only physiological and biological interventions to a more holistic or

comprehensive way of supporting patients psychologically, sociologically and

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spiritually (Porter, 1997, Kolcaba, R., 1997, Kolcaba, K., 2003). Furthermore, there has been

an increased awareness and integration of ethics in education and practice in medical and

other professions of Conventional Medicine (Terawaki et al., 2014).

1.6 Overview of Ghana

Ghana has an estimated population of about 29 million (WHO: Global Cancer

Observatory 2018), and Capital City is Accra. The country is well administered and a model

of political democracy and economic reform on the African continent (The World Bank 2015,

BBC 2018). Ghana is also one of the most stable countries in the region with a respectable

record of peaceful political elections and transitions. The country also enjoys a stable,

independent judiciary, and secure freedom of speech, press and broadcasting freedom, and

consistently ranking amongst the top in Africa and the globe (The World Bank 2015, BBC

2013, Anku-Tsede 2013). Despite the stability and consistent growth forecast (7.4 for 2019),

the country still has a high poverty rate and inequality of wealth and living standards (The

World Bank 2015). A total of 28.5% of the population live in poverty with a life expectancy

of 61, and percentage literacy of 67.3% (World Bank 2013).

Geographically, Ghana is located on the Gulf of Guinea and the Atlantic Ocean in the

south of the West African sub-region (Sub Saharan Africa) and shares a border with Ivory

Coast (Côte d'Ivoire) to the west, Burkina Faso to the north and Togo to the east (Moellering

et al. 2011, Jackson et al. 2001). The total landmass is nearly the same as that of the United

Kingdom 238.537 kmsq, consisting of different climates and terrains (Moellering et al. 2011,

Utley 2016). The country has three cardinal regions which have different climate, resources

and living activities, namely the northern, southern and coastal (See Figure 2).

The northern part of Ghana is mainly savanna and wildlife, the southern part consists

of mineral resources and fertile agricultural land, and the coast consists of a labyrinth of

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castles, ports, harbours and beeches (Utley 2016, Moellering et al. 2011). Overall,

Ghana has over fifty languages with English as the national or official language.

Other significant languages include Twi, Fante, Ewe, Ga, Hausa, Nzema and

Dagbani. According to Utely (2016), outsiders sometimes perceive Ghana to be a

monolingual state because most of the population can speak “Twi’’ which is spoken

by the Akan’s’, the largest ethnic group in Ghana, spread across many of the regions.

The Brong -Ahafo region, where the study took place, is dominated by Akan people.

Figure 2 Map of Ghana and bordering nations

1.6.1 Ghana’s Health Service Delivery System

The government of Ghana categorises Ghana’s health system into

conventional and Traditional Medical Systems (Salisu, Prinz 2009, Aseweh Abor et

al. 2008). The government, private companies, individuals and faith-based or non-

governmental organisations operate the Conventional Health System.

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Administratively, the Ministry of Health is the government department which regulates the

entire health sector through policy planning and formulation, regulation, and coordination of

stakeholders (Salisu, Prinz 2009, Aseweh Abor et al. 2008). The Ministry of Health has three

hierarchies of administrations, which are the Central, Regional, and Metropolitan District

administrations. These administrations are concurrent with operational activities that extend

to the sub-districts and community levels. The Ghana Health Service is responsible for the

implementation of government policies and regulation of public sector health delivery

(Aseweh Abor et al. 2008, Salisu, Prinz 2009, Ghana Health Service 2013).

On the other hand, the Teaching Hospital Board regulates and implement government

policies in the Teaching and Tertiary hospitals (Aseweh Abor et al. 2008, Salisu, Prinz 2009).

The public sector health delivery is through a network of health centres, district hospitals,

regional hospitals, tertiary and teaching hospitals (Govindaraj et al. 1996). Furthermore, the

National Health Insurance Scheme (NHIS) finances the public health sector delivery (Salibu,

Prinz,2009, Gobah, Zhang,2011) and subsidised by central government funding. The

fundamental principle of the NHIS is to provide financial protection for the poor and to

ensure equitable access to primary health care (Salisu, Prinz 2009).

The private health sector consists of faith-based organisations or hospitals, private

medical and dental facilities, private maternity homes or clinics, and private pharmacies (See

Figure 3) (Salisu, Prinz 2009, Aseweh Abor et al. 2008) and provides about 40% of the total

health care services in Ghana, (Abekah-Nkrumah 2006, Olivier et al. 2014). The private

sectors do not receive direct financing from the central government. However, they have

exemptions from some taxation for the services they provide and reimbursed for the cost and

training of health professionals in their facilities. Although the Traditional Medical Sector in

principle is under the authority and administration of the Ministry of Health, in practice, it is

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less controlled and challenging to do so because they are not formalised and lack an

identifiable professional body and regulations.

Figure 3 Ghana Health Delivery Structure

1.6.2 Access to Conventional Health Services in Ghana

The World Health Organisation (WHO) has called for health systems to move

towards universal coverage and defines universal coverage as the access to adequate

and appropriate health care at affordable prices (McIntyre et al. 2008, Dye et al.

2013). Some health analysts describe accessibility to health as living within 3-5 miles

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of appropriate health service (Nagelkerk 1994). According to Dye et al. (2013), the eventual

goal of universal health coverage is for people to obtain all the health services they need at

where they are without the risk of financial ruin and impoverishment, now and in future.

Ghana renewed its commitment to ensuring a more extensive and accessible coverage

through the introduction of the NHIS in 2003, which admittedly has achieved some

improvement in reducing out of pocket payment according to some evaluation analysis,

(Okoroh et al. 2018, Dake 2018).

In general, the country’s plan to provide regular and accessible health care for all the

population has been described as patchy by the director of the Ghana Health Service (Salisu,

Prinz 2009). Some studies assessing the impact of the NHIS have concluded that poor

households are less likely to register in the scheme or benefit from it (Sarpong et al. 2010).

Currently, the methods of registration or enrolling into the system appears cumbersome and

bureaucratic, requiring people to travel to the cities or rely on technology to do so, making it

difficult for the rural poor. Also, the NHIS do not cover some treatments and medications,

and this continues to burden the poor in society. Hence, there is the need to evaluate these

obstacles occurring amongst the poor appropriately to ensure that the full benefit of the

scheme is realised by all (Dixon et al. 2011).

In general, underfunding, insufficient workforce and infrastructure, lack of

accessibility due to poor road and transport networks characterises Ghana’s Conventional

Health System (Nagelkerk 1994, Sarpong et al. 2010, Buor 2003). Equally, there is difficulty

in retaining the already insufficient health workforce and in distributing them to deprived

communities (MOH 2000, Asase et al. 2010). In Ghana, the ratio of a Conventional medical

doctor to the population is 1:20,000 while that of a Traditional Healer per population is 1:200

with even more alarming rationing of specialist doctor per population, 1:300,000 (Tabi, Soo

2003). Consequently, Traditional Medicine, which is perceived to be available, accessible

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and affordable in Ghana and other African communities, is essential in health care

provision to the population (Van den Boom et al. 2004). In other words, many of the

population, especially those in the remote setting, rely on Traditional Healers for their

health care needs. Traditional Healers are readily available in rural communities or

travelled to remote communities where conventional doctors or services cannot reach

or are not willing to go.

1.6.3 Cancer Incident Statistics in Ghana

Cancer is a disease characterised by uncontrolled growth of abnormal cells,

which may affect other organs of the body (Sawadogo et al. 2012). The disease is

considered as one of the leading causes of death with a substantial global socio-

economic burden (Sawadogo et al. 2012, Jemal et al. 2011, Bray et al. 2018). It is

estimated that 18.1 million new cases of cancer and 9.6 million deaths from cancer

occurred worldwide (Bray et al. 2018). According to the projections of WHO, this

number will escalate to 21.4 million by 2030, with limited resource countries being

the most heavily affected, (Sankaranarayanan et al. 2011). More than 70% of cancer

mortality and burden currently occur in Africa, Asia and other poorer continents

(Jemal et al. 2011, Jemal et al. 2010, Coughlin, Ekwueme 2009).

The African continent and for that matter, Ghana continues to experience one

of the highest rates of cancer incidence and mortality for both men and women

(Sawadogo et al. 2012, Bray et al. 2018). The incidence and mortality in the region

are estimated to be 75% compared to 46% in high-income countries (Jemal et al.

2010). The country facts sheet for Ghana on cancer indicates that there was a total of

42746 prevalence in the last five years (WHO: Global Cancer Observatory 2018).

Also, there were 22823 new incidences of cancer and 15089 deaths due to cancer in

2018 (WHO: Global Cancer Observatory 2018). The current 2018 statistics continued

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to make the point on the acceleration and effects of cancer on the poor and emerging

economies and low-income countries (Bray et al. 2018).

Ghana like other sub-Saharan African countries continues to find it challenging to

provide an adequate solution to the increasing cancer incidence and burden due to poor

infrastructure, insufficient health workers, lack of diagnostic and screening equipment and

poor access to health care. Admittedly, the benefits of recent advancement in cancer care are

far from being a reality for the higher proportion of the Ghanaian population. Regrettably,

national disease data and statistics precisely for Ghana and most African Countries are

usually not available or accurately reflect the situation on the ground as many people may go

undiagnosed or unaccounted in the statistics (Klufio 2004, Aikins et al. 2010, Jemal, et al.

2011, Wiredu, Armah 2006). The problem is due to the lack of a national register, accurate

capturing, recording and preserving of data at community and institutional facility levels.

Hence the only available data may be confined to few institutions or smaller geographical

settings (Wiredu, Armah 2006, Jemal, et al. 2011).

Although the data from developing countries may be obsolete, limited in coverage,

quality and accuracy, this is mostly the only source of information on some disease profile

made available to the World health organisation (Wiredu, Armah 2006). Moreover, until

recently, cancer, unlike other communicable diseases, had not been given enough attention as

a public health problem in Africa (Wiredu, Armah 2006). Nonetheless, the impact of cancer

continues to challenge the Ghana health system and places an overwhelming burden on the

population that is affected.

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1.7 Pre-Field Reflexivity: Researcher’s Background and Biography

Reflexivity is a process where qualitative researchers deconstruct the research

encounter by engaging in self-awareness, analysis, introspection, personal accounts, and

highlight the socio-political, cultural, professional and theoretical context of the study (Finlay

2002, Alvesson, Sköldberg, 2017, Mauthner et al. 1998, Hammersley, Atkinson 2007)

(See chapter 3.19 and 3.26 for in-field and post-field reflexivity). In Pillow’s (2003)

view, reflexivity is simply a matter of recognition or awareness of self, others, truth

and transcendence. Reflexivity happens at different degrees: some influences are

accessible and easy to identify and articulate than others at separate times (Mauthner,

Doucet 2003, Mauthner et al. 1998, Neumann, Neumann 2015). The interest of

researchers and society drives research (Neumann, Neumann 2015, Neuman 2005,

Pillow 2003) and hence, the pre-field situatedness concerns how and why I became

interested in conducting this study in Ghana.

The current interest in this study was to understand the motivation and

experiences of people living with cancer and other chronic illnesses and their use of

Traditional Healers. Also, my interest extends to understanding the sociocultural

relationship between people living with cancer and Traditional Healers and the

implications for the provision of health services and interventions in indigenous

communities in Ghana. Both my sociocultural and professional background and the

difficulty in reconciling them were the impetus for the study. I grew up in a small

town under the metropolitan district of Techiman in the Brong-Ahafo Region of

Ghana. Traditional religious beliefs and practices were widespread and robust, usually

indoctrinated through festival, storytelling and other modes of cultural instruction.

The community held Fetish priests and Traditional Healers in high esteem. The

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village forbids members to go and fetch water from the rivers or go to the farm at certain

sacred days and times.

The perception was that the ancestors and the gods would punish those who disobey

or disrespect these rules. The herbalists and the fetish priests acted as health advisers,

performed rituals that could eradicate illness from the village and provided most of the

healthcare needs of the population. The population trusted these practitioners for their

wisdom but also feared them for their possession of supernatural powers to decide matters

and punish people. Although people attended hospitals for emergencies and some illnesses,

they still consulted the herbalist or the priest to discern the spiritual cause of the illness and to

resolve it. Admittedly, the village is now moderate in their cultural beliefs because of the

influx of people from the city. However, it has always had the memories of these experiences

and exposures. I wanted to understand the motivation for the strong relationships between the

community and the Traditional Healers in these settings.

As a professional nurse, I use research or clinical evidence in practice or making

clinical decisions daily and find it difficult to accept some premises of Traditional Healers or

Traditional Medicine such as the supernatural connotations and anecdotal evidence to support

assertions. I usually struggle with the tension between my background (insider) and

professional perspectives (outsider) about Traditional Healers and how to maintain the

appropriate balance (Coffey 1999, Fetterman 2009, O'Reilly 2008). Nonetheless, I remained

open to understanding the practical and deep motivations for users of Traditional Healers.

According to Seale (1999), Allan and Arber (2018), being open about these tensions and

emotions enhance the credibility and integrity of the study. Neumann and Neumann (2015)

were insightful in their suggestion that an individual consists of a fragmented and developing

set of identities. My situation is usually fluid, sometimes accepting some aspects of

Traditional Medicine and rejecting others (Cudmore, Sondermeyer 2007, Allan, Arber 2018).

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Consciously or unconsciously, these biographies, experiences and identities

entered the field with me and had the potential to influence my thoughts and

decisions. Furthermore, My MSc project laid the foundation by exploring doctors’

views and experiences of Traditional Medicine and the possible integration with

Conventional Medicine as recommended by the World Health Organisation. The

study found that almost all the participant doctors had the experience of using

Traditional Healers or Traditional Medicine in the community or the family when

they were growing up (Badu Appiah 2011). However, most doctors strongly

disagreed with any form of integration between Conventional Medicine and

Traditional Medicine because of Traditional Medicine’s lack of scientific evidence or

medical training for its practitioners (Badu Appiah 2011).

Many of the doctors saw Traditional Healers as a hindrance to better treatment

outcomes by preventing the population from seeking advice early (Badu Appiah

2011). Also, the study found that most of the doctors were resentful towards

Traditional Healers and unsympathetic to patients who use their services (Badu

Appiah 2011). However, the conceptualisation of health and health-seeking

behaviours in indigenous communities is complicated and something that needs more

exploration.

1.8 Summary of Chapter One

The chapter provided an overview of the socio-cultural and economic context of the study

and how health beliefs and practices influence choices regarding pathways to treatment and

care. Also, I discussed the socio-cultural values and health care or health delivery system in

Ghana. These included the general lay health practices, use of Traditional Healer and

Conventional Medicine. Moreover, the chapter considered the profile of the Traditional

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Healer with regards to the pathways through which they come into Traditional healing, how

they acquire their healing knowledge and their methods of training. Although almost all

Traditional Healers in Ghana tend to seek answers from a supernatural power, some have

more action-oriented to spirituality than others. However, orientation they have depends on

their route or pathway to the Traditional healing profession. The chapter also gives an

overview of the cancer statistics in Ghana, which identifies the rising prevalence of cancer.

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The literature review is divided into two parts. The first part, which is the general literature review was conducted to establish the gaps in the literature and to help formulate the research question. This part of health beliefs, illness conceptualisation and health seeking behaviours and use of THs/TM in Ghana The second part of the review was a theoretical review that was conducted as per my methodology to place the study findings and theory in the theoretical literature of trust. The Theoretical literature review the importance of true examined the concepts of trust that were relevant to participants motivations and relationships, experiences and re indigenous communities, interaction and relationships with the THs.

In this chapter, I discussed the philosophical and theoretical underpinnings of GT or CGT and justifies why the interpretive-constructive approach is the most suitable for my study. I situate myself in the study through reflexivity and acknowledge my potential biases. I also discuss access negotiation, participants recruitment and data collection and analysis using the method of iterative coding and constant comparison method

The findings chapter discusses and shows evidence of participants motivation and experiences of using THs. I have categorised the findings under three broad headings: Placing trust in one’s community and Identity, Finding solace in Therapeutic Hospitality and Conviviality and Aiming to avoid upset and manage emotions The section shows how trust formed the fundamental premise of participants relationship with THs. Participants trusted the THs because of shared identities and the THs reputation that reflected the shared traditions or cultural values. The section examines participants experience of friendliness and welcoming reception and atmosphere with the THs. Avoidance of upset or the managing of emotion describes how THs behave in a culturally appropriate manner to avoid upsetting participant and managing their emotions. For example, the use of euphemism or indirect language to minimise the impact of their words on participants.

In this chapter, I

discuss and

compare the finding

of the study with

extant theoretical

literature and other

studies. The

discussion was

focused on trust

and how

participants

conceptualised it in

their context and

how that influence

their motivation

and experiences in

using the THs.

The conclusion chapter describes the process of the study and what I learnt in the journey. I also considered the recommendation and implication of the study to health policy and delivery in Ghana. There is also an implication of the study about the training and relationship of doctors in Ghana with the local communities. The need to involve THs in health delivery, as recommended by the World Health Organisation.

Figure 4 Summary of chapters to Thesis

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CHAPTER TWO: LITERATURE REVIEW

2.1. Chapter Overview

The literature review has two-parts. The first part was the general review that

was done to identify the gaps in the literature and to develop the research questions.

The second part of the literature review was a theoretical review that was performed

as a way of situating the findings and the theory in extant theories about Trust (see section

2.8, for details on a theoretical literature review).

The nature of literature review in Grounded theory methodology has been a matter of

debate since the inception of the methodology by its pioneers (El Hussein et al. 2017,

Charmaz 2014, Gibbs 2015, Ramalho et al. 2015). There is an expectation on researchers

using Grounded theory methodology to minimise their exposure to extant literature and

theories and to limit their influence to ensure that the concepts and categories of their studies

are grounded in data (El Hussein et al. 2017, Gibbs 2015, Charmaz 2014) (See 3.12:

Theoretical Sensitivity). Hence, some authors propose that the literature review in using

Grounded theory methodology should only be conducted after the research or data analysis

(El Hussein et al. 2017, Henwood, Pidgeon 2003). Perhaps, this highlights the debate and

lack of clarity on how the Grounded theory researcher should approach the literature review

and the appropriate time to conduct it.

The Constructivist Grounded theory, the version of the methodology which was used

for this study acknowledges the importance of understanding the discourse around the

research topic and contextualising the research, fulfilling ethics and regulatory requirements

and setting the initial direction of a study (Bryant, Charmaz 2007, Gibbs 2015, Charmaz

2014, Creswell 2012, Ramalho et al. 2015). Equally, research funding bodies require

applicants to demonstrate their knowledge in the field of enquiry through the literature

review, which is discouraged by some versions of the methodology (Ramalho et al. 2015).

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The Constructivist Grounded theory Methodology approach offers a pragmatic and a

two-stage (pre the study and post the analysis ) approach to the literature review (El

Hussein et al. 2017, Gibbs 2015, Charmaz 2014). This two-stage approach to

literature review was applied to this study.

The first stage of the literature review (the initial or general review) was

conducted to address the initial research interest, identify the gaps in the literature,

and provide a justification for conducting the study (El Hussein et al. 2017, Gibbs

2015, Charmaz 2014). Equally, the initial literature review was essential in

understanding the context of the study and in developing the research questions and

preparing the interview schedule for the study (Gibbs 2015, Charmaz 2014).

Questions around factors influencing the health-seeking behaviours and the use of

Traditional Healers in Ghana and other similar settings were considered in the general

review. Additionally, the general literature review was influenced by questions on

knowledge and barriers to cancer prevention in Ghana. Moreover, the general review

answers the questions on how people who are living with cancer use Traditional

Healers and their motivation for doing so.

The first part of the literature review (general review) begins with an outline

of the search strategy and critical appraisal of the relevant literature. Following this, I

discuss the key factors influencing the use of Traditional Healers or Traditional

Medicine in Ghana. Moreover, the general review considers how people living with

cancer use Traditional Healers more than the ordinary population, the type of

Traditional Medicine that they use, and how they do not seem to talk about it with

their doctors. Furthermore, I discuss cancer awareness and health-seeking for cancer

symptoms in Ghana. Also, I outline the research questions, aims and objectives.

These were based on the synopsis of the knowledge and theory gaps in the literature.

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I also discuss how my study would help to bridge some of the identified gaps in knowledge.

After this, I present the theoretical literature on trust.

2.2 Search Strategy and Critical Appraisal

The search strategy was developed to identify and appraise the appropriate evidence

and to evaluate them for their values and relevance. Grant and Booth (2009) described the

literature review as a springboard for conceptual innovation and thinking anew through

identifying and engaging with relevant and significant literature on a theme or subject area. It

also includes evaluating their contributions and limitations. The review provides a narrative

on the research through review and analyses of what we know about Traditional Healers and

people living with cancer in Ghana and similar settings. In doing so, the knowledge gaps in

methodology, theory and findings in the literature are identified to influence the research

questions and to make explicit the importance of my study (Grant, Booth 2009). In other

words, the study is justified in seeking to bridge some of these knowledge gaps. I first

describe my search strategy, critical appraisal of existing literature and then evaluate and

discuss their findings.

2.2.1 Databases and Search Terms

A search was conducted using the following databases: MEDLINE, Social Science

Citation Index (Web of Knowledge), CIHNAL, Psych Articles, Psych INFO, PROQUEST

and Psychology and Behavioural Science and Google Scholar to identify scholarly articles on

Traditional Medicine, cancer and health-seeking behaviours. The search was conducted

between June 2013 and 2014 and updated regularly through alerts and re-running of the

search (latest in June 2019). Updating the search helped in capturing the most up to date

knowledge on the subject. There was also a search in relevant journals, books and conference

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reports at the University of Surrey Library. I also explored the appropriate references

to the literature for their potential inclusion in the review.

The University of Surrey library staff helped to obtain literature that was not

available at the school from the British Library and other external libraries through

the interlibrary request. The searches were conducted using appropriate MESH terms,

subject headings and keywords such as Traditional (Herbal, Indigenous, Folks, and

Alternative Complementary) medicine ( treatment, therapy, care ), (cancer, tumour or

chronic diseases), Ghana (Sub-Saharan Africa, Africa and Asia ) Behaviour (Beliefs,

culture, determinants, motivation, choices, decisions). Boolean operators and

truncators were utilised to capture studies as per eligibility criteria. I uploaded all

papers from the searches into RefWorks and Endnote bibliography software. Using

this software facilitated screening and removing duplicates, keeping track of the

articles and referencing them.

2.2.2 Inclusion Criteria and Exclusion Criteria

The concept of Traditional Healers and Medicine are old, and authors who

wrote on some of the most critical pieces of literature on the subject wrote them long

ago. Hence, I did not intend to limit the years covered in the search, but for practical

purposes, I included published articles spanning the last 20 years in the search.

Empirical research articles with abstract and published in the English language met

the inclusion criteria and vice versa. The included literature also had adults as their

participants, peer-reviewed and had full sources available. I included studies

conducted in a developing or impoverished continent such as Asia and Africa and

excluded those done in Europe and America to ensure relevance or similarity to the

context of my study. Also, some articles were excluded based on the irrelevance of

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their title and content of the abstract. For this purpose, a PRISMA flow chart was used that

helped to identify what was included and excluded (See Figure 5).

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Figure 5 PRISMA Flow Chart

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2.2.3 Critical Appraisal of the Literature

The search results revealed that most of the empirical studies on the use of Traditional

Healers by people living with cancer and their health-seeking behaviours in the indigenous

population were conducted using qualitative methodology. Perhaps, the researchers preferred

qualitative methods because they could explore in more depth lay people's meanings,

motivations, conceptualisations or sociocultural phenomenon. Also, it may allude to the

nature of research in this field, mostly intended to understand peoples’ experiences in using

different health care systems in places of medical pluralism.

Moreover, there may be practical and logistical barriers to conducting extensive

surveys or quantitative studies in rural parts of Ghana or other African countries. Most

studies have focused on the socio-economic factors influencing the use of Traditional Healers

while neglecting the need to understand or conceptualise the experiences of these users and

their cultural, identity and motivations which is the focus of the exploration of my study. I

read, analysed and critically appraised the quality of the literature using the Critical Appraisal

Skills Programme (CASP) (See Appendix 1 for CASP tool) tool for qualitative studies

(Noyes et al. 2015, Joanna Briggs Institute 2015).

In this study, the CASP appraisal tool was found to be very systematic and

appropriate for the type of studies to be appraised and hence used. After assessing the

materials to be included in the review, they were categorised into themes based on the

similarities of their focus and findings (Neill 2000, Joanna Briggs Institute 2015, Noyes et al.

2015). Throughout the review, I referred to the original papers when necessary for

information or content accuracy and representation (Neill 2000; Noyes et al. 2015; Joanna

Briggs Institute 2015).

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2. 3 Factors Influencing the Use of Traditional Healers in Ghana

I have categorised the factors that influence the use of Traditional Healers in

Ghana and most African countries into socio-economic, socio-cultural and belief

systems. Classifying the elements in this manner reflects the understanding,

conceptualisation and determinants of health behaviours in these settings. However, in

practice, the distinctive categories are blurred with nuances. Multiple factors influence

peoples’ health-seeking behaviours (Langlois-Klassen et al. 2007, Peltzer et al. 2008,

Kwansa 2010) and in Ghana, involves switching between different therapeutic

modalities or using them simultaneously (Tabi et al. 2006, Bazzano et al. 2008,

Awusabo-Asare, Anarfi 1997).

2.3.1 Socioeconomic Factors

Studies have drawn attention to the influence of socio-economic factors on the

health-seeking behaviours in communities that are impoverished. The pieces of

literature highlight factors such as the lack of affordability, availability and

accessibility to Conventional Medicine as the main socio-economic factors

influencing the use of Traditional Healers in these poor resource communities

(Bazzano et al. 2008, Tabi et al. 2006, Aries et al. 2007, Fenny et al. 2015, Dalaba et

al. 2018). Generally, the unavailability or lack of access to Conventional Medicine is

more acute in remote and poor communities in Ghana. Hence, these populations rely

on Traditional Healers who usually reside in their communities (Tabi et al. 2006,

Sarpong et al. 2010, Buor 2003, Tabi, Soo 2003). Other studies have mentioned the

attitude of medical staffs at hospitals and clinics to influence health-seeking

behaviours of patients or the communities they serve (Macha et al. 2012, Agyemang-

Duah et al. 2019, Mwaka et al. 2015).

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A study by Bazzano et al. (2008) focused on the care-seeking behaviours for the new-

borns in Northern Ghana using both quantitative and qualitative data. The quantitative data

was a birth surveillance data of 2878 children from July 2003 to June 2004. The qualitative

data includes observation (84 hours) and multiple data collection methods including a focus

group of parents, in-depth semi-structured interviews with a key informant (old mothers and

grandmothers), interviews with mothers and expert’s local health providers (n=132). The

study identified financial constraints and remoteness from health facilities to have a

significant influence on the participants’ health decisions. Some parents took their children to

the Traditional Healers because they could not afford the transport and hospital cost (Bazzano

et al. 2008).

The study highlighted the importance of more comprehensive and affordable health

care coverage and improvement in health-seeking behaviours through health education and

removal of financial barriers (Bazzano et al. 2008). Similarly, Aries et al. (2007) study on

fracture treatments after a road traffic accident in Techiman, a city in the Brong-Ahafo

region of Ghana (n=46) identified socio-economic factors to influence the decision to choose

between Traditional Healers and Conventional Medicine. A higher proportion of participants

(n-=29) opted for treatments from the bonesetters. These participants cited the cost of

treatments (Aries et al. 2007) and bonesetters competence or experience in treating bone

fracture (Aries et al. 2007, Solagberu 2005) for using Traditional Healers.

Although most participants in Aries et al. (2007) study were concerned with money,

they attended the hospital immediately after the accident before transferring to the bonesetters

on the basis that the doctors or hospitals had sophisticated diagnostic equipment and the

knowledge to halt emergencies. A study by Sato (2012) on the actions taken for self-reported

episodes of acute and previously diagnosed chronic illnesses supports the notion that doctors

are experts in dealing with emergencies and not so good with chronic diseases. The study

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found low use of Traditional Healers for acute conditions and higher use of

Traditional Healers for chronic conditions.

However, the cost of treatment was the main reason for most participants in

Aries et al. (2007) study who were admitted as an emergency to the hospital later

requesting to be discharged to the bonesetter and not the issue of competency. In

Amegbor’s (2017) study about the preferences of healthcare therapy in Ghana, most

participants relied on self-care, using both indigenous and biomedical initiatives to

escape the financial burden of Conventional Health Care. Some participants of the

study used home remedies and ordinary herbal products or bought un-prescribed

tablets, ointments and medications from an unqualified chemist or street hawker to

treat themselves (Amegbor 2017). These studies highlight the importance of financial

consideration in health decisions and whether a person would use the Conventional

Medicine or Traditional Healers in Ghana.

Additionally, a study by Macha et al. (2012), explored the manner of health

care financing and the primary beneficiaries of such financing in Ghana, Tanzania and

South Africa. A triangulated data of household surveys, interviews and focus group

were collected in 2008 for the study. The data collected in each country were: Ghana:

2986 households survey interviews (n=14050) and a focus group (n=26), Tanzania:

2234 (n=12200) households survey, interviews and a focus group (n=22) and in South

Africa: 4800 households survey interview (n=22000) and a focus group (n=44). The

study found that the structure and methods of financing Conventional Health Care in

all three countries were similar and favoured the rich or the wealthy. All the three

countries operated with a health insurance system which required initial registration,

regular membership renewal and annual premium payments (Macha et al. 2012).

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Majority of the rural populations and the poor in all the three countries in the study

faced a financial challenge of paying for the premium, travelling to the cities or registration

centres to register or having the technology and internet access to register (Macha et al.

2012). The general acknowledgement is that arbitrary rolling out and expanding national

health insurance will not necessarily translate to an increased usage of Conventional

Medicine unless it matches with affordable, accessible and functioning facilities or services

(Macha et al. 2012, Kuuire et al. 2016, Fenny et al. 2015, Agyemang-Duah et al. 2019).

The increase in the national health insurance scheme (NHIS) coverage in Ghana has

not adequately addressed the fundamental tenets of the scheme to provide access to adequate

and equitable health services to the entire population, especially the poor and vulnerable

(Kuuire et al. 2016). Studies have highlighted insufficient workforce, poor building

infrastructure, and transport connecting systems as constraints to the rural populations’ ability

to have access to Conventional Medicine (Nagelkerk 1994, Sarpong et al. 2010, Buor 2003).

In most Ghanaian communities, there is a low ratio of Traditional Healers to the

population, and ready availability and unimpeded accessibility to Traditional Healers (Tabi,

Soo 2003). Contrary, there is a high ratio of patients to doctors per population with the

situation even worse regarding the number of specialist doctors per population (Tabi, Soo

2003). The shortage or insufficient doctors are due to the lack of facilities to train more

doctors, government’s inability to provide enough incentives comparable to the developed

countries which have led to brain drain (MOH 2000, Asase et al. 2010).

The impact of such doctors’ shortages is more felt in the remote and rural

communities which are not attractive to doctors. Consequently, the rural populations in

Ghana and most African communities rely on Traditional Healers who are available in their

communities (Van den Boom et al. 2004) or are willing to travel to these communities where

Conventional Health Professionals are not available. Other factors hindering access to

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Conventional Medicine in Ghana are the lack of proximity to Conventional facilities

and poor road and transportation systems (Tabi et al. 2006, Tabi, Soo 2003, MOH

2000, Dalaba et al. 2018, Fenny et al. 2015). Some authors consider appropriate

healthcare as the one that people need and can access in their immediate communities

(Dye et al. 2013) or at least within three to five miles of where they live (Nagelkerk

1994).

In Ghana, most Conventional Health facilities are established in the cities and

away from rural communities. Equally, most of the linking roads to these facilities

are very rough, has potholes and challenging to use, especially when it rains (Tabi et

al. 2006, MOH 2000). Hence, even those rural populations who manage to get into the

NHIS may be unable to use conventional medical services due to the unfortunate lack

of proximity and transport network (Fenny et al. 2015). On the contrary, the lack of

any requirement for transportation and long-distance travelling make using the

Traditional Healers more attractive and convenient in most Ghanaian indigenous

communities. Furthermore, staff attitudes at Conventional Health facilities influence

the health-seeking behaviour of patients.

In the study by Macha et al. (2012), both the focus group interviews and the

household surveys identified staff attitude to influence health-seeking behaviours. The

study identified negative staff attitudes such as bribery and corruption and asking

participants to pay for drugs and services that should be free to influence patients’

health-seeking decisions. In Ghana, some participants in the more indigent

population did not trust the hospitals and NHIS staffs, and hence, they were unwilling

to register for the NHIS (Macha et al. 2012). Contrary, the same study identified staff

attitudes as positive, such as politeness and excellent interaction in privately own

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facilities which attracted the rich or those who could afford private care (Macha et al. 2012).

Although the study highlighted functional interactions in the privately own hospitals,

it does not discuss the nature or elements of the interactions. Other studies have documented

in more detail, the influence of staff attitude to the use of health services (Agyemang-Duah et

al. 2019, Mwaka et al. 2015). Both Agyeman-Duah et al. (2019) study (n=35) in Ghana and

Mwaka et al. (2015) (n=24) in Uganda, broadly explored the facilitators and barriers to

biomedical or Conventional Health Care use. Both studies highlighted the importance of staff

attitude to health service use. The study by Mwaka et al. (2015) described negative staff

attitudes such as disrespect, bribery or unofficial payments, and discriminating against the

poor or giving special services to those who have high statuses in society.

On the other hand, Agyeman-Duah et al. (2019) identified positive staff attitudes such

as friendliness, cordiality, approachability and quality of care (quick recovery and

effectiveness of treatment ). It should be noted that 20 participants of Agyeman-Duah et al.

(2019) study were health professionals and may have theoretical knowledge of the influence

of positive behaviours on patients and their health service use. What is not known is how they

demonstrate these in practice. Both studies found the use of English language by hospital

staff and their failure to speak the local dialect and understand the local culture an abhorrent

attitude, a deterrent to Conventional Medicine use and contributed to low patient satisfaction

(Mwaka et al. 2015, Agyemang-Duah et al. 2019)

There is not much clarity on whether the barriers or hindrances to Conventional

Medicine use always drive people to Traditional Healers. However, Mwaka et al.’s. (2015)

clearly stated that patients living with cervical cancer used Traditional Healers mainly

because of language and staff attitude as a barrier to biomedical care. Furthermore, the lack

of practical functionality of most Conventional facilities and staff attitude discouraged the use

of Conventional Medicine (Macha et al. 2012, Agyemang-Duah et al. 2019). Some authors

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have described incomplete waiver policies and lack of required services at the

institutional levels as a challenge to Ghana’s Conventional Health System (Macha et

al. 2012, Agyemang-Duah et al. 2019).

Agyeman-Duah’s et al. (2019) conducted their study at Ejusu in the Ashanti

Region of Ghana. They discovered that most participants, including NHIS members,

were dissatisfied with the service that they received and described the system as

inoperative. The reason for the study participants dissatisfaction was that the NHIS

did not cover many illnesses, services and drugs (Agyemang-Duah et al. 2019). Some

of the study participants were also concerned about the lack of clarity on what the

scheme covers and, the fact that many of the items covered were in name only and not

available in practice (Agyemang-Duah et al. 2019).

Unfortunately, the study did not mention the specific list of illnesses, drugs

and services that the NHIS covered or did not cover and hence it is not known the

level cover of treatment that people living with cancer were entitled to receive.

Undoubtedly, all the studies above show how multiple socio-economic and health

system factors influence whether people in indigenous communities would choose

Conventional or Traditional Medicine for treatment.

2.3.2 Sociocultural Factors

Culture as a way of life relates to how people of community experience and interact with

others and the wider socio-spiritual or psycho-physical environment (Geertz 2017). At all

stages of human life, socio-cultural processes impinge on health, ill-health and our

perspective and interpretation of them (Nettleton 2013). People’s sociocultural background

and understanding of health influence their preferred method or model of treatment and

whom they identify or recognise as appropriate to provide the treatment (Kleinman 1980,

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Helman 2007, Nettleton 2013). Equally, culture affects the health decision-making process,

such as which stakeholders are involved and who makes the final decision.

Hence, we should study and discuss treatment-seeking behaviours from a broader

cultural context (Landy 1977, Helman 2007, Kleinman 1980). However, culture should not

serve a broad-gauge or a sole measure of health behaviours because of its lack of

homogeneity and different individual or subgroup behaviours in all communities (Helman

2007, Geertz 2017, Kleinman 1980). Different members of a cultural group may have a

different expectation, understanding and attitude toward the same cultural values and norms

(Koffman 2006) and hence have a varied attitude towards health.

Additionally, there may be multiple distinctions or variation of cultural attributes

within the confines of a specific cultural group or society across the different socio-economic,

professional and religious strata or categories (Helman 2007, Hall, 1989, Leach 1973). These

groups may exhibit different health-seeking behaviours and practices from the rest of the

broader cultural group. Hence, we should always consider culture in the appropriate context

of socioeconomics, politics, history, geography and the influence they may have on the group

of people at a specified period (Kleinman 1980, Helman 2007).

A study by Kakute et al. (2005) considered the barriers of exclusive breastfeeding by

mothers in rural Cameroon, initially using four focus groups discussion (n=40). The

researchers then formulated a survey questionnaire from the focus groups discussions to

recruit breastfeeding mothers from four villages (n=320), 80 from each village (Kakute et al.

2005). Although most of the participants (94.4%) attended the antenatal clinic and received

advice on exclusive breastfeeding, the community’s cultural beliefs influenced their health

behaviours. The study is not clear on the exactness and the quality of advice that the antenatal

clinic staff gave to the women and whether the women understood the information.

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Many of the participants, two hundred and seventy-one (84.7%) gave solid

food to their infants before the age of six with others doing so at a very early age. All

participants practised mixed feeding and gave additional foods such as chewed

cocoyam, plantain, banana, groundnut and oranges to their babies before they were

six (Kakute et al. 2005). The study identified mixed feeding as an old cultural practice

which the elders or older women enforce in the communities with the intentions of

protecting babies from illnesses. Any attempt by the women to disobey such a

practice could cause a conflict between them and their husbands, mothers-in-law, and

the village elders which could attract curses or misfortunes (Kakute et al. 2005).

Furthermore, all participants had the cultural belief that sexual contact was a

prohibition during breastfeeding as it destroys the milk and can destroy the child. To

eschew such risk, the mother had to feed the child with other foods and then wean

them off the breast milk as soon as possible so that the husband can have sexual

contact with them at the earliest opportunity (Kakute et al. 2005). Most participants

had the notion that breast milk was an incomplete food and could not provide all the

necessary nutritional requirements for the child’s growth. Hence, the mother needs to

give the child solid food to meet the nutritional requirement and equally enjoy the

pride of feeding the child with the families own farm products. More than half

(52.2%) of participants believed that colostrum milk was inadequate and bad for the

baby. Hence, all Fulani women in the study preferred not to commence breastfeeding

immediately but wait until at least after two days. Instead, they preferred to give their

babies cow’s milk and Viindi. Viindi is the water they obtain from washing off

passages of Quran, which they have written with charcoal and believe to be highly

nutritious and offers protection to the child (Kakute et al. 2005).

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Although the study is critical in highlighting the dynamics of cultural practices in

health behaviours, it does not necessarily say that the participants used the services of

Traditional Healers. However, the participants were breastfeeding women who had no health

issues and hence, it was not necessary for them to see a Traditional Healer. The study

acknowledged that these communities and the practices were controlled and enforced by

Traditional leaders and elders who are in similar positions or provided identical services as

the Traditional Healers.

Other factors such as the influence of family, friends, social networks, education and

occupation influence health behaviours (Aries et al. 2007, Tabi et al. 2006, Moyer et al. 2014,

Ngom et al. 2003, Gyasi et al. 2015, Solagberu 2005). Some participants in Aries et al.

(2007) study were influenced to leave the hospital for treatment at the Traditional Healers per

the family leaders’ experience, advice and the entire families’ perception of the ease to visit.

Also, in a study by Tabi et al. (2006), some participants used Traditional Healers

because of the experiences and persuasions of their parents or family. A study by Moyer et

al. (2014) explored the impact of social factors on the place of delivery or childbirth in

northern Ghana. The study identified power, social hierarchy, and a widespread sense of

shared family or communal responsibility to influence whether a woman delivered in a

Conventional Medical facility or at home. The family head, husband and community

soothsayers all played an essential role in deciding the facility that the women used for

delivery.

The study found that even the women who made their own decisions sometimes

needed the spiritualist and the husband's approval to operationalise this decision (Moyer et al.

2014). A study by Ngom et al. (2003) on gatekeeping and women’s health in the Kassena

Nakanna District in the northern part of Ghana (n=2856), used the terms compound and

husband gatekeepers to describe how hierarchies and cultural practices affect health-seeking

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behaviours in some communities. The health-seeking behaviour of participants was

affected by their reliance on the compound gatekeepers who provided spiritual and

moral direction and the husbands who provided the legal authority and economic

support (Ngom et al. 2003). The respect for older people, tradition and hierarchy is

fundamental in the Ghanaian culture. Likewise, the hierarchy influences health

decisions, and in most cases, the community elders or stakeholders make the decision

corporately or at least approve the decision.

Education and demands from employers were found by Tabi et al. (2006) to

influence the choice of treatments for some employees. The demand from employers

for the evidence of employees visit the doctors for treatment, and formal education

did not favour the choice of Traditional Medicine. Similarly, Gyasi et al. (2015)

analysis of the predictors of using Traditional Healers in the Ashanti Region of Ghana

found higher use of Traditional Healers amongst market workers or traders than

public sectors workers. Education may have a bearing on the finding as people

working in the public sector in Ghana tend to have formal education or qualification

in contrast to market traders. The findings contradict the findings of Chen et al. (2008)

(n=5046) assessment of the demographics, and socioeconomic statuses of people

living with cancer’ use of Traditional Healers post-diagnosis in China.

The study found that 97% of participants used Traditional Medicine, and they

were associated with higher education, younger age, higher income or socio-economic

status. The disparity between the findings of the two studies suggests that while

Traditional Medicine may be cheaper in Ghana, it may be expensive in China and

more affordable to the affluent. The issue of education and its benefits are usually

contentious within some indigenous populations in Africa. Some see education as

enlightenment to the unhygienic and unscientific superstitious practices of

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Traditional Healers. Others perceive education as anti-African traditions or cultures which

dissuade people from using Traditional Healers (Tabi et al. 2006).

The study by Awusabo-Asare and Anarfi (1997) did not directly identify non-

spiritual factors in their findings. However, they found that HIV/AIDs patients who believed

in the scientific concept of disease aetiology used Conventional Medicine for treatment.

Some participants also preferred Traditional Healers for the thought that their illnesses may

be a misfortune. Primarily, the scientific theory of disease aetiology offers a non-spiritual

explanation to the cause of a disease (Wade, Halligan 2004, Dick 2010, van der Geest 1997)

and hence encourages people to seek Conventional Medicine.

2.3.3 Spiritual Belief System

A study by Okerefo and Fiaveh (2017) examined how religiosity or spiritual beliefs

influence health-seeking behaviours in Accra, Ghana. The study found an active link between

health-seeking behaviours and religiosity. Participants who believed in spiritual causation

and healing of diseases relied on prayer alone or on both prayer and biomedicine to find

solutions to their illnesses (Okyerefo, Fiaveh 2017). The study also found that participants

who believed in spiritual healing preferred getting away from the routine busy life activities

to a sacred and serene landscape such as the forest where they could wrestle with the mishaps

they had in their life.

Several studies have acknowledged the influence of spiritual beliefs on illness

causation in health-seeking behaviours and choices in Ghana (Tabi et al. 2006, Bazzano et al.

2008, Awusabo-Asare, Anarfi 1997, Kwansa 2010, Adjei et al. 2013, Kpobi et al. 2018,

Farnes et al. 2011). These include diseases such as Asram characterised with ‘green veins’

on a child’s body, excessive crying and growing leaner in Bazzano et al. (2008), epilepsy in

Tabi et al. (2006), Adjei et al. (2013) and Kpobi et al. (2018). Also, HIV/AIDS in Awusabo-

62 | P a g e

Asare and Anarfi (1997) and Kwansa’s (2010) study were seen as the consequence of

a curse or attack from an evil person and hence required treatment from Traditional

Healers. Supernatural beliefs and human vulnerability to spirit and deities are

common in Ghana and underpins most cultural practices. For example, in Farness et

al. (2011) study, pregnant women believed that the pregnancy increased their

vulnerability, exposure and made them a target to spiritual attacks from a jealous

person.

Consequently, they preferred to receive support from the Traditional Healers

who could protect them from evil spirits. A study by Kwansa (2010) acknowledged

the importance of spiritual therapy in Ghana, at least as a coping strategy to find

meaning and hope in life or hereafter. Traditional Healers are perceived to have the

powers to deal with spiritual illnesses and misfortunes or offer the necessary spiritual

protection, guidance and answers under challenging circumstances in conformity with

the indigenous Ghanaian culture (Farnes et al. 2011, Tabi et al. 2006, Awusabo-

Asare, Anarfi 1997, Abel, Busia 2005). Broadly, Ghanaians and Africans, in general,

tend to seek a spiritual explanation to diseases and events because of the inherent

beliefs about God and ancestral spirits (Neba 2011, Castle 1994, Tsey 1997, Abel,

Busia 2005).

Individuals may behave in this manner even for diseases that are viewed to

have no spiritual causation or have a clear medical explanation for their causes

(Musara 1991, Irwin et al. 1991, Lindan et al. 1991). Some people seek spiritual

interpretations due to the shock and uncertainties from suddenly occurring illnesses

and worsening of illnesses and chronicity of health conditions. Others seek

Traditional healing to ascertain answers to why they or their relative may be suffering

from illnesses or misfortunes (Castle 1994, Johnston 2002, Neba 2011).

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Moreover, people review their health choices and make changes accordingly as

circumstances change. Some participants in both Aries et al. (2007) and Solagberu (2005)

study returned to the hospital when they developed infections or perceived a lack of progress

in their treatment with the Traditional Healers. All these studies have highlighted essential

elements influencing the choice of Traditional Healers in Ghana.

2.3.4. Psychological and Emotional Motivations for Using Traditional Medicine

A study by Yarney et al. (2013) found that participants used Traditional Healers to

improve emotional and physical wellbeing and to manage the perceived toxic and dire

consequences of Conventional treatment. Psychological and emotional support is essential for

people living with cancer throughout their disease trajectory and influences their decision to

use Traditional Healers (Miller et al. 1998, Clegg-Lamptey et al. 2009, Wanchai et al. 2010,

Aziato, Clegg-Lamptey 2015). A study by Clegg-Lamptey et al. (2009), was on people living

with cancer regarding the psychological aspects of breast cancer treatment in Accra-Ghana

(n=89). The study identified specific patient concerns such as fear of destructive

Conventional Medicine treatment (chemotherapy, radiotherapy and mastectomy), depression

and shock of the diagnosis to cause a psychological challenge to people living with cancer.

Several participants in the study had concerns about the lack of psychological support

in Conventional facilities. These included staffs and institutional lack of sympathy and

emotional support, lack of information and communication concerning their treatment, lack

of any available counselling services, and slow or bureaucratic services. Overall, 67% of

participants were dissatisfied with the level of psychological support they received in the

hospitals, and 49.4% ended up with an alternative or non-conventional medical treatment for

their cancer treatment. Although the study did not say whether these patients used alternative

treatments for a psychological reason, it appeared to allude that the lack of psychological

support in the hospitals may have influenced the participants’ choice of Traditional Medicine.

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The study concluded that people living with breast cancer in Ghana are not

receiving emotional and psychological support and the need for adequate and enough

psychological support for people living with cancer in Ghana. Similarly, the findings

of other studies have supported the severe psychological distress of people who were

living with cancer experienced from the time of diagnosis and throughout their

disease progression. These studies show a complete lack or limited support that

people living with cancer receive for their emotional needs (Wanchai et al. 2010,

Clegg-Lamptey, et al. 2009).

In Ghana, the provision of psychological and emotional support to patients in

Conventional Medicine is limited or lacking with patient care focusing mainly on

physical needs. Most of the population, therefore, use prayers, religious and social

activities and Traditional Healers therapies to address these unmet needs alongside

Conventional Medicine or alone. Although the general perception is that people use

Traditional Healers because of the Traditional Healers acknowledgement and support

for their psychological needs, there is a lack of literature on how Traditional Healers

provide services and support in Ghana. In Wanchai et al. (2010) study, Traditional

Healers were perceived to be holistic practitioners and provided psychological support

through listening, acting humanly, allowing enough time for their patients during the

consultation and therapeutic encounter.

A study by Bignante’s (2015) investigated the culturally specific interaction

between patients and healers in Northern Senegal, (n=160), using interviews, focus

groups interviews and observation. The participants were 100 patients, 20 herbalists

or people selling herbal remedies in the marker and 40 traditional healers. The study

identified elements of psychological and emotional healing or support emanating from

participants relationships with the Traditional Healers to influence their use of the

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Traditional Healers. To understand the kind of patient-healer relationship that supports

patients emotionally and psychologically, the researcher interacted more intensely with 20

patients and 15 healers who had a high reputation in the communities through extensive

interviews, observation and interactions (Bignante 2015).

Consequently, the researcher was able to provide a clear understanding of the several

elements of the relationship and interaction between participants and the Traditional Healers,

which supported them emotionally and influenced their use of the Traditional Healers. The

study found that the Traditional Healers discussed patients’ problems, fears and things that

were making them unhappy or causing them sadness with the view that these issues affect the

patients' general wellbeing (Bignante 2015). Some participants described how they went to

the Traditional Healers for the opportunity to discuss personal matters such as quarrels with

their friends, issues concerning their partners or spouses, or to deal with feelings of sadness,

depression or grief and impotence and to find peace and emotional wellness (Bignante 2015).

Furthermore, the study discussed that several participants indicated their preference

for the Traditional Healers because of their unique ability to heal with words, keep patients

calm, let patients worries go away and making patients feel protected and at home in their

clinic. Although some of these supports that the Traditional Healers offer may appear social,

they turn to affect or exacerbate the psychological wellbeing of patients and therefore require

health professional attention together with the illnesses and the opportunity for patients to

discuss them. Perhaps, one can understand the complexities of these issues and why

conventional health professional may not want to discuss them or feel they are not equipped

to do so. It appears that in general Traditional Healers are members of their communities and

have the requisite knowledge to interact with patients on a more personal level.

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2.4. People Living with cancer’ Silence about Their Use of Various Traditional Healers

The use of Traditional Healers by people living with cancer is on the increase in both

the developed and developing world (Verhoef et al. 2005, Paltiel et al. 2001, Boon et

al. 2000, Ernst 1998). Also, studies have reported greater use of Traditional Medicine

by people living with cancer compared to the general population (Mao et al. 2011;

Patterson et al. 2002, Richardson et al. 2000). However, there is a paucity of enough

studies that have investigated the issues of cancer, and Traditional Healers use in

Ghana, which is one of the reasons for this study. Hence, I considered studies that

have looked at other chronic diseases and Traditional Healers for review in this

section. For a coherent structure and discussion, I have included the following themes:

prevalence or percentage of Traditional Medicine use, types of Traditional Medicine

used, and the level of communication between people living with cancer and their

doctors about Traditional Medicine or Traditional Healers.

Table 1 Summary of studies on people living with cancer use of Traditional Healers

Study Number of

participants (n)

Site/source of participants Percentage of

Traditional Medicine

users

Yarney et al.

(2013)

people living with

cancer (n=98)

Korle-Bu Hospital-Ghana 73.5% (herbal,

massage, Chinese

medicine, and

prayers)

Broom et al.

(2010)

People living with

cancer (n=500)

Two Sri-Lankan Hospitals 67.4% (Sinhala,

Ayurveda &

Traditional religious

practices

Gozum et al.

(2003)

people living with

cancer (n=107)

Yakutiye hospital-Turkey 41.1% (herbs)

Brahmi et al.

(2011)

People living with

cancer (n=100)

University Hospital of Fez-

Morocco

46 % (Herbal, Pure

honey, Holy water

from Mecca, special

diets, religious

practices)

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2.4.1. Prevalence of People Living with cancer’ Use of Traditional Healers in Ghana

All the studies found that Traditional Medicine use amongst cancer or chronic disease

patients is high, although the percentage and type of Traditional Medicine used varies. The

variations in Traditional Medicine use were likely as the studies did not ask the same

questions or used the same methods. Also, they used definitions that included or excluded

some forms of Traditional Medicine. For example, Brahmi et al. (2011) study of patients

with cancer quoted 46% as the percentage of Traditional Medicine users in his study. The

study also quoted 37% and 22% for Traditional Medicine technique users (e.g. Yoga &

massage) and special diet respectively. Also, Gozum’s (2003) study of patients with cancer

also reported a figure of 41.1% for using Traditional Medicine

However, the only Traditional Medicine considered in Gozum’s study were herbal or

plant medicine. On the other hand. Yarney et al. (2013) reported a much higher figure of

73.5% because it reported many forms of Traditional Medicine: herbal, Chinese, massage and

prayers together. Some of the studies found that some patients used more than one

Traditional Medicine or therapies or simultaneously used Traditional Medicine and

Conventional Medicine (Amira, Okubadejo 2007, Broom et al. 2010, Gozum et al. 2003).

Studies in Uganda and South Africa have corroborated the mixing of Traditional Medicine

and Conventional Treatment by HIV/AIDS patients (Langlois-Klassen et al. 2007, Peltzer et

Amira &

Akubadejo (2007)

patients living

with hypertension

(n=325)

Lagos University hospital-

Nigeria

39.1% (Herbal

products: native

herbs, bitter leaves,

garlic, ginger &

spiritual therapy

Hasan et al.

(2009)

patients living

with chronic

disease (n=321)

Public hospital-Malaysia 63.9% (herbal,

vitamins, Traditional

Chinese Medicine &

Ginseng

Ezeome &

Anarado (2007)

people living with

cancer (n=160)

Enugu Hospital-Nigeria 65% (herbs,

faith/prayer healing,

Aloe Vera, medical

tea and black stone

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al. 2008). Again, this highlights the complexity of health-seeking behaviour and the

fact that many people use both different treatments simultaneously to achieve

different results.

2.4.2. Different Forms of Traditional Medicine used by People living with cancer

Furthermore, the studies identified a variety of Traditional Medicine that people use in Ghana

and other communities. Broom et al. (2010) study in Sri Lanka found that participants with

cancer used Indian Traditional Medicine such as Ayurveda, Sinhala, and spiritual practices

but the primary medicine used was herbal or plant-based medicine. Herbal medicine was used

by all participants (100%) in Gozum et al. (2003) study, 24% in Brahmi et al. (2011) study,

51.9% in Ezeome and Anarado (2007) study and 26% in Hasan et al. (2009) study. The other

studies asserted that herbal medicine was the most widely used Traditional Medicine but did

not provide any figures to support this assertion. On the other hand, Yarney et al. (2013) (n=

98) reported massage as (66%), herbs (59.2%), vitamins (55.1%) and prayers (42. 9%). The

higher use of massage in this study is not consistent with the view of Herbal medicine as the

mainstream Traditional Medicine in Africa and Asian communities as identified in other

studies (Bodeker, Ong 2005, Burford et al. 2000, Hampshire, Owusu 2012, Shukla, Sinclair

2009).

The study did not offer any explanation for this deviation. However, massage

has been shown to reduce pain, fatigue, stress, anxiety, depression and recommended

in oncology settings (Cassileth, Vickers 2004, Post-White et al. 2003, Myers et al.

2008, Weinrich, Weinrich 1990). Hence, it is possible that massage was offered to

participants as part of their care by oncologists and may explain this aberrancy. The

multiplicity of different items and materials and practices involved in Traditional

Medicine and their variation in different cultures highlight the complexity of

Traditional Medicine.

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2.4.3 Lack of Doctor-Patient Communication about Traditional Medicine

The World Health Organisation has been embarking on a significant policy initiative

which principally aims to increase research and development of Traditional Medicine,

improve dialogue between Traditional Healers and doctors and utilise Traditional Healers in

the national health systems ( WHO, 2013, Sato,2012). The policy development was in

response to the popularity and increasing use of Traditional Medicine both in the developed

and developing countries in recent times. There is no evidence to suggest that communication

between doctors and their patients about Traditional Medicine will reduce the number of

Traditional Medicine users. However, the assumption or prediction is that open and honest

discussions and conversations between patients and health professional about Traditional

Medicine would ensure safety or avoid drug interaction and provide a better and more

prudent use of Traditional Medicine.

Furthermore, such conversations will dwindle the notion that Traditional Medicine

and its practitioners would and should always remain and function outside the mainstream

Conventional Medical Systems ( Stone, Matthews,1996). Despite this recognition and efforts

to improve communication and safety for Traditional Medicine users, many studies have

highlighted the lack of communication or discussion between patients and their health

professional about Traditional Medicine (Yarner et al. 2013, Gozum et al. 2003, Broom et al.

2010, Brahmi et al. 2011, Ezeome 2007). For instance, 83.3% of Traditional Medicine users

in Yarney’s et al. (2013), 80.5% in Broom’s et al. (2010) study 54.5% in Gozum’s et al.

(2003) study, 55.8% in Ezeome and Anarado (2007) study did not inform their clinician that

they were using Traditional Medicine. Although Brahmi et al. (2011) study made the same

assertion, it did not provide the exact percentage or number of participants who did not tell

their clinicians that they were using Traditional Medicine.

Studies have corroborated the lack of communication about Traditional Medicine

between patients and clinicians (Davis et al. 2012, Langlois-Klassen et al. 2008, Tovey et al.

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2006). The study by Langlois-Klassen et al. (2008) specifically investigated the level

of communication between HIV/AIDs patients and doctors about Traditional

Medicine in Uganda (n=137). The findings were that 87 % anti-retroviral (n=67) and

84% of none anti-retroviral users (n=70) did not inform their doctors that they were

using Traditional Medicine. Equally, Tovey et al. (2006) study (n=92) found that

62.9% of participants who used Traditional Medicine did not inform their doctors

during encounters. Most patients assumed that the doctor knows it all and will ask

about Traditional Medicine if it was necessary or had an implication on their

biomedical treatment.

Also, some patients were under the impression that doctors are prejudiced to

Traditional Medicine use and hence did not see the reason or the benefits of

discussing or informing them (Davis et al. 2012). Other studies described patients’

ability to judge the doctors perceived lack of interest and apathy to discuss any other

form of treatment and hence such patients felt discouraged to talk about any other

treatment they were using (Langlois-Klassen et al. 2008, Davis et al. 2012, Broom et

al. 2010). However, patients were willing to discuss or talk to their doctors about

Traditional Medicine if the doctors asked them or they perceived that their doctors

were open to the idea and willing to discuss them (Davis et al. 2012, Ezeome,

Anarado 2007, Langlois-Klassen et al. 2008). Perhaps, more studies are needed to

investigate the potential drug interactions between the two treatment modalities

(Langlois-Klassen et al. 2008, Peltzer et al. 2008).

Additionally, it is reported that there should be understanding and acceptance

by health care workers that for socio-cultural and economic reason, some patients will

continue to use other treatment approaches and therefore, health professionals should

encourage discussions about them (Langlois-Klassen et al. 2008, Peltzer et al. 2008).

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2.5 Cancer Awareness and Help-Seeking for Cancer Symptom

The use of Traditional Medicine by people living with cancer is on the increase in

recent times (Paltiel et al. 2001, Ernst 1998, Boon et al. 2000, Verhoef et al. 2005). However,

several factors hinder the effort to deal with the challenges of cancer in Ghana and most

developing countries (Anderson et al. 2011, Jemal, et al. 2011, Sankaranarayanan et al.

2011). Public awareness, health education, screening, and early detection or diagnosis of

cancer are central to reducing cancer mortality in sub-Saharan Africa (Abotchie, Shokar

2009, Edwin 2010, Mena et al. 2014). For example, increased awareness and uptake of Pap

smear and Human Papillomavirus (HPV) screening schemes help the early detection of

premalignant cell changes for early intervention to avoid the disease progression (Edwin

2010).

However, inadequate infrastructure and equipment, culture and belief systems are

hurdles to the few available preventions and awareness programs in Ghana and other

developing countries (Valsecchi, Steliarova-Foucher 2008, Anderson et al. 2011, Kingham et

al. 2013, Kwok, Sullivan 2006, Williams, Amoateng 2012). Also, a review on optimising

cancer management in Africa has highlighted impediments such as lack of research and

essential data to make informed decisions (Anderson et al. 2011). Ghana, at present does not

have any active screening and education program or policy initiative for preventing or raising

awareness of cancer disease in the population (Abotchie, Shokar 2009, Aikins et al. 2010).

The few and patchy programs aimed at addressing the problem have come from non-

governmental or foreign organisations who have limited capacity and usually focus on a few

rural communities (Mena et al. 2014).

The consequences of the situation are inadequate knowledge and awareness, poor

prognosis, late medical attention and patients’ reliance on Traditional Healers for treatment

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(O'Brien et al. 2012). Some studies have highlighted the low level of knowledge of

cancer in Ghana and other African communities. First, in Abotchie and Shokar (2009)

cross-sectional study of knowledge, beliefs and acceptability of cervical cancer

screening amongst university students in Ghana (n=140). Second, in Opoku et al.

(2012) study of knowledge, attitudes, beliefs, behaviour and breast cancer screening

practices in Accra and Sunyani-Ghana using both quantitative and qualitative data

collection approaches (n=500). Third, in Mangoma et al. (2006) investigation of the

perception and understanding of women in rural communities on cancer, barriers to

screening and the sources of information on cancer for participants in Zimbabwe

using both quantitative and qualitative data collection tools (n=356). The study by

Opoku et al. (2012) did not provide examples of specific knowledge deficit of

participants. However, Abotchie and Shokar (2009) study specified that 92.1% of

participants did not know there is a relationship between factors such as the Human

Papilloma Virus (HPV) and smoking with cervical cancer. Some participants in both

Mangoma et al. (2006) study and Abotchie and Shokar (2009) study did not know the

signs and symptoms of cervical cancer and the purpose of cervical cancer screening.

However, neither of the studies mentioned the number or percentage of

participants who had this knowledge deficit. Interestingly, participants in Abotchie

and Shokar (2009) understood that indiscriminate sex and multiple sexual partners

could lead to cervical cancer. Mangoma et al. (2006) study further identified other

features of the low level of knowledge, although these appeared to be more of

inadequate knowledge or understanding of the causes of cancer. Women perceived

cancer as dirtiness of the uterus caused by men through the accumulation of sperm

into them or through sexually transmitted diseases (STD) (Mangoma et al. 2006).

Some participants did not see the need for attending cancer screening or discovering

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their cancer risk or status as they believed that cancer is not curable (William et al. 2014).

Moreover, studies have found transcendent beliefs to influence peoples’ knowledge of

cancer and their attendance of screening intervention. A study by Kwok and Sullivan (2006)

was on the influence of belief systems on cancer screening behaviour of Chinese women in

Australia (n=20). The study observed that some participants’ viewed cancer as part of one’s

destiny supernaturally, and hence, any attempt to alter the process was not necessary.

Moreover, in Opoku et al. (2012) study in Ghana, some participants perceived cancer to have

an esoteric cause, for example, witchcraft. Consequently, some participants in Opoku et al.

(2012) study preferred reliance on God through prayers and Traditional Healers for treatment.

However, participants of Mangoma et al. (2006) study were interested in obtaining

appropriate information about cancer from a health professional if they were available. The

lack of comprehensive health information from qualified persons is a concern in Ghana and

most developing countries (Kingham et al. 2013, Anderson et al. 2011).

A few studies have underlined some of the sources of cancer information in Ghana

and Africa (Opoku et al. 2012, Abotchie, Shokar 2009, Williams 2014, Mangoma et al.

2006). All these studies identified the media (radio, television and newspaper) and traditional

healers (herbalists and spiritualists) as the source of public information on cancer. Mangoma

et al. (2006) study also identified family and friends as sources of information on cancer in

Africa. These sources of information differ from the developed countries where doctors, other

health professionals and reputable organisations and charities provide health information. The

diversity of information outlets in Ghana and the difficulty in verifying them is a challenge to

both patients and the public (Mangoma et al. 2006, Opoku et al. 2012).

However, a good understanding, cooperation and integration between conventional

practitioners and Traditional Healers can be an asset in disseminating health information to

the rural population in Ghana. Doctors in the Conventional Medical System can train and

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educate Traditional Healers about cancer and work with them to create the needed

awareness and raise the knowledge of cancer in Africa (O’Brien et al. 2012). Many

studies have identified cervical cancer as the most common cancer affecting women

in Ghana (Nkyekyer 2000, Nartey et al. 2016). Although cervical cancer is high in

Ghana, there is still low level of awareness and use of available prevention programs

because of social and psychological barriers in Ghana (William et al. 2014, Abotchie,

Shokar 2009, Williams 2014). All the three studies William et al. (2014) (n=220),

Abotchie and Shokar (2009) (n=140) and Williams (2014) (n=34) were similar in

their focus around exploring their participants' knowledge of cervical cancer

screening and the socio-cultural and psychological barriers or belief about cervical

cancer careening.

These studies (Abotchie, Shokar 2009, William et al. 2014) identified women

fear of being stigmatised as promiscuous to prevent them from attending cervical

screening clinics. In Abotchie and Shokar (2009) study, some women perceived the

procedure to be painful and could lead to the loss of their virginity and give others the

impression that they are promiscuous or without good character. Also, in both

Williams (2014) and William et al. (2014), most participants were concerned that the

procedure of cervical screening and other cancer screening programs would lead to

the invasion of their privacy which was culturally inappropriate, primarily if a male

doctor performed the procedure.

Similarly, women were afraid to ask their husbands for permission to attend

cervical cancer screening for fear that their husbands may react negatively to their

request (Williams 2014, Awusabo-Asare et al. 1993, Abotchie, Shokar 2009). In

William et al. (2014) study, some participants had concerns that they cannot have sex

with their husbands when they get cervical cancer and consequently be divorced and

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hence, they preferred not to know. The study by Awusabo-Asare et al. (1993) examined the

effect of social values on the vulnerability of women to HIV/AIDS in Ghana and identified

that most marriages or relationships are patriarchal in Ghana. The study concluded that

financial, socio-cultural and sexual emancipation for women was necessary for them to have

access to timely and appropriate treatment to illnesses.

Generically imposing health systems and practices from Europe and America are

unlikely to be useful or benefit some people in Ghana. Cancer awareness and education

programs should involve local stakeholders and focus on developing culturally friendly

programs (Opoku et al. 2012, Abotchie, Shokar 2009). Such a culturally friendly approach by

Government and relevant agencies can help to strengthen public knowledge through

education and increase their uptake of screening programs (Opoku et al. 2012, Abotchie,

Shokar 2009). Although the conclusions and findings of these studies are significant, they did

not focus on understanding peoples’ living with cancer’ motivations and experiences in using

Traditional Healers. Also, no theory currently exists in the literature that conceptualises the

experiences of people living with cancer in using Traditional Healers and their motivations to

do so in Ghana.

2.6 Summary of chapter and Research Question

This chapter shows how the choices of treatment and health-seeking behaviours in

Ghana are affected by different and complex factors such as socio-cultural, socio-economic,

spiritual and psychological. These elements act as barriers to accessing cancer prevention and

education programmes and awareness amongst the population. The review highlights the

importance of designing health programmes and system in Ghana in a manner that takes into

consideration the socio-cultural beliefs of the target populations or communities. Moreover,

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the literature review shows that people living with cancer use Traditional Healers or

Traditional Medicine more than the rest of the population across the globe.

However, there is a gap in knowledge and understanding of why people living

with cancer are using Traditional Healers or Traditional Medicine and what their

experiences are in the process as most studies have focused on barriers to cancer

prevention and screening programs. Some people living with cancer use of the

Traditional Healers even when they can afford Conventional Medicine or using

Traditional Healers alongside Conventional Medicine suggests a more profound and

complicated reason for people living with cancer use of Traditional Healers than we

currently know. Equally, studies have not focused on investigating and conceptually

understanding the experiences and motivations of people living with cancer in using

Traditional Healers in Ghana and elsewhere. Hence, no theory currently exists to

explain the socio-cultural dynamics between Traditional Healers and people living

with cancer and how such relationships influence people living with cancer decision

to use the Traditional Healers services

2.7 Research Aims

My study proposes to explore the reasons and experiences of people living

with cancer in using Traditional Healers in the Brong-Ahafo region of Ghana. Based

on the gaps in the literature and the purpose of the study, the following are the

research aims and research questions that I intend to answer. The broad aims of my

study are to bridge the identified gaps in the literature. The study intends to offer a

conceptual understanding and explanation of the experiences of people living with

cancer in using Traditional Healers in Ghana. Also, the study explores the dynamics

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and tenets of the relationship between Traditional Healers and people living with cancer and

how the relationship motivates patients to use Traditional Healers.

Moreover, my study will provide an understanding of the motivations, experiences,

and health-seeking behaviours of people living with cancer and give policymakers some

information in tailoring healthcare and cancer programmes in the rural communities in

Ghana. Furthermore, the study will contribute to the current body of knowledge and act as the

impetus for other students and academics to engage in similar studies in another setting to

create a more understanding of this phenomenon and lead to the possible development of

formal theory in future.

2.7.1 Research Questions

1. What are Ghanaian people living with cancer’ cultural beliefs and motivations for

using Traditional Healers or Traditional Medicine?

2. Why do people living with cancer combine Traditional Medicine with Conventional

Medicine?

3. What sociocultural beliefs and relationships enable the use of Traditional Healers?

4. What are the experiences of using Traditional Healers?

2.8 Overview of Theoretical Literature Review on Trust

The Constructivist Grounded theory methodology requires a final phase literature review

(theoretical review) which is conducted at the end or towards the end of a study to

contextualise the constructed grounded theory or conceptualised ideas concerning established

theoretical concepts or extend theories (current). This review is crucial in situating the study

within and across different disciplines and to compare the constructed grounded theory to

established theories and to highlight the contributions to knowledge (Bryant, Charmaz 2019,

Gibbs 2015, Charmaz 2014)

In this part of the literature review, I provide a theoretical review of the concept of

trust in help-seeking behaviours. I first highlight key definitions of trust, the importance of

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trust in society, and how trust functions to mitigate the complexities and

vulnerabilities in unforeseen situations. Also, I review trust as an interconnected

concept, comprising deference to authorities and identities (Kramer et al. 1996, Tyler,

DeGoey 1996, Tyler 2001), a reputation (Sztompka 1999, Misztal 2013, Ensminger

2001), encapsulation of self -interest, social coherence and stable systems of

language, and familiarity and habits (Misztal 2019, Misztal 2013, Heckscher 2015,

Sztompka 1999). Trust was found to be essential to my thesis as it was identified in

the literature and eventually formed the foundational identities of both participants

and Traditional Healers regarding help-seeking with symptoms and illness

experiences.

2.9 General Understanding of Trust

Trust is vital for human interaction, relationships, cooperation and smooth

functioning of both indigenous and modern societies (Misztal 2013, Luhmann 2018,

Cook 2001, Hosking 2014, Heckscher 2015, Bok 1979, Hirsch 2005, O'neill 2002).

Whenever trust is misplaced or abused, there is the possibility of destructive

consequences which may be perpetual or take longer to remedy (Hosking 2014;

Hardin 2006; Cook et al. 2005). The actors of trust are a trustor and trustee who

encounter each other in a situation or a relationship involving risk and uncertainty

about the future (PytlikZillig, Kimbrough 2016, Rousseau et al. 1998, Bacharach,

Gambetta 2001, Gambetta 2008). Trust can be conceptualised with regards to the

psychological state of vulnerability because of one’s willingness to place trust in

someone (Mayer et al. 1995, Fink et al. 2010, Rousseau et al. 1998, Möllering 2005).

Others see trust as the trustors' confidence in the trustee to fulfil an expectation

in the future or broadly consider the trustor’s interest in an intended action (Luhmann

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2018, Misztal 2013). Trust within the healthcare setting conveys patients’ confidence in the

health systems or professionals to function in their best interest or fulfil their expectation

(Hall et al. 2001, Thom et al. 2004, Lord et al. 2012). Patient’s trust is usually in the

behaviours and attributes of health professionals such as their technical and interpersonal or

relational competence, and fiduciary obligations (Thom et al. 2004).

Similarly, Dugan et al. (2001) identified fidelity, confidentiality, honesty and

competence as the main conceptual domain of analysing trust in healthcare. Also, other

definitions of trust focus on the generalised or innate disposition of individuals or people to

do the right thing (Messick, Kramer 2001, Kramer et al. 1996). Some people consider the

work of both the Conventional Health Professional and Traditional Healers as a vocation or a

“calling’’ and hence trust these practitioners because of their innate inclination or

characteristics to do the right thing (Messick, Kramer 2001, Heckscher 2015, Goffman 2017,

Goffman 2010). The different conceptualisations of trust had led to some authors describing

the domain of trust or signals of trustworthiness as a broad spectrum of processes

incorporating various trusting views, linguistic variables and historical and socio-cultural

context (Bacharach, Gambetta 2001, Hampshire et al. 2017, Hosking 2014, PytlikZillig,

Kimbrough 2016, Heimer 1999).

Primarily, trust in someone can explain trust as a feeling, attitude, disposition and

relationship relating to behaviour and actions, or the potential in a dynamic socio-cultural or

relational context (PytlikZillig, Kimbrough 2016, Hosking 2014). Consequently, the varying

signals of trust reflect the different community or sociocultural context and would continue to

vary over time. The complexities, risk and uncertainty in health care decisions can become

overwhelming, especially for illiterate and impoverished indigenous communities who may

have limited access to information or the understanding of it (Northouse, Northouse, 1998,

Berry 2006).

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In other words, for patients who have low health literacy or unable to

understand and act on medical advice as often in unforeseen situations, trust is

necessary to simplify, reduce complexities and vulnerabilities (Hardin 2006,

Luhmann 2018, Misztal 2013, Cook 2001) and increase the propensity or justification

to act without necessarily eliminating all the risk from the trustee’s behaviour (Misztal

2013, Heimer 1999, Hardin 2006, Dodd 1994). Most of my study participants were

vulnerable by the very nature of their condition and had tremendous anxiety regarding

the outcome or consequences of their illnesses and thus relied on trust in dealing with

these situations.

According to Heimer (1999), traditional communities usually focus on

reducing uncertainty about the intentions and competence of others by focusing on

habits and specific behaviour and values which the community expects every member

to comply. In contrast, modern societies have the unavoidably intense and regular

contact with strangers and hence focus on vulnerability reduction through schemes

such as insurance, contracts, legal certification and accreditation (Heimer 1999)

Although trust is an essential aspect of society, there is a general

acknowledgement that trust carries the risk of uncertainty and disappointment to

trustors as they may not realise their hopes. Some authors describe the risk of

uncertainties and disappointments as the problem of trust regarding the difficulty in

identifying the right people to trust or the correct signals of trustworthiness in others

(Gambetta 2008, Bacharach, Gambetta 2001). Inadequate and deficiencies in

communication and interpretation make it difficult for anyone who engages in trust to

assess or achieve the full motives, potential actions and possible responses of trustees

to changes or contingencies (Coleman 1994, Bacharach, Gambetta 2001, Gambetta

2008). Hence, it is always possible for an opportunist who can learn to mimic the

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attributes and characteristics of trustworthiness in a society or organisation to achieve their

interest (Bacharach, Gambetta 2001).

In the same manner, people can deceive their trustors by signalling certain behaviours

of someone who has a reputation in order to influence the trustors’ confidence in them

(Bacharach, Gambetta 2001). In such circumstances, it is challenging for the trustor to know

whether the signals exhibited by the trustee are genuine or intended to deceive (Hampshire,

Hamill et al. 2017, Bacharach, Gambetta 2001, Gambetta 2008, Cook 2001). Also, in some

situations, a failure of the trustee to function as deemed appropriate can even leave the trustor

in a worse off situation than before and highlights the inherent risk of believing that another

person would act in our interest or behave appropriately (Faulkner, Simpson 2017).

Moreover, in relationships in which there is a power imbalance, it is difficult to assess

whether the trust is genuine or not as the trustor may not have any opt-out options. Hence, the

trustor may act in a specific manner from fear and unable to hold the trustee accountable for

their actions (Cook et al. 2005, Hardin 2006, Bacharach, Gambetta 2001, Heckscher 2015)

2.10 Conceptualising Trust as Interconnected Self-Interests

Trust is defined as encapsulated or interconnected self-interest in which the trustor

assumes that their interest is interconnected with the trustee’s interest. Hence, the trustor's

actions are influenced based on the conviction that the trustee would look after their interest.

Conceptualising of trust in this manner is relevant in situations in which we believe

that it is in the trustee’s best interest to fulfil our expectation or consider our interest in their

actions (Hardin 2006, Cook 2001). The interconnection of interest may be subtle to the extent

that the trustee may not even be aware that they are fulfilling their interest by considering the

interest of the trustor. The encapsulated interest exists in situations in which the trustor has

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enough information or have enough knowledge to judge the trustworthiness of the

trustee (Hardin 2006).

Nee and Sanders (2001) proposed that trust in ethnic ties and community

identities are often the de facto position for people when they face uncertainty or

contingent situation of the familiar and unfamiliar. The hypothesis they put forward is

that co-ethnic relationships are incentives for the trustee to fulfil the trust obligations

bestowed on them by the trustor. Typically, people who have a closer sense of identity

are more likely to be interested in being trustworthy than a stranger, as they want to

avoid the intrinsic and informal sanctions of risk in an ongoing relationship. The cost

of betrayal of trust in such relationships would not affect only the trustor but also the

trusted party (Coleman, 1988, Nee, Ingram, 1998).

The criticism of the encapsulated interest trust conceptualisation is that it may

not always indicate a trusting relationship, but instead, a committed relationship in

which one actor can take undue advantage of the other or the situation (Nee, Sanders,

2001). Close community networks, traditions, neighbourhood relationships and

identities influence and strengthen the concept of encapsulated interest relationship

between most indigenous Ghanaian communities in general (Utley 2016, Hardin

2006).

2.11 Trust as Deference to Authority

Peoples’ identification with a group, community or authoritative figure

increases their propensity to trust others in the same group (Tyler, Dawes 1993,

Dawes et al. 1990, Tyler 2001). Tyler (2001) described such trust as social trust,

which develops from socio-cultural bonds, identities or identification within human

institutions and societies. Equally, others see such trust as an in-group dynamic in

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which members favour or trust their in-group by having the right attitude, behaviour and

perception about them (Kruglanski, Higgins 2007, Brewer 2007, Turner et al. 1979, Tajfel,

Turner 1986, Tajfel 2010). The commitment and deference of trust to a group or a group

authority facilitate the dynamics of groups or social relationships, identity formation and

validation (Tyler, DeGoey 1996, Tyler 2001, Braithwaite, Levi 2003, Adjei 2013).

In indigenous communities, members who have traditional positions, roles and

symbolise any dimension of the ancestral tradition are trusted by the rest of the population to

have moral values. Such trust facilitates voluntary respect and commitment to these members

or authorities and their decisions. Hence, deference trust is usually the attribution to the

motives and intentions of groups or authorities (Tyler, 2001, Heckscher, 2015) to

benevolently act towards the general wellbeing of the trustor in decisions (Tyler 2001,

Heckscher 2015, Abrams, Hogg 2006).

In such situations, the assumed trustworthiness of the motives of authorities or

traditions becomes the crucial factor under consideration and not necessarily evidence of any

concrete outcome. However, there is no suggestion that people arbitrary trust in authorities

and identify with groups. Instead, the authorities must exhibit the right attitude and standards

of their status. There are concerns that deference to socio-cultural group identities or

identification and authorities can create favouritism towards group members while delimiting

outsiders (Kruglanski, Higgins 2007, Brewer 2007, Turner et al. 1979, Tajfel, Turner 1986,

Tajfel 2010).

Another criticism of a deference trust is the notion of apprehension and entrapment

through totally depending and becoming servitudes to those who are considered trustworthy

in the group and ethnic authorities (Nee, Sanders, 2001). Consequently, trust as deference to

authority is not devoid of the potential distrust from the possibility of duplicity by

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opportunists who may use their positions for unwarranted privileges to take advantage

of vulnerable or ardent members (Nee, Sanders, 2001).

2.12 Trust in Reputational and Good Behaviour Characteristics

Reputational trust depends on the past deeds that people can access through

information, or the trustors’ familiarity and encounter with an organisation, institution

or an individual (Good 2000, Layton 1971, Misztal 2013, Ensminger 2001, Sztompka

1999). Heckscher (2015) described indigenous communities as thick societies which

are tightly knit and in which people closely interact, encounter and know each other.

In such communities, there is the opportunity to access the reputation and

performance of other community members to facilitate the decision to confer trust in

others or not. In contrast, assessing the reputation of people in modern and

sophisticated societies is done through reviews, publicly available collective

knowledge and regulatory bodies (O'neill, 2002, Heckscher, 2015).

In general, people are more likely to believe in the reputation that they can

link to a profession, category or a collective identity than the individual as the former

is more simplified and manageable (Frowe 2005, Bacharach, Gambetta 2001,

Gambetta 2008, Heckscher 2015). Trust in the collective or categories are easy to

manage because of specific standardised reputational characteristics and behaviours

that may define the group (Brewer 2007, Tajfel 2010, Tajfel, Turner 1986).

Respectively, reputational trust can be presented or expressed through appearance and

demeanour of good manners and behaviours which may reveal the identity,

personality, status or professional groups (Giddens 1991, Dasgupta 2008, Bacharach,

Gambetta 2001).

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In general, Traditional Healers in Ghana learn the values and cultures of behaviour

including the culturally appropriate demeanours such as calmness, patience and resilience in

a stressful and demanding situation which reflect the indigenous socio-cultural and traditional

propriety. However, both collective reputational and appearance trust can be misleading as

individuals can hide behind such a reputation or appearance to act up (Luhmann 2018,

Misztal 2013, Sztompka 1999). Equally, there is always the possibility of mimicry and

pretence of the reputational qualities and characteristics by opportunists or confident

tricksters who have different motives from a group or a community (Dasgupta 2008,

Bacharach, Gambetta 2001, Good 2000, Yeboah 2000, Ensminger 2001).

2.13 Endurance of Community Norms and a Generalised Culture of Trust

Traditional communities assert collective values and trust in their members through

norms of reciprocity, traditions, history and intimately engaging networks (Putnam et al.

1994). The enforcement or binding nature of these elements in indigenous communities and

subscription to a shared moral authority create coherence and order which equally influence

identity trust formation (Sztompka 1999, Heckscher 2015, Kramer et al. 1996, Tyler, Huo

2001, Tyler 2001, Tyler, Blader 2013). The shared ancestral traditions and socio-cultural

morality or values in most Ghanaian communities normatively bound members as the

foundation of their behaviours and identities that can be trusted. Furthermore, in traditional

societies, regular or repeated social order (social stability) is an active ingredient in signalling

trustworthiness (Goffman 2017, Heckscher 2015, Luhmann 2018, Sztompka 1999)

Primarily, the stability of tradition and culture, long-lasting, persistence and

continuity of networks and encounters provide some certainty and reliability for trust.

Generally, tradition and culture act as anchorage of trust or trustworthiness because of their

centrality to the continuity of identity and acting as a springboard for other forms of trust

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(Giddens 1991, Sztompka 1999, Smith et al. 1982, Hamer 1994). Tradition

encourages trust and trustworthiness through patterning and repeating of practices

(Misztal 2013), reducing irregularities through the summation of distinct values which

facilitate comprehension and continuity of historical experiences (Misztal 2013,

Sztompka 1999, Fentress, Wickham 1992). However, the stability of tradition does

not imply only completely inert societies signal trustworthiness or to say that

communities lose trustworthiness or trust because of a social transition (Giddens

1991, Sztompka 1999).

In contrast, modern societies can undergo changes and development regularly

and at a drastic pace, requiring more than tradition and culture to maintain social

order, stability and reliability (Oneill 2002, Heckscker 2015). Equally, the values for

maintaining trust in modern societies are different from those in traditional

communities and centre on interactive sensibility and civic engagement such as

civility, tolerance, integrity, reasonableness, multiculturalism, inclusiveness and

equality (Misztal 2013, Gambetta, Hamill 2005, Anderson, 2013, Heckscher 2015)

Hence, in modern settings, normative stability and continuity of social order require legally

recognised systems, reputational measurements, a set of private and public institutions,

professional bodies, contracts and plethora of information to ensure cooperation and trust

(Hosking 2014, Putnam et al. 1994, Heckscher 2015, Knight 2001). These institutions have

the power to outlast socio-political transitions and regimes usually. The effective functioning

of the law and these institutions are the pointers and enforcers of an order of stability in

modern societies (Cook 2001, Hardin 2006, Sztompka 1999, O'neill 2002).

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2.14 Trust as a System of Language and Communication

The Communication Accommodation Theory (CAT) provides a broad framework

which offers an explanation and prediction of the possible alteration we make in creating and

maintaining social distances in community and social interaction using language (Giles, Ogay

2013). According to the CAT, communication, or language is not devoid of a socio-cultural

and historical context in which communities or individuals exist (Garrett 2010, Giles, Ogay

2013). Although personal identities influence communication in individual encounters, there

is the evidence that entirety of both the verbal and nonverbal aspects of even individual

interaction is dominated by sociocultural and community identity of the person (Giles, Ogay

2013).

The theory explains the relational and identity processes in communication and

language interaction (Coupland, Jaworski 1997), including non- verbal communicative

symbols of a socio-cultural group (Giles, Ogay 2013). Similarly, Tracy (2013) described

language as a codified abstract or systematic knowledge that represents something deeper or

substantial than their verbal expression. Equally, language can be used to show the lack of

trust, identification and social distances or divergence with a group or community.

Furthermore, Luhmann (2018) discusses language and communication as a powerful tool

which can be used to regulate identities, statuses, choices and distances in communities and

fundamentally affect interaction and trust. In this sense, language becomes a medium for

creating, maintaining and changing power base into action (Reid, Ng 1999).

Groups and social hegemony turn to be accompanied by linguistic dominance and

style, which, when used continuously, can simplify the power of other groups and lead to

mistrust. Language depoliticises and harmonises power through the deceptive act of covering

up and justifying power through the strategic use of language. While the powerful employ

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language to maintain and sabotage any act of power or opposition, the powerless

equally use language to gain power or challenge those with higher powers (Reid, Ng

1999). In this sense, there is a power display and dynamics in the anger,

dissatisfaction and resentments that may exist in therapeutic and health care

relationships.

The link between language and power highlights the capacity of language or

linguistics to isolate or include people, raise the social barriers to interaction and

create a sense of exclusion (Giles, Ogay 2013, Garrett 2010, Luhmann 2018, Reid,

Ng 1999). The exclusions, barriers and inequalities created by language can lead to

those who perceive themselves to be victims to frown on the powerful with distrust

and scepticism. People can, therefore, perceive language as common grounds,

leverage or empowerment in their relationships with others and the basis of trust. In

contrast, unfamiliar language can make people feel afraid, dominated and unable to

trust others.

2.15 Trust as Familiarity and Habits of Communities

Furthermore, a key element in estimating the trustworthiness of others is

familiarity (Heckscher 2015, Sztompka 1999, Luhmann 2018, Bacharach, Gambetta

2001) with either the socio-physical environment or relationships and encounters.

People are likely to trust others in the environment that they feel comfortable and

familiar with people whom they have a close association or share relationships. In

effect, familiarity breeds trust (Giddens 1991, Giddens 1990) through the sense of

security, certainty, predictability and positive expectation. Familiarity creates the

opportunity for actors to know each other and to form an opinion about each other.

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Many Ghanaian trust Traditional Healers and people from their communities because of their

familiarity with them.

Similarly, trust relationships and accountability, blossom in communities which have

relatively persistence interaction, re-encounters and mutual dependence (Luhmann 2018).

From this perspective, some authors conceptualise trust relating to familiarity and trusting in’

’habits’’ as identical (Misztal 2013) Trusting in “habits” is a disposition that offers

predictability, provides security, continuity and strength to face uncertainties and

complexities of social life, particularly in vulnerable and unsettled situations (Misztal, 2013,

Durkheim, 2012, Gulati, 1995, Gilson, 2006, Wuthnow, 2004, Misztal, 2019, Latour, 2013).

Like familiarity, prior knowledge and occurrences build habits which are employed to

alleviate the risk in handling contingencies (Misztal 2019, Misztal 2013). Indigenous

communities usually rely on their past and the shared understanding of the traditional system

and their prior knowledge to trust each other and to distrust the unfamiliar and cumbersome

situations.

2.16 Summary

The chapter provided an overview regarding the importance and conceptualisation of

trust in societies and the therapeutic encounter. It also highlighted the complex facets of risk

and vulnerability, when making health decisions and how trust functions to bridge the gap

and make it easier for people to act and make health decision. The chapter has discussed

some of the theoretical frameworks of trust that are relevant to my study.

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CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGICAL CHOICES

3.1 Chapter Overview

The chapter primarily is divided into three parts. In keeping with Constructivist

Grounded Theory (CGT), the chosen methodology for this study, I have attended to

reflexivity in these parts (See Chapter 1.7: pre-field reflexivity, 3.19: in-field

reflexivity and 3.26: post-Field reflexivity ). The first part (3.2-3.6), I deal with

methodological concerns. I give an overview of the relevant paradigms associated

with Grounded theory (Interpretivism, Constructivism, Constructionism, Symbolic

Interactionism and Pragmatism) and more specifically, the Constructivist Grounded

theory (CGT) methodology. Also, I give an overview of the selected Grounded theory

methodology over other comparable methodologies that could have been used for the

study (Ethnography and Phenomenology). Additionally, the first part of the chapter

describes the process of choosing Constructivist Grounded theory and the rationale

for choosing it over the Glaserian and Straussian approaches. The second part of the

chapter (3.7-3.19) discusses the study methods, including the critical elements of the

Constructivist Grounded theory method, ethical considerations such as seeking

approval, and how relevant accesses were negotiated and the cultural challenges to

consenting study participants. This part also considers my approaches to recruitment

and data collection (Interviews and Observation). The third part of the chapter (3.20-

3.26) is where I describe the methods of analyses of the data and the development of

categories, leading to theory development.

3.2 Choosing Interpretivism Approach over Positivism

A theoretical or philosophical paradigm serves as the premise that provides a

framework, justification and a guide for academic pursuit and acquisition of

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knowledge through empirical evidence (Strauss, Corbin 1998, Guba, Lincoln 1994, Kuhn

1970). In social research, a paradigm is seen as interrelated shared worldviews, beliefs and

values that guide research approaches (Schwandt 2001, Crotty 1998). There are diverse types

of paradigms or theoretical assumptions which are a continuum between the positivists and

subjective approaches with positive-objective and the interpretive framework views at their

extremities (Charmaz 2014, Denzin, Lincoln 2011, Orlikowski, Baroudi 1991).

The purpose of my study was to explore participants' subjective interpretation and

construction of the phenomenon through language and interaction. Such interpretation

provides an understanding of participants’ motivations and experiences of using Traditional

Healers in Ghana. An interpretive or qualitative methodology was suitable because it allows

participants with specific and relevant experiences to share their stories (Elster 2015, Willig

2013, Cohen et al., 2011). Similarly, an interpretative methodology allows participants to

express the meanings behind their behaviours and actions (Elster 2015, Willig 2013, Cohen et

al., 2011). Contrary, Positivism which disregards subjective phenomena such as beliefs,

values, and experiences underlying human behaviours would limit my understanding of

participants’ motivations and experiences and the socio-cultural context of the participants’

actions (Gray 2013).

However, some people criticise the qualitative approaches for their lack of objectivity

and generalisability (Creswell, 2017, Denzin, Lincoln, 2011). However, interpretive studies

are not concerned with generalisation or validity but with credibility and transferability and

an in-depth understanding of issues within their social context (Charmaz 2014, Creswell

2012, Yardley 2000, Noble, 2015). Furthermore, the positivist (empiricism), assumes the

existence of an objective, single reality independently of human perception or interaction

which the researcher can discover, measure or characterise (Denzin, Lincoln, 2011,

Thompson, 2000). Thus, the researcher can explain the behaviour of humans through the

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application of rigorous and systematic procedures of scientific methods of inquiry

(Crotty 1998) of generating and testing hypothesis (Macionis, Gerber 2010, Bowling

2009, Lincoln et al. 2011).

Positivism views the researcher as an independent, neutral or value-free

individual, separate from the influence of social interactions and context of research

(Macionis, Gerber 2010; Bowling 2009; Lincoln 1994). In contrast, the interpretive

paradigm postulates the position of multiple realities and social construction and

subjective interpretation of participants and the researcher (Denzin, Lincoln 2011;

Creswell 2012). My study data and findings are one story or perspective of the reality

that exists. The interpretive paradigm, unlike positivism, acknowledges the centrality

and criticality of a value-laden researcher and their interaction with participants and

the social context (Creswell 2012).

3.3 The Influence of Constructivism, Social Constructionism and Symbolic Interactionism on

Constructivist Grounded Theory (CGT)

The interpretive epistemological paradigms of Constructivism and Social

constructionism influences Constructivist Grounded theory methodology (Creswell

2012). Broadly, the literature uses these epistemological approaches interchangeably

(Denzin, Lincoln 2011, Creswell 2012, Charmaz 2014, Lincoln et al. 2011, Mertens

2014). Constructivism focuses on the individual learning and assumes reality to be an

individual construct, created by an individual’s knowledge and experiences within the

real world (Denzin, Lincoln 2011, Lincoln et al. 2011, Mertens 2014, Guba, Lincoln

1994). Constructivism emphasises on how we develop meaning from what we know

based on individual learning within a social setting (Thomas et al. 2014, Young,

Collin 2004).

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Ghanaians are familiar with symbolic, cultural and historical strands and attach

meanings and interpretations to them. They also talk about the relevance of their ancestral

history and how Traditional Healers are part of the cultural quintessence of the symbolic

depiction of the ancestral moral framework. Social constructionism focuses on the social

processes, actions and interactions, their historical context, and how they influence

knowledge and meaning construction (Thomas et al. 2014, Young, Collin 2004). The use of

language and Symbolic Interaction help humans to dynamically and flexibly seek knowledge

and adapt to the relevant context. Consequently, a person can develop multiple realities at

separate times and contexts based on social needs and interactions.

The Constructivist Grounded theory methodology, with its emphasis and

underpinning Symbolic Interactions and social context, blurs the boundary between

Constructivism and Constructionism even more (Charmaz 2014). Symbolic Interactionism

and Pragmatism have a tight bond and application with Constructivist Grounded

methodology (Milliken, Schreiber 2012, Lomborg, Kirkevold 2003, Chamberlain-Salaun et

al. 2013). Pragmatism relies on practical consideration of problem-solving and what works

best rather than theoretical concerns (Mounce 2000, Charmaz 2014). Thus, Pragmatism

emphasises the importance of values of theories and beliefs on the effectiveness of their

practical application or usefulness (Mounce 2000, Charmaz 2014). The theoretical

perspective of Symbolic Interactionism with its pragmatic philosophical root views human

beings as active agents. As active agents, they interact with their world to produce multiple

realities and not passive recipients of larger social forces (Charmaz 2014, Corbin, Strauss

2008).

The theory in this study is not a representation of the only reality but a product of the

practical values and meanings that myself and participants gave to situations, experiences and

interactions in the context of the study. Essentially, Pragmatism encourages subjectivity of

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meaning, human agency, emergent process of actions and interaction to grounded

theory and not structures (Charmaz 2014, Corbin, Strauss 2008). Symbolic

Interactionism adheres to the notion that we construct society, self and reality through

the interpretation of language, interactions and symbols (Charmaz 2014). Also, the

inherent dynamic interpretation of interactions and language means people can change

the meanings they assign to symbols and interactions (Dennis, Smith 2015, Handberg

et al. 2015, Charmaz 2014).

The findings of the study are some perspectives of reality which were a

product or a constructed view of both I and participants experience during interactions

and associated meanings we assigned to language (Charmaz 2014, Handberg et al.

2015, Dennis, Smith 2015, Atkinson et al. 2007). The premise of Symbolic

Interactionism is that human action always occurs in a situation that confronts an

actor and that the actor acts to define or assign meaning to the confronting situation

based on their experience. Therefore, Symbolic Interaction stresses the importance of

the meanings people give to their activities or experiences through the interpretation

of actions, interactions and symbols in contrast to deterministic explanation to human

conduct (Dennis, Smith 2015). The knowledge that this study generates is temporal

and contextual, my interpretation and conceptualisation of the meaning that the

researcher believed participants gave to the situation. Hence, the study intended to

offer a fresh or a new perspective or theory to the phenomenon of using Traditional

Healers rather than offering absolute explanatory categories and outcomes (Dennis,

Smith 2015, Charmaz 2014, Atkinson et al. 2007).

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3.4 Choosing Grounded Theory (GT) Methodology

I chose Grounded theory methodology, specifically the Constructivist version

because of its suitability to respond to the nature and aims of my study, the research

questions and congruence with my philosophical, ontological and epistemological

assumptions. The phenomenon of my interest shaped the selection of Grounded theory and

the Constructivist approach as the methodological choice. Some authors describe these

choices as a fit or coherence between the researcher and their chosen methodology or method

which makes it easy for the researcher to justify the methodology by enjoying and engaging

with the study (Walsham 2006). Thus, the research aims guided the selection of the

methodological approach (Glaser 2004). I did not just say yes to my biases or indicted any

methodology but instead examined their suitability and possibilities for the nature of the

study and in answering the research questions.

The study followed an inductive and emergent ground-up approach rather than

imposing or handing down any pre-existing theory onto the study (Urquhart 2013, Creswell

2012, Gibbs 2015, Charmaz 2014). Such an approach is consistent which with Grounded

theory or Constructivist Grounded theory approach. Also, the findings from the literature

review indicated the suitability of using a qualitative approach in exploring peoples’

motivations, experiences and interactions. The qualitative methodology had been used in the

past to study peoples’ health-seeking behaviours, and factors influencing health decisions or

choices.

Moreover, Grounded theory (Constructivist Grounded theory) examines and explores

actions, social processes and structures through interaction, and how those interactions

influence events and activities (Corbin, Strauss, 2008, Charmaz 2014). I intended to

understand why most patients with cancer use Traditional Healers in the Brong-Ahafo region

of Ghana and the processes involved in these practices and how they influence health-seeking

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activities. Grounded theory was suitable in exploring and examining participants’

health-seeking behaviours, motivations, and experiences in using Traditional Healers

in a sociocultural, historical and economic context to provide a broad view of the

phenomenon.

Additionally, Grounded theory (Constructivist Grounded theory) was more

suitable for my study in exploring realities created by individual subjectivities and

inner worlds. These were then raised analytically through data analysis to try and

understand the core dimensions present in these individual realities (Glaser 2002).

The underlying position of my study was that the concept of reality is not sealed or

watertight but continually changing. These changes are due to the influences of

changing groups or individual encounters, social interactions, and dynamic settings or

context. The reality of the study was construction or understanding of meanings and

interpretations that participants assign to the situation or the phenomenon under

investigation.

Furthermore, Grounded theory (Constructivist Grounded theory) was suitable

for my study as the primary purpose was to develop a substantive theory and

conceptual understanding of the participants’ experiences. Thus, the conceptualisation

of participants experiences as it was best fitting to the data or emergent from it, which

is not usually the focus of other qualitative methodologies (See Table 2 in this

chapter: summary of methodological relevance to theory development). Grounded

theory (Constructivist Grounded theory) captures individual participants’ subjective

experiences, motivations and subjectivities of their use of Traditional Healers. The

participants’ accounts are then raised to analytical level through data analysis,

interpretation and provide a theoretical understanding and explanation of the realities

of the phenomenon.

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Although a qualitative approach like Ethnography and Phenomenology can be

relevant in carrying out the study, I did not find them appropriate. In choosing to use

Grounded theory (Constructivist Grounded theory), I was concerned with the flexibility to

access relevant data from any person or individual with the experience of the topic of interest

(Corbin, Strauss 2014, Lambert et al. 2011). Ethnography focuses on understanding or

describing the cultural meanings of a phenomenon and employs an observational approach

using thick description for data collection. Hence, I did not consider ethnography as the most

appropriate methodology to give me the flexibility and provide a holistic view of the

dynamics of participants experience and motivation, including their socio-cultural and

historical context.

Similarly, Phenomenology is not concerned with conceptualising experiences but

instead looks at the commonalities or essence of an event or phenomena and describes them.

Although phenomenology equally would have enabled me to gain insight into participants’

experiences or their world, the outcome would not be a theory development (Creswell 2012,

Charmaz 2014, Gerrish, Lacey 2010). The table below is a summary of the relevance of

comparative methodology in theory development and how Grounded Theory was selected as

the most suitable.

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Table 2 Methodological Relevance to Theory Development (Goulding 2005, Starks, Trinidad

2007)

Characteristics Phenomenology Ethnography Grounded Theory

Focus Understanding the essence

of the experience.

Describing and

Interpreting a culture

sharing group

Developing a theory grounded in

the data from the field.

Kind of Problem suited

for the design

Needing to describe the

essence of a lived

phenomenon.

Describing and

Interpreting Shared

patterns of the culture

of a group

Grounding theory in the views of

participants

History or Discipline

Background

Drawing from philosophy,

psychology and Education

Drawing from

Anthropology and

Sociology

Drawing from Sociology

Unit Of analysis Studying several individuals

who have a shared

experience

Studying a group that

shares the same culture

Studying a process, actions or an

interaction involving many

individuals in a context

Study Aim: Developing

Theory to represent

Participants experience

Gain Insight into participant

Worldview. Development of

a theory is not an outcome

Depends on existing

theories to explain a

phenomenon

The primary outcome is towards

theory development. Appropriate

for developing a theory

representative of participants

experiences

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3.5 Choosing the Constructivist Grounded Theory (CGT)

3.5.1, Brief History of Divisions in Grounded Theory (GT)

The founders of Grounded theory, sociologist Barney Glaser and Anselm Strauss

entered the methodological debate with a successful collaborative seminal work on death and

dying in hospitals and subsequent publication “The Discovery of Grounded Theory:

Strategies for Qualitative Research (Charmaz 2014, Charmaz, Mitchell 2007, Howard-Payne

2016, Glaser, Strauss 2009). The timing of their work and entry to the methodological debate

was critical, especially at a time when qualitative research was losing ground to the positivist

conception of objectivity, generality, and replicability of research and falsification of

competing theories and hypothesis that included quantitative approaches (Charmaz 2014,

Charmaz 2012, Gibbs 2015).

However, Glaser and Strauss refocused qualitative inquiry to an analytic level through

explicit codification and systematic analyses of qualitative data. They encouraged the

development of theories (substantive or theoretical understandings) grounded in data. Soon

after developing Grounded Theory, Strauss and Glaser were contending on their differences

of opinion and position on realism which led to their separation (Howard-Payne 2016).

Strauss went on to work with Juliet Corbin (Strauss, Corbin 1998, Strauss, Corbin 1990,

Strauss, Corbin 2012, Corbin, Strauss 2008). Strauss came from a pragmatic and social

interactionist (interpretive) background and focused on human agency, emergent processes

and subjective understanding to Grounded Theory (Charmaz 2012; Charmaz 2014). In

contrast, Glaser focused on systematic structures, rigorous codification, empiricism and

discovery, a reflection of his quantitative leaning (Charmaz 2012; Charmaz 2014).

Kathy Charmaz, a former student of both Glesser and Strauss at the University of

Chicago (Kenny, Fourie 2015), forged a departure from both Strauss and Glaser. Charmaz

developed a more pragmatic version of Grounded Theory that brought an emphasis on

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Constructivist and Constructionist approaches into Grounded Theory. These divisions

lead to three main approaches of Grounded theory which are the Constructivist (CGT)

approach, Classic or Glaserian and Straussian approaches. Constructivist Grounded

Theory (CGT) differs from the Straussian and Glaserian approach at the philosophical

and ontological level, use of literature, data analysis and coding practices.

3.5.2 Classic Grounded Theory: The Glaserian Approach

The Glaserian version of Grounded Theory is central and indispensable to data

(Glaser 1992, Glaser 2004, Glaser 2001). Glaser views everything concerning the

phenomenon under investigation as data (all is data) and hence applies loose data

analysis, which will allow the natural emergence of theory from the data. The

researcher assumes the position of an independent or neutral observer who

conceptualises data without taking an interpretive stance, indicating a robust

Positivist-Objectivist leaning (Glaser 2009, Martin, 2006). Glaser alludes to the

possibility of understanding reality from the data without considering the context

(Sosa 1993, Howard-Payne 2016, Charmaz 2014).

Hence, Glaserians treat data as real or objective facts that contain the theory that the

researcher can discover independently of their interaction with participants (Charmaz 2014).

Glaser insists that while employing the coding procedure, the researcher should patiently

“trust that emergence will occur, and it does (Glaser 2007, Glaser 1992, Glaser, Holton

2004). Researchers are to ask a series of questions of concerns to participants in the data and

then look for accounts that resolve the concerns (Glaser 1992, Glaser, Holton 2004). Glaser

developed a system of dealing with the human tendency and inevitability of inadvertently and

unconsciously introducing personal bias or interpretation. Glaser does this by alluding to

careful and rigorous coding procedure, constant comparison, restraint from the literature and

extant theories and collection of a large volume of data from multiple sources (Kenny, Fourie

101 | P a g e

2015, Glaser 1992, Glaser 2004). These premises, he argues, will correct bias and diminish

any personal input or influence of the researcher on the theory and help uncover underlying

patterns of the phenomenon and make data objective (Glaser 2004). However, I rejected the

Glaserian approach because of the over-emphasis on the emergence of the theory and

researcher neutrality.

The limiting of any researcher input is not corresponding to my ontological and

epistemological persuasion about reality and knowledge. Again, the naturalistic approach

supports the use of unstructured interviews and opposes the use of interview schedules in

collecting data (Glaser 2004). Hence, using the Glaserian approach would have denied me the

flexibility and possibility to clarify issues with participants, probe for more responses, and

elaboration and steer the interview to the point of theoretical interest (Charmaz 2014).

Equally, it was not practicable for me not to be exposed to the literature or extant theories

until the end of the study as the university required extensive literature review and

submission of proposal and application for ethical review and the transfer viva.

3.5.3 Straussian Grounded Theory

Although Strauss had some positivist learnings, he acknowledges the relationship

between concepts and Symbolic Interaction and positions Grounded theory as a way of

interrogating data (Strauss, Corbin 1990, Strauss, Corbin 1998). Since these publications, the

position of Strauss and Corbin has shifted towards the pragmatic realism position (Howard-

Payne 2016, Sosa 1993). The pragmatic realism position places reality in settings or contexts

and the possibility of multiple realities and co-construction of data (Howard-Payne 2016,

Strauss, Corbin 2012). To this effect, the revised position of Corbin, a comrade of Strauss,

brings her closer to the Constructivist interpretive theorising perspective (Howard-Payne

2016, Corbin, Strauss 2012, Strauss, Corbin 2018, Corbin et al. 2014, Kenny, Fourie 2015).

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However, the highly systematic and rigorous coding structures intended to

create (not discover) a meticulous theory closely corresponding to data still espoused

objectivist stands (Strauss, Corbin 1990, Strauss, Corbin 1998). The robust and

systematic procedure mostly follows the same sequential progression as Glaser but

more meticulous and specified (Strauss, Corbin 1990). The Straussian position has

more in common with the Constructivist approach, the version of Grounded Theory

that I used for this study. However, the Straussian approach does not provide enough

subjectivity and flexibility in data analysis and theory development and was not

suitable for my study. Also, I do not allude to the objectivist view of data. Instead, I

see the whole research process as co-constructed.

3.5.4 Constructivist Grounded Theory (CGT)

The choice and interest in Constructivist Grounded Theory methodology were

guided primarily by the research questions and the nature of the study to explore and

understand the experiences and motivation in patients with cancer in using Traditional

Healers in a socio-cultural context. Also, I found the Constructivist Grounded Theory

methodology to be more dynamic and contemporary, offering a systematic but

flexible perspective and approach in responding to the challenges in the field.

Constructivist Grounded Theory emphasises the co-construction of data and open

acknowledgement of subjectivity and open reflexivity, which are corresponding to my

philosophical assumptions. The flexible approach of Constructivist Grounded Theory

also makes it ideal for studying a new terrain and gives the researcher room to work

with what may be available and what participants may be willing to share.

The Constructivist Grounded Theory lays stronger emphasis on co-

construction of knowledge or the shared reality between researchers and research

participants through social interaction (Charmaz, Mitchell 2007, Charmaz 2014,

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Altheide, Johnson 1994, Guba, Lincoln 1994). The co-constructionist acknowledges that

knowledge and understanding of reality are products of society (Orlikowski, Baroudi 1991).

Apart from considering how participants viewed their experiences and theorise their

interpretation, it was recognised that the resultant theory was co-construction involving

multiple realities. Respectively, Clarke refers to reality as involving different actors in the

research and the impact of the broader environment on the researcher and the researched

(Clarke 2012, Clarke 2005).

Also, the Constructivist approach conceives of the world and reality as a new social

process, an extension of human consciousness, interactions and personal explanations of

experiences and encounters (Burrell, Morgan 2017). Hence, the Constructivist researcher

should broadly seek to understand how, through their participation in social processes and

social practices, members of a social group enact a reality (Orlikowski, Baroudi 1991). Also,

the social group can ascribe meaning to these realities, which then help them to constitute or

formulate a social action (Orlikowski, Baroudi 1991).

Moreover, I chose Constructivist Grounded Theory because it allows for open and

honest acknowledgement of subjectivity and presupposition in my study. The participants'

accounts that I presented were not a generic reflection or representation of the experiences

and motivation of people living with cancer in using Traditional Healers in Ghana. The aim

was to tell the story of participants and to represent their voices instead of generalising their

views. Subjective realities do not merely imprint on individuals. Instead, they develop from

negotiations through interaction with others, and exposures or experiences with languages,

symbols, history, culture and society (Lincoln et al. 2011, Creswell 2012). I relied on the

participants’ narrative of their experiences and subjective views or meanings of the situation.

In the social constructivist approach, individuals attempt to understand their world

through the subjective meanings of experiences directed towards themselves or others

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(objects or things) (Creswell 2012). Consequently, no conception or model of

research or reality is pristine (Van Maanen 2011). The researchers’ socio-cultural or

economic, exposure and experiences profoundly sway what they see and the meaning

they attach to them (Gilgun 2013, Charmaz 2014, Charmaz 2012). The application of

the Constructivist Grounded theory approach to this study was that the initial

objectives and topic were subject to refinement and amendment as the inquiry

continued.

Although I laid out all the necessary groundwork and framework for the study,

it was not possible to predict all eventualities at any time or phase. Social research is

often unpredictable because of its dependence on many actors’ involvements, e.g.

participants, informants and gatekeepers. In Constructivist Grounded theory, there is

no guarantee that even the initial broad concepts would work in the field. Hence,

researchers should be flexible to work with the tools that participants, stakeholders

and key informants give them in the field (Gibbs 2015, Charmaz 2014, Charmaz

2012).

3.6 Summary of the Methodological and Philosophical Standpoint in This Study

More explicitly, the philosophical or methodological orientation for this study

is based on Constructivism and more specifically the version advocated by Kathy

Charmaz (Gibbs 2015, Charmaz 2014, Charmaz 2012, Charmaz, Mitchell 1996). The

theoretical underpinnings are rooted in the interpretive framework or traditions of

Symbolic Interactionism and pragmatism (Charmaz 2014). My study embraces the

ontological view of multiple contextual realities that actors such as the researcher and

participants constructed through their exposures, experiences and interactions in a

socio-cultural context.

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Hence, the study did not intend to give a linear view of reality. Instead, my study

reflects the multiple views and interpretation of my participants. I was not a neutral or

independent observer; somewhat, my biography, privileges, culture, or profession influenced

my orientation to this research interpretation and co-construction and analysis of data

(Moustakas 1994). Furthermore, it was impossible to separate my values and research.

Hence, my axiological position is that every study is value-laden, and the onus is on

researchers to openly share them (Moustakas 1994, Creswell 2012, Creswell, Creswell 2017,

Charmaz 2014, Urquhart 2013).

The paradigm that underpins my study makes it clear that qualitative methods of data

collection which minimise the distance between the researcher and the participants and allow

participants to share their experiences in their settings was the best approach. In this study, I

collected and analysed data using an inductive research process to generate a theory on the

experience of people living with cancer in using Herbal Medicine in the Brong-Ahafo region

of Ghana (See this chapter 3.7 overview of study sites)

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Table 3 Summary of GT Methodologies and the Choice for CGT Approach

Summary of GT methodologies and choosing CGT

Approach Underpinning

Philosophy and

Ontology

Coding

Principles

Position of

researcher Use of literature Selection of

Phenomenon

Uniting

Concepts

Classic or

Glaserian GT

Soft Positivism

The

constant

questioning

of data.

Designed to

discover

GT

Independent,

neutral and

value-free to

the research

process

Should be Avoided

until the end

Does not

commence

with pre-

defined

research

context or

proposal

Memo

Writing

Constant

Comparison

Theoretical

Sampling

Coding and

Theoretical

coding

Nor suitable for

examining

actions and

social processes

Not

suitable.

Against

researcher

input,

subjectivity

and

construction

Not suitable:

Objectivist

orientation.

Not suitable.

Against PhD

research

guidelines, initial

proposal and ethics

committee

Not suitable

Straussian

GT

Post-Positivism:

Influenced by

Symbolic

Interactionism

and Pragmatism

Systematic

procedures

Designed to

create a

Theory

from Data

Findings are

representative

of participants

only.

Appropriate use of

literature at all

stages

The

researcher

chooses a

phenomenon

and setting

Not suitable:

objectivist and

rigid treatment

of data

Not

suitable:

Rigid

analysis and

lack of

flexibility

Not suitable for

the aims of the

study towards

developing a

theory that is

co-constructed.

Suitable: meets

PhD, ethic and

protocol guidelines

and

Suitable for

the current

study and

PhD

research

guidelines

Constructivist

GT

Interpretivism or

Constructivism:

Influenced by

Constructionism,

Symbolic

Interactionism

and Pragmatism

Open-ended

and flexible

approach.

Designed to

construct

GT

Interdependent;

holds that the

findings are co-

constructed

(both

participants

and researchers

views)

Appropriate use of

literature at all

stages. Compile

temporal or Initial

Literature review.

The

researcher

chooses a

phenomenon

and setting.

Suitable for the

kind of question

Suitable:

Flexible

and

innovative

approach

Suitable for co-

construction of

data and

theory.

Suitable: meets

PhD, ethic and

protocol

guidelines.

Suitable for

the current

study and

PhD

research

guidelines

3.7 Overview of Study Sites and Region

The recruitment of study participants took place in two public hospitals and

five herbal clinics in the Brong- Ahafo Region of Ghana. The phenomenon and

interest of the study, methodology and potential for successful recruitment of relevant

patients led to the selection of these sites and the Brong- Ahafo region. I was led to

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these oncology hospitals based on the possibility of capturing people living with cancer who

had relevant experiences and knowledge of the phenomenon of interest. Also, I had links to

these hospitals that facilitated the negotiation of access to the field.

The region was chosen for the study because of its large rural population, rich cultural

traditions and people who use Traditional Healers (Henry et al., 2013; Addo-Fordjour et

al.,2008). Besides, the region has several herbal clinics or traditional establishments which

treat illnesses (Henry et al., 2013, Addo-Fordjour et al.,2008). Hence, the Brong-Ahafo

region of Ghana provided a safe place of opportunity to conduct this study.

The Brong-Ahafo region is the second-largest region in Ghana with a total landmass

of 39,557 square kilometres and a population of 2,310983 according to the 2010 national

population census (Ghana Tourism Authority 2019). The location of the region is along the

middle belt of Ghana. It shares a local boundary with five other regions, and an international

border with The Republic of Cote D' Ivoire (Ghana Tourism Authority 2019, Government of

Ghana 2015). There are 22 district administration capitals headed by a regional

administration or capital. The farming and fishing are the principal occupations of the

population in the region (Government of Ghana 2015, Ghana Tourism Authority 2019,

Henry et al. 2013).

3.8 Recruitment and Sampling (Selective to Theoretical Sampling)

Participants in this study were male or female people living with cancer from the

Brong-Ahafo region of Ghana. The inclusion criteria considered adult patients (aged 18 years

or older) (Laird 2002), with a current cancer diagnosis who had used or were using

Traditional Healers for their current health condition confirmed by a conventional doctor. I

excluded people living with cancer who were under the age of eighteen or had not used

Traditional Healers (See Table 4 and 5 for details of the participants’ demographics).

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Participants recruited from the hospitals were asked to confirm their demographics

details as part of the Informed consent process and before starting the interviews.

However, the lack of record-keeping in the Traditional Healers setting made it

impossible to confirm or verify the patients’ details in the herbal clinics.

The study developed interviews schedules or a list of topics that had to be

covered in the semi-structured interviews to allow flexibility and fluidity (Lewis-Beck

et al. 2004, Castillo-Montoya 2016). The interview schedules were developed based

on the literature review, research questions, and the overall phenomenon under

investigation (Lewis-Beck et al. 2004, Castillo-Montoya 2016, Seidman 2012). The

intention of the interview schedules was not to elicit socially correct answers but to

understand participants stories and the meaning they make of it (Castillo-Montoya

2016). Hence, the questions were “open questions’’ that stimulated conversation and

were suitable and relevant to participants understanding based on the local language

and culture without any jargons or prejudice (Brinkmann, Kvale 2015, Patton 2002). I

piloted the interview schedules with five adults from Ghana who live in the UK. The

feedback of their understanding of the questions helped verify that the questions were

able to facilitate a conversation about the topic of interest (Castillo-Montoya 2016,

Brinkmann, Kvale 2015). Using the feedback from the piloting and my supervisors, I

amended and finalised the interview schedule.

Sampling in Constructive Grounded theory (CGT) is a sequential progression

from selective or purposeful sampling to theoretical sampling (Draucker et al. 2007).

Selective sampling in Constructivist Grounded Theory is the initial sampling to

address the initial research question or central idea. It involves establishing criteria

and parameters for samples, situation and settings before starting the fieldwork

(Morse 2010, Bryman 2012, Draucker et al. 2007, Charmaz 2006). The focus is to

109 | P a g e

gather data most relevant to the phenomenon under investigation from people with the

relevant experiences or characteristics (Urquhart 2013, Creswell 2012, Pope, Mays

2008; Thompson,1999). In making the initial sampling decision to recruit people who were

living with cancer and had used or were using Traditional Healers, the Brong -Ahafo Region

and the study sites appeared suitable for my study. It was necessary to visit the recruitment

sites for collection on two separate occasions (Phase 1, 2015 and Phase 2, 2016). At the first

phase of the study, twenty-one participants were interviewed: eleven in the hospitals and ten

in the herbal clinics.

I conducted ten hours of observations: six hours at the hospitals and four at the herbal

clinics. I conducted interviews during the day and then spent the evening and night

transcribing and then analysing the data. The first couple of interviews were conducted in the

hospitals and another couple of interviews in an herbal clinic. The interviews were recorded

on an Olympus digital voice recorder, which has microphones for audio enhancement and

noise reduction, a USB port for charging and uploading data to a computer. The recorder also

had the capability for encrypting files and earpiece for playback at different motion which

facilitated the transcription.

After the analysis and comparison of the first four interviews, there was a

simultaneous data collection at both the hospitals and the herbal clinics based on the evolving

categories (theoretical sampling) such as ‘’boosting spirits, jovial and friendly, cordiality,

informality and as if they know you’’. Theoretical sampling is the collection of data as

directed by the initial data analysis to broaden, elaborate and strengthen emerging categories

(Charmaz 2014; Charmaz, 2012). Hence, both the data analysis and collection co-occur with

the emergent concept and guide the researcher’s decision on what data was needed and where

to get them (Pope, Mays 2008, Draucker et al. 2007, McCann, Clark 2003, Glaser 2009).

110 | P a g e

Using theoretical sampling, I was able to gather pertinent data to elaborate and

develop emerging provisional codes and their theoretical properties. Theoretical sampling is

not very seamless as the literature sometimes portrays it but involves tussling as some puzzles

may not fit together. I made decisions about which of the issues emerging in the data

collection and analysis needed to form the basis of theoretical sampling for further

investigations.

Soon after coming back to the UK and completing the analysis of all the

interviews of the phase one visit, I went back to the field to collect more theoretical

data for saturating the emergent categories and their properties (Bryman 2012,

Creswell 2012, Urquhart 2013). Also, I followed up on saturating properties of my

categories such as tradition, language and familiarity and goodwill. During the second

period of data collection, I extended my data collection to the herbal clinic more

frequently. The herbal clinics provided me with further data about motivations for

using these clinics. The questioning and suggestions from my supervisors rejuvenated

my momentum and thoughts and guided the collection of relevant data to expand

categories and their properties.

3.9 Negotiating Access to the Study Sites: Hospitals and Herbal Clinics

Although I had useful links in making contact and negotiating access to the

hospitals, I anticipated some difficulties and had a sense of trepidation. Through

family and friends, I commenced the negotiation of access using communications and

contacts. The use of support networks and relationships to start access negotiation

before going to the field is recommended in ethnographic research (Hammersley,

Atkinson 2007).

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Allan & Arber (2018) encourage researchers to take advantage of their social,

professional and cultural links in the field to gain access, establish rapport, gain trust

and information about the communities, institutions and relevant people. My cousin (a

specialist Gynaecologist) and uncle (Consultant medical radiologist) facilitated the access by

discussing with relevant hospital authorities my request to use their facilities for recruitment.

They obtained favourable responses. Moreover, they provided information about the working

patterns of the clinics and sought assurances from staffs’ willingness to support the

recruitment activities.

However, such leads were projections that had to be tested to see whether the host

community would genuinely accept, welcome and provide the necessary support

(Hammersley, Atkinson 2007). When I arrived at the hospitals, I had an introductory meeting

with the medical director, administrators and matron who introduced me to the medical and

nursing team and asked them to support me. However, the negotiation of access was an

ongoing daily activity that required me to continually introduce myself, establish and

maintain rapport and ask for permission and support (Hammersley, Atkinson 2007).

In contrast, the herbal clinics were owned by private individuals and hence making

contact and negotiating access before travelling to Ghana was difficult. I negotiated access to

most of the herbal clinics when I was in Ghana. Three herbalists initially agreed for me to

recruit from their clinics through the assistant of a teacher whom I met during my MSc data

collection in Ghana. However, these herbalists wanted a face to face discussion with me

before they could confirm their participation. In the herbal clinics, I faced the challenge of

staffs’ suspicion as they doubted my identity and intentions. Most of the Traditional Healers

expressed their unhappiness with the doctors’ lack of respect and disdain towards them.

Hence, they were cautious in granting me access to their facilities in case I was a

doctor who wanted to spy on them or expose their practices. Although it was not possible to

112 | P a g e

control these feelings, I needed to remain open, establish rapport and show interest in

both staffs and patients at the clinics (Allan, Arber 2018, O'Reilly 2008, Fetterman

2009). I interacted with the “pharmacists’’ or the staff in charge of the herbs or

medicines. He explained to me some of the components of the medicines and how

they work. Moreover, I adopted the typical cultural greetings, postures, and showed

humility by supporting staffs whenever possible. At the first herbal clinic interview,

the herbalist appeared agitated and concerned that I may be related to doctors or

collecting information to slander his reputation. He kept walking up and down the

corridor and coming to stand behind the entrance of the interview room. I realised the

need to do something profound to break this suspicion and to convey trust.

The only conceivable way of assuring the herbalist that I was not a doctor and

had no ulterior motive was to allow him to listen to part of the interview. However, I

was also aware that allowing the herbalist to listen to some part of the interview

would not be consistent with the ethical principles of confidentiality. Also, doing so

would breach the assurances that I gave to the patient and her confidence in me.

Hence, I asked the patient’s permission to share the interview with the Traditional

Healer. Fortunately, the patient was okay with my request and had no reluctance. The

patient had been coming to the clinic for over a year and knew the herbalist very well.

The patients described how the clinic was a family to her. Hence, she agreed for the

interview to be shared with the herbalist without hesitation.

I invited the herbalist to listen to the recorded interview, and suddenly the

“penny dropped’’. The herbalist listened to the beginning of the interview, which

consisted broadly of the introduction of myself and open demographic questions

about the participant. The herbalist became satisfied in a few minutes and told me he

113 | P a g e

now knows I was honest. He mentioned that he did not have to listen to the entire interview

and did not have the time.

The interview questions and the answers that the participants gave were not indicative

of an “espionage’’. The herbalist became relieved, and from that time onwards, his attitude

and reception were different towards me. The identity of a researcher or participants’

perception of a researcher has implications on how the participants or the settings would

receive the researcher (Wolcott 1999; Fetterman 2019; O'Reilly 2008). During the study, I

received different reaction and interaction from participants depending on their perception of

my identity. Most authors acknowledge the importance of researchers continually seeking to

understand the perspective of participants and negotiating and reflecting on their roles and

identities (Fetterman 2019, Coffey 1999).

Figure 6 Researcher's Multiple Identity

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3.10 Data Collection: Interviews

The primary method of data collection for this study was the use of semi-structured

in-depth interviews (n=35), using an interview schedule. The research interview offers

the opportunity for dialogue through which the researcher listens and facilitates

interaction and then interprets participants' responses to satisfy his or her theoretical

curiosity and understanding (Masson 2002). Interviews were used as the primary

mode of interaction with study participants and their accounts through the perspective

of Symbolic Interaction. The approach gave me an understanding of what the

participants experience meant to them. The approach gave an insight into how

participants juxtaposed their experiences with the Traditional Healers and the

Hospital.

The initial or opening question was a warm-up question that required

participants to tell me about themselves. The initial questions put the participant at

ease and stimulated their interest. I audio recorded the interviews to capture all

participants’ responses and to quickly refer to them for recollection and accuracy

(Kvale 2008). I conducted the interviews in a quiet room and offices where there was

privacy at the sites. However, some participants at the herbal clinics were comfortable

to have the interview under a tree. The interview schedule was useful in covering

specific areas while retaining the sensitivity and flexibility to pick up, probe and

pursue relevant leads and insights (Kvale 2008, Horowitz, Gerson,2002, (Bryman

2012, Masson 2002).

Interviews were ideal in exploring the individual experiences of the

participants and the meanings they attached to these experiences (Horowitz, Gerson

2002, Kvale 2008). The Interviews allowed me to probe participants to share their

stories while at the same time, guiding the dialogue towards a conceptual direction.

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The use of semi-structured interviews enabled me to listen to the participants' narrations of

their experiences, encounters and construction of the phenomenon under investigation and

was suitable for gathering rich qualitative data for this study (Masson 2002, Kvale 2008).

However, I was cautious not to allow the presuppositions of myself or participants to

force any framework on the entire interview process and outcome (Masson 2002, Charmaz

2014, Howard-Payne 2016, Horowitz, Gerson 2002). I remained focused and alert during the

interviews to ensure salient issues, including what participants said unconsciously were

followed up immediately or during subsequent interviews without free associations (Kvale

2008, Charmaz 2014). I used the approach of probing to explore participants responses in a

more in-depth, clarify any ambiguities, and encouraged participants to talk freely and

spontaneously about their experiences (Bryman 2012, Masson 2002, Bowling 2009, Bryant,

2007, Charmaz 2006).

However, when I had to ask participants to elaborate or clarify their responses, I did it

with ‘open questioning’ to get more details. For example, I asked participants, ‘can you tell

me more about this or that’? Can you explain that in detail? After completing the initial data

analysis, I went back to the field to collect more theoretical data from saturating the emergent

categories and their properties (Bryman 2012; Creswell 2012)

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Table 4 Participants demographics (Phase 1 visit)

PARTICIP

ANTS

NAME

INTERVIEW

CODE

GEND

ER

A

GE

OCCUPATION NATIVE

TOWN

SETTI

NG

DIAGNOSIS

Abrafi VN870067 Femal

e

29 Traditional

Midwife

Kintampo Hospit

al

Cervical

Ohemaa VN870068 Femal

e

71 Farmer Berekum Herbal Cervical?

Akomea VN870070/71 Femal

e

28 Finance

Institution

Nsoatre Hospit

al

cervical

Assifuah VN870072 Femal

e

68 Businesswoman Intotro so Herbal Cervical?

Serwaa VN870073/74 Femal

e

52 Secretary Bechem Hospit

al

cervical

Kyeremant

eng

VN870075 Male 70 Farmer Berekum Hospit

al

Prostate

Aborampah VN870077 Male 73 Farmer Berekum Hospit

al

Prostate

Kwarteng VN870078 Male 72 Farmer Berekum-

Biadan

Herbal Prostate?

Asantewaa VN870081 Femal

e

77 Farmer Berekum Herbal Breast?

Pinaman VN870083 Femal

e

40 Farmer Bosanko Hospit

al

Vulvar

Buruwa VN870085 Femal

e

30 Hairdresser Drobo Herbal Cervical?

Kwartema VN870090 Femal

e

37 Farmer Sampa Hospit

al

Cervical

Kyeremaa VN870092 Femal

e

32 Sells clothes Kwasiboo

Kurom

Hospit

al

Lung and liver

Kisiwaa VN870101 Femal

e

50 Farmer & Market

woman

Techiman Herbal Cervical

Nkrumah VN870106/07 Male 70 Retired Teacher Techiman Herbal Prostate?

Husain VN870113 Male 56 A sub-Chief Techiman Hospit

al

Lungs and

Liver

Asumadu VN870117 Male 57 Hunter Bore Herbal Ulcer

Kyeremeh VN870120 Male 44 Library Assistant Buoyem Herbal Prostate?

Fremah VN870125 Femal

e

31 Farmer Whediem Hospit

al

cervical

Aboagyewa

a

VN870129 Femal

e

56 Farmer Awurowa Herbal Leg ulcer, Skin

cancer?

Ataa VN870130 Femal

e

43 Farmer Techiman Hospit

al

Breast

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Table 5 Participants demographics (Phase 2 visit)

PARTICIPANT

S NAME

INTERVIEW

CODE

GEND

ER

A

GE

OCCUPATIO

N

NATIVE

TOWN

SETTI

NG

DIAGN

OSIS

Opambuor VN870144 Male 68 Farmer Nyame

Bekyere

Hospit

al

Prostate

Adomako VN870147 Female 80 farmer Tepa

Siawkurom

Herbal Cervical?

Akoto VN870148 Female 47 Farmer Bechem Hospit

al

Cervical

Boampong VN870151 Male 76 Retired. Public

Service

Sunyani Hospit

al

Prostate

Barwuah VN870152 Male 74 Farmer Domasi Herbal Prostate?

Nuamah VN870153 Male 27 Learning a

Trade

Durobo Hospit

al

Prostate

Nyanta VN870155 Female 58 Farmer Kumso

Yorso

Herbal Cervical?

Asabia VN870157 Female 41 Trader Sanwuri Herbal Cervical?

Fuseini VN870160 Male 72 Farmer Nsoatre Herbal Prostate?

Duffie VN870161 Female 42 Not working Gomoah

Abuoso

Herbal Uterine?

Fordjour VN870162 Male 62 Farmer Akumfi

Muna

Herbal Prostate?

Boasiako VN870163 Male 25 High school

Student

Accra Herbal Skin?

Yamoah VN870168 Male 31 Teacher Cape coast Herbal Liver?

Nyamekye VN870169 Female 29 Market woman Abanse Herbal Cervical?

3.11 Theoretical Saturation

Theoretical sampling is a continuous process that halts when saturation or theoretical

saturation of categories is achieved (Morse 2010, Glaser, Strauss 2009, Glaser 2009).

Categories are considered theoretically saturated when new or additional data no longer

reveal new theoretical insights or properties of the core categories and usually evident by the

recurrence of similar instances (Charmaz 2014, Morse 2010, Glaser 2009, Strauss, Corbin

2012, Gibbs 2015). Saturation helps the researcher to focus on collecting data that would

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enhance the theory development or develop the emerging categories rather than

imposing an off the shelf theory on the data.

The number of participants from each setting (hospitals and herbal clinics) in

the end, were guided by saturation and the point by which nothing new was emerging

(Charmaz 2014, Bryman 2012, Guest et al., 2006, Dey 2012). Saturation of all

categories signified the end of the data collection for this study. People question the

practicalities of saturation and its prominence over logistical issues such as time,

money and practical field issues that may influence the completion of a study

(O’reilly, Parker, 2013, Guest et al., 2006, Bryman 2012, Dey 2012, Thorne, 2005).

Moreover, the saturation of a concept or a category is not definitive but a

claim that researchers make when they are satisfied with the explanatory powers of

the newly developed concept (Charmaz, 2014, Gibbs 2015). Admittedly, there were

practical constraints such as not intending to overstay my visa in Ghana or time off

from work. Also, I was aware of the period needed for completing the PhD. However,

there was no decision to leave the field or force saturation because of these external

constraints. Instead, the analysis and data collection continued as usual until

saturation was reached.

3.12 Theoretical Sensitivity

Theoretical sensitivity denotes the ability to generate concepts or categories,

relate them to hypotheses and integrate these hypotheses into emerging theoretical

codes (Glaser 1992, Urquhart 2013). At some point, the researcher must move

beyond the data, define the phenomenon in abstract terms and illustrate their

conceptual relationships (Charmaz 2014). Hence, theoretical sensitivity enables the

researcher to construct analytic codes, leading to abstract concepts that have clear

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empirical indicators and can be unique from other concepts (Charmaz 2014). Furthermore,

theoretical sensitivity helps researchers to seize unexpected moments of insight in the

interviews and data collection to subsequently guide theoretical sampling and theory

development (Gibbs 2015; Charmaz 2014). My awareness and understanding of a broad

range of related concepts facilitated my thinking about data analysis. However, I did not

impose any concepts on the data as they had to earn their fit and relevance.

My theoretical insights and sensitivity came from academia, reading, profession and

attending conferences and PhD study groups. Also, supervisory and professional discussions

played a part in sharpening my sensitivity to extant concepts and theories. I reviewed the

literature as part of the ethics application and continued to make use of the University of

Surrey’s resources. The notion of having theoretical sensitivity before the study is

contentious on the basis that this might taint and impede the generation of categories from the

data (Glaser 1992).

However, it was unpractical for me to start the study or data analysis on a ‘tabula

rasa’ and sheath myself in pure innocence and substantive ignorance (Henwood, Pidgeon

2003, Charmaz 2012, Charmaz 2014). Instead, I exercised theoretical “agnosticism’’ and

subjected all prior theories and theoretical conjectures to rigorous scrutiny rather than

ignoring or denying them (Henwood, Pidgeon 2003, Gibbs 2015). Thus, I did not impose any

external concept on the study; instead, I pondered and engaged with these concepts and

activities that raised my theoretical sensitivity or acclimatisation with sensitising concepts.

For example, I read about the Comfort theory (Kolcaba, 2003, Kolcaba, 1997, Boudiab,

Kolcaba 2015) and wanted to apply it to my study. However, I dropped it after scrutiny since

it was not fitting to the data. The Comfort theory is the satisfaction of the basic human needs

for relief, ease and transcendence arising from stressful healthcare situation. The Comfort

theory assumes that Human beings have holistic responses to complex stimuli, comfort is a

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desirable holistic outcome that is germane to the discipline of nursing, and human

beings strive to meet or to have met these basic comfort needs (Kolcaba, 2003,

Kolcaba, 1997, Boudiab, Kolcaba 2015).

3.13 Iteration and Constant Comparison

A unique feature of Grounded theory is that the data analysis and data

collection happen in parallel and not consecutively as with other qualitative methods.

Grounded theory methods commence with inductive data. However, the method

immediately proceeds through iterative strategies of moving back and forth between

the data and analysis using constant comparison (Charmaz 2014, Gibbs 2015). The

constant comparison involves comparing instances of identified categories or

concepts with other instances of data in the same class (Creswell 2012, Urquhart

2013). The use of Constant Comparison method helps to explore variations and draw

analytic distinctions (Hallberg 2006, Charmaz 2014).

The concept of iteration and constant comparison in Grounded theory

safeguards the researcher from adopting participants view uncritically, collecting

randomly partial data and relying on existing theories or concepts (Charmaz 2014).

Repeatedly moving between data collection and data analysis helps to give analytic

structure and direction to the data collection (Coffey 1996, Charmaz 2014). However,

engaging in an iterative process does not necessarily constitute a theory construction

if they do not lead to the explication of abstract concepts (Clarke, Montini 1993,

Charmaz 2014).

Through the iterative, comparative and inductive process, Grounded theory

method encourages persistent interaction between the researcher, the data and the

emerging analysis (Bowen, 2008a, Charmaz 2014, Bowen, 2008b, Draucker et al.

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2007, Strauss, Corbin 2012). Hence, there is a continuous interplay and simultaneous

proceeding of data collection, analysis and theory development (Bowen, 2008b;

Strauss, Corbin 2012).

3.14 Seeking Relevant Ethics Approval in UK and Ghana

Research Ethics are the principles of moral, rights and legal conducts that inform and

guide research studies (Hardicre 2014, Fathalla, Fathalla 2004). Human research is dynamic

and complex, requiring the excellent co-operation, trust and legally or morally accepted

conventions and expectations between the researcher, potential participants and the setting

(Rubin, Rubin 2011, Silverman 2000). Imperatively, researchers should respect the principle

of self-autonomy or self-determination, non-maleficence, beneficence and justice always

(Murphy, Dingwall 2007, Beauchamp 1982). These principles underpinned the study and

formed a protective mechanism for me and the participants against inadvertent perilous effect

(Long, Johnson 2007, RCN 2011). Ethics committees and institution are necessary to

safeguarding safety and quality assurance in research (Hammersley, Atkinson 2007).

I first submitted the study protocol and relevant documents to the University of Surrey

Ethics Committee for assessment and approval (See Appendix 2-5 for relevant submitted

documents) and received feedback to respond to some concerns. After addressing these

concerns, I received a full approval (See Appendix 6-for approval certificate). Furthermore, I

submitted the study to the Kintampo Health Research Centre Institutional Ethics Committee

(KHRCIEC) (See Appendix 7 for approval certificate). Kintampo is a city in the Brong-

Ahafo region of Ghana where one of the three health research centres of the Ghana health

service is located. The research administrator provided the necessary assistance and guidance

in the process through email and telephone contacts.

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KHRCIEC after approving the study referred it to the Scientific Review

Committee of the centre to consider its scientific validity. Three independent experts

of the Scientific Review Committee reviewed the study and provided their robust

feedback and suggestions. I addressed their concerns and obtained a full scientific

approval (See Appendix 8 for certificate). Through these reviews, the relevant

authorities assessed the benefits of the study and satisfied themselves that I had

minimised risk from or in the study to potential participants (National Research

Council 2014). Obtaining formal Ethics approval in Ghana was not automatic

permission to operate in the local facilities. The study required another high-level

access, call “clearance’’. Clearance seemed more of a political security pass to the

local institutions and the patients.

The KHRCIEC administrator made me aware of this before I arrived in

Ghana. I submitted a letter requesting for clearance in person to the regional health

administration where the staff asked me to wait to discuss my request with the

regional health director. In Ghana, ones’ profile and wealth or lack of it can open or

block access to high dignitaries. Hence, I felt intimidated that I may not get a

favourable response. Fortunately, the regional director showed interest in the study

and permitted me to recruit from the public hospitals in the region.

3.15 Obtaining Informed Consent (IC) and the Challenges around Cultural Consent

The ethical principle of Informed Consent offers protection to both research

participants and researchers in case of litigation (National Research Council 2014,

Murphy, Dingwall 2001, Heller 2011, Murphy, Dingwall 2007). However, the

protection of researchers against litigation is only possible if the researchers can

demonstrate that they have acted in the best interest of participants. Hence,

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researchers should give all essential information and opportunity for invited subjects to

navigate around the complex decisions of participating in research (National Research

Council 2014). Doctors and nurses in the hospitals usually informed patients who met the

inclusion criteria if they would speak with me.

I gave potential participants a copy of the Participants Information Sheet explained

the study to them in the local dialect and allowed time for participants to contemplate and

process the information and ask questions before committing to take part (Cameron, Murphy

2007, RCN 2011). I relied on the services of research assistants in the hospitals to sign as

witnesses after observing that I had gone through the normal Informed consent process

properly. I stressed to all potential participants that their taking part in the study was

voluntary and will not affect their care or relationship with hospital staff.

Also, I assured participants of confidentiality and anonymity to their participation,

responses to questions and protection of their data. I notified participants of their right not to

answer every question or withdraw from the study at any point without having to give a

reason. I told participants that they could withdraw their data even after their interview, in

which case the data will be destroyed (deleted from all records). However, participants could

not withdraw their data after it had been analysed or once I had returned to the UK. Hence, I

gave participants a Ghana telephone number, purposely acquired for the study and told them

when I would leave the country so that participants could make contact if they had any

concerns.

I faced practical challenges around cultural differences in what constitutes consent

and the process of obtaining it. Most Ghanaian perceive more questioning, asking for more

information and documentation to indicate distrust. Consequently, some potential participants

required me to show them my trust by merely taking their word seriously as a guarantee or

consent without any documentation or signature. Some potential participants felt

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uncomfortable and did not understand why I should call a witness or asked them to

sign a piece of paper when they had willingly offered to take part in the study. They

thought I did not trust them. Moreover, some participants were sceptical and feared

that they were signing a piece of paper that would implicate them in a problem.

Interestingly, even some of the study participants who had high education had

the notion that trust is best shown by taking peoples’ word for what they say. These

dynamics highlight the importance of tailoring consent to the characteristics of a

context (Oakes 2002). I assured these participants of my trust and explained to them

the necessity to illustrate to the University supervisors and governing institutions that

I followed due processes. Nonetheless, some participants had strong sentiments of

mistrust and refused to participate in the study. Others felt offended to sign the

consent form. Because of these challenges and complexities, some participants took

part in the study through verbal and not written consent. However, their verbal

consent was captured as part of the interview recordings.

3.16 Observations: The Dynamics of Doctor-Patient versus Herbalist-Patient Relationships

The primary method of data collection in Grounded theory is through

interviewing of participants. However, a background observational data is vital in

enhancing the richness and understanding of the context of a Grounded theory study

(Charmaz 2014, Charmaz 2006, Charmaz, Mitchell 2007).

In any social context, usually what people say may differ from their actions

and how they explain their actions to each other (Charmaz, Mitchell 2007). Hence, the

information that researchers capture from participants during interviews may not

directly reflect the behaviour of participants in practice. The observational data was,

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therefore, crucial in providing an understanding of participants behaviour and real-time

interaction with staff in the hospitals and the herbal clinics.

In contrast to ethnographic observation which focuses on describing the settings,

structures and topics of interest, the Grounded theory researcher focuses on the phenomenon

of interest, as well as the processes and interactions related to the phenomenon (Charmaz

2014, Charmaz 2006, Charmaz, Mitchell 2007). Grounded theory researchers have selectivity

over the scenes that they observe and then systematically direct their attentions towards them

across different settings to gain more knowledge (Charmaz 2014, Charmaz 2006, Charmaz,

Mitchell 2007). The observations for this study were focused on participants actions,

interactions and behaviours in the context of the study. The observations enriched the data

and provided an understanding of the relationships and context within which the patients

sought help outside the hospital and their reported trust in Traditional Healers.

I conducted a total of 20 hours of observations (10 in each visit) of staffs’ interactions

and engagement with patients at the hospitals and herbal clinics. The observation data was

integrated with the interview data for the analysis. The observations were conducted during

the times when I was not conducting interviews or looking for a potential participant. I

documented the observations as part of the field notes immediately it was possible to do so

and ensured they accurately reflected the dynamics at the sites (Emerson et al. 2011,

Wolfinger 2002).

I did not want to make staff suspicious, apprehensive or alter their approach of doing

things. Hence, I took the field notes away from the clinics and staffs, sometimes when I got

home. I was worried that staffs’ awareness or impression that I was writing what goes on in

the clinics could jeopardise the maintenance of my access or encouraged staffs to act

artificially and to modify their practices and behaviours. Moreover, multiple activities and

interactions were happening at the same time. Hence, I could not observe and document

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everything carefully. I used Emerson’s et al. (2011) ‘Salience Hierarchy’, in writing

field notes to focus on observations that struck me as most noteworthy exciting and

telling. For example, I found it interesting in documenting how staff showed care and

communicated with their patients, and the following are examples from a hospital and

an herbal clinic.

I remained vigilant to capture opportunities where staffs had direct interactions

with patients and how they communicated and supported the patients. The hospitals

appeared very busy with large numbers of patients, staffs and relatives. There was no

appointment system, and usually, clinics were full by 8 am as many patients come

very early from very far. Also, the doctors saw patients based on tier ticket number,

which staffs issued to patients as registration on their arrival. Most doctors were

usually late to the clinics with nurses unable to tell their whereabouts or provide

I was sitting at the corridor with patients who were waiting for the doctor. A

patient came out from a clinic room, walked to me and asked me ‘’ mepa wo

kyɛo, ɛhe na yɛ gye aduro’’ (please where do we collect medicine or where is

the pharmacy). I told the patient that I was new and directed her to the

receptionist. The receptionist asked the patient ‘’ how many times have you

come to this hospital? Every patient knows the pharmacy. Before the patient

could respond, the receptionist asked her to walk through the corridor, and she

would find it (OFN, SRH, 18/05/16).

On a different occasion in the herbal clinic, I was sitting outside with many

patients and some relatives. One of the security men came and asked whether

they got their medicine. One patient said to the security that he was relaxing

and would go and collect his medicine later. The security willingly went to

collect the medicine and brought them to the patient (OFN, HC, 20/05/16).

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information to patients. It appeared this had become the norm and the receptionist did not

seem obligated to apologise to the patients.

Also, the relationship between hospital staffs and patients was very paternalistic, non-

interactive and patients appeared very mindful and unsure of how they should behave at

times. Most patients looked anxious and frustrated facially and based on their body language.

Some of them would take a walk to the main hospital entrance or ''roadside'' and come back

later to check whether the doctor had come to the clinic. Others asked me what the time was,

and it appeared they were concerned that they might miss their transport to their village.

Some clinic staffs shouted aloud to patients, warned them to keep quiet or face the

consequence of not being seen by the doctors.

Doctors and nurses usually told patients what to do rather than engaging with them in

any meaningful discussion and allowing them time to ask questions or voice concerns. Some

patients appeared anxious and upset but unable to express them in front of the nurses.

Occasionally, two patients would be talking and then stop abruptly as soon as they see staff

coming close to them or passing. Some patients were observed to go out of the consultation

room and then come back to clarify the instructions that the doctor or the nurse previously

gave them. These could be as simple as how they can locate a department. Such patients

appeared frightened at the thought that the nurse will not take it kindly with them and would

treat them like children. On one occasion, the nurse said to a patient “where was your ear

when I was talking, you did not listen, and now you are coming back to disturb”. Staffs also

had an influence on which the patient was seen first.

Usually, patients who were related to doctors or nurses in some capacity had the

advantage to bypass other patients to see the doctor, sometimes almost immediately. I

observed how the nurses quickly made doctors aware if someone who knows them or has a

high-status in society arrives. The doctor will then ask the nurse to allow that patient to come

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in immediately. The lack of trust for doctors was evident to me right from the onset.

Some patients refused to talk to me, thinking I was a doctor or a member of staff.

These patients feared that whatever they share with me may have consequences on

them later.

Furthermore, most of the doctors and nurses did not give much attention to

privacy and confidentiality. At times, more than one doctor and nurses share some

clinics. Some staffs who did not work in the clinic usually visit for a chat with the

clinic staffs in the presence of patients, sometimes interrupting the consultation.

Clinic staffs discussed patients’ condition amongst themselves, across the room

without any reservation. However, some doctors and nurses were liked by patients for

their patience and helpfulness. Most patients preferred to see doctor “F’’ who was

very experienced and had returned to the clinic after retirement. Doctor “F’’ appeared

to be patient and showed more consideration to patients. Interestingly, both patients

and other staffs had high respect for doctor “F’’, and my experience in meeting him

was one of warmth and support.

Contrary to the hospitals, the situation in the herbal clinics was calmer and

peaceful as patients behaved with more spontaneity. Although patients waited for

sometimes before seeing the Traditional Healers, they appeared happy. Both staffs

and patients were comfortable and relaxed without any sense of rush or hurry. Even at

times when there were more patients, it appeared the patients themselves did not

notice or pay any attention. Patients, relatives and some staffs sat under a parasol,

played local games and interacted friendlily with each other. The playing of local

music was familiar to all the Traditional clinics, and people appeared they were

enjoying the songs. Strikingly, staffs in the herbal clinics actively supported patients

and would usually ask patients and relatives if they needed water or a seat. Staffs

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supported patients in carrying their luggage, transferring into cars and running the errands to

the local shop for them.

The patients were freer and showed no reservations in talking to me or participating in

the interview. There was more interaction amongst patients, and the staffs frequently assured

patients that the Traditional healer would see them soon. The herbalist themselves had very

calm personalities and showed personal concern and care for patients. It was not a surprise

that some participants described the atmospheres of the Traditional clinic to a community or

family. There was a sense of belonging, compassion and trust.

3.17 Confidentiality and Sensitivity to Participants and Their Data

Confidentiality is an ethical obligation or principle which I complied by adhering to

the UK Data Protection Act 2018, and its equivalence in Ghana (Dovi 2013, Asante 2016,

The Government of Ghana 2012). As part of confidentiality to participants, I conducted the

interviews in quiet rooms away from other peoples and did not share the interview schedules

and participants responses with staffs. In a specific Herbal clinic, I allowed the herbalist to

listen to the first part of an interview to gain his trust and maintain continued access to the

clinic. However, this was done with the full permission of the patient. Also, the transcription

of all interviews was performed by me. Additionally, I observed confidentiality by limiting

access to data for supervisors only and appropriately managing the storage of data (Fathalla,

Fathalla, 2004; Melton 1997, RCN 2011).

The digital audio recorder for the interviews was protected with a password, and the

interviews were transferred immediately, or at the earliest possibility onto a password-

protected University of Surrey computer shared drive for backup. I also securely stored a

copy of the data on an encrypted USB stick as a backup. The consent forms which had

participants names were separately locked in a cabinet at the University of Surrey in a card

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access room. Furthermore, I preserved the confidentiality and anonymity of

participants by using interview codes and pseudonyms in the transcripts, analysis,

reporting the findings and presenting and documenting participants’ demographic data

(RCN, 2011).

Unlinking the data this way made it impossible to associate participants with

any information or excerpts in reports (Fathalla, Fathalla, 2004, Melton 1997, RCN

2011). The storage of the research data will last for least 10yrs and administration

data for 6yrs following their last access before destruction by the policies of the

University of Surrey. Ethics in research surpass merely seeking formal approval;

instead, researchers should be sensitive to ethical issues throughout their study

(Creswell 2012). I prioritised the participants’ welfare always and remained vigilant

and sensitive to feelings of distress or discomfort. I was able to demonstrate

closeness, authenticity, empathy and deep sensitivity to the culture and traditions of

participants because of my familiarity with the socio-cultural settings (James 1992,

Broom, Kirby 2013).

I usually wore the local “Tie-Dye cloths and presented in a manner that was

congruent with the culture. The sensitivity to participants also allowed them to

emotionally and physically express themselves without any prejudice or rush.

Although I showed much sensitivity to participants, they always had the potential to

be emotionally upset. Hence the counselling team or service of Techiman Holy

Family and Sunyani Regional Hospitals were made aware of the study and stood

ready to offer support to participants if necessary.

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3.18 Researcher’s Safety and Risk minimisation

Although Ghana is a safe and democratic country, the foreign office offers

some specific advice that travellers should ensure adherence. Some of this

information was to avoid carrying or displaying large sums of money in public,

travelling at night and attending informal gatherings or parties in unfamiliar locations alone.

All interviews were conducted at the hospitals and herbal clinics during the day to ensure

safety. Also, the timing of the interviews made it easy for participants to access support from

the hospitals if they become distressed. I always had my mobile phone switched on (vibration

during interviews) and made sure that family members were aware of my schedules or

itinerary for the day and the approximate time of returning home.

3.19 In-field reflexivity and Emotional Labour

In-field reflexivity relates to the dynamics of how researchers collect data in the

context (Neumann, Neumann 2015), using verbal and nonverbal communication, social

characteristics and socio-cultural orientations (Neumann, Neumann 2015, Pillow 2003). In-

field reflexivity extends to the emotional dynamics of the researcher's connection, sensitivity,

experiences and interactions with the participants and context, and their potential impact

(Coffey 1999; Allan 2018; Hochschild 2012).

The field is an interaction with actual persons during interviews, observations or data

collection in which we make deliberate decisions (Neumann, Neumann 2015, Wheeler 2013,

Neuman 2005). Although my familiarity with the culture and language helped in establishing

report and relationships, I had to maintain a sensible balance and judgement (Hammersley,

2007). Some participants did not understand why I would ask them to elaborate or clarify

their responses since I understood the language. However, it was vital for me to understand

the meaning of words in the sense that the participants used them or understood

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them(Lofland, Lofland 2006, Starks, Trinidad 2007, Charmaz 2014). I felt the

constant compulsion of wanting to identify with participants. Equally, I had to ensure

that the doctors' interest and views did not influence the study. I found this

challenging as explicitly disagreeing with their opinions could jeopardise continuing

access and their support to me (Pollner 2010).

I continuously adapted to the environment and situations to maintain the trust

of participants, doctors, the herbal practitioners and negotiated their implicit and

explicit demands. Gestalt psychologists or traditions describe such dynamics or

situational interactions in the field, framed in accordance to the situation, context and

people involved as contact mechanism or patterns (Neumann, Neumann 2015,

Clarkson, Mackewn 1993). I was susceptible to the confluence type contact

mechanism in which through spending time with people, one develops the inclination

to agree with them (Neumann, Neumann 2015, Clarkson, Mackewn 1993). I

displayed confluence behaviour as a way of trying to avoid conflict in the field.

Confluence behaviour can impede researchers from asking specific vital

questions if they are uncomfortable to participants or can potentially jeopardise their

relationships with the participants (Clarkson, Mackewn 1993, Neumann, Neumann

2015). For example, I shielded my views and avoided partisan conversations to

preserve the trust of participants, doctors and herbalists. My interaction with

participants and their context has given me a deeper understanding of how the

perception of healthcare vary across communities and the need to avoid imposing a

system of health model in any society. I have become more appreciative to how we

experience healthcare in the UK after listening to participants accounts of their

experiences in the hospitals.

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Furthermore, my experience and interaction involved negotiating and dealing with

sensitive emotions. Although the emotional connection to participants and setting was

positive (Coffey 1999), it could equally be demanding and deleterious to the researcher

(Hochschild 2012, Allan, Arber 2018). The researchers can suffer emotional stress, especially

in dealing with sensitive issues or participants with heightened emotions (Lee-Treweek,

Linkogle 2000, Dickson-Swift et al. 2008, Dickson-Swift et al. 2009). Hearing sensitive

issues and observing deplorable institutional cultures can induce negative feelings in

researchers (Allan, Arber 2018). Researchers can develop anger, frustration, sadness,

disappointment, injustice, embarrassment and even numbness (Coffey 1999, Allan, Arber

2018). Some participants gave upsetting accounts on longer queuing and waiting time in the

hospitals, anxiety and lack of systems for redress. I felt my inability to support participants on

these practical concerns was inappropriate.

Equally, I did not have access to professional emotional support during the fieldwork.

My empathetic emotions presented me to participants as ''human'' and encouraged

participants to trust me and openly share their stories (Halpern, 2001). Being privy to these

participants situations strengthened my identification and understanding with their

experiences and to represent their voices correctly. It was essential to deal with these

emotions properly and not allow them to impede the progress of the research (Pillow 2003,

Finlay 2002). Some people deal with such feeling through emotional labour in which they

express positive or desirable emotion to the encounter or situation (Brotheridge, Grandey

2002, Ashforth, Humphrey 1993, Hochschild 2012, Morris, Feldman 1996).

Emotional labour, therefore, manages impressions or feelings to create a publicly

accessible expression (Hochschild 2012, Gardner, Martinko 1988, Ashforth, Humphrey

1993). The practice of emotional labour can cover significant issues and be catastrophic to

employees or researchers (Hochschild 2012, Brotheridge, Grandey 2002). I differ from

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labelling my experience of managing the emotional situation and challenges in the

field as “emotional labour’’ as described often in the text (Hochschild 2012,

Brotheridge, Grandey 2002, Ashforth, Humphrey 1993). My emotions were

culturally genuine, and I did not engage in a “large-scale’’ emotional work to show

emotions or superficially act emotions and empathy (Down et al. 2006).

Researchers are recommended to be open and honest in discussing or

managing psychological risks at all phases of the research to avoid burnout and not

see them as a weakness (Hochschild 2012, Allan, Arber 2018). Initially, I shielded my

emotions from supervisors for the concern to avoid the perception of weakness or

allowing emotions to obstruct the study. However, they were quick to notice the

emotional intensity of the early interviews and observations. They offered me support

and practical advice to take breaks or time out, enjoy some recreation and continue to

share my feelings with them. The relationship between my supervisors and myself

grew until it became normal for me to openly share and discuss my feelings at the

supervisory meeting, through emails and at any opportunity. I was able to share the

sensitive issues in the field and how they were coming back to my memory during the

transcription and analysis of the interviews. I also was able to share the frustrations at

work and impact the death of my parents were having on my studies.

3.20 Data Analysis

In this section, the methods and procedures are discussed that were used in

analysing the data. I describe how I transcribed, coded and developed categories from

the data using the iterative and constant comparison method. The coding was done at

three stages: Open coding using the line-by-line method, Focused coding to form

categories and Theoretical coding to lift substantive categories to more conceptual

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levels of theory development. As the analysis progressed through these phases, categories

subsumed more data, developed and related to their properties and increased their theoretical

power.

3.21 Transcribing the Interviews

Transcription of data is an essential part of the preliminary stages of data analysis in

transforming the audio recorded interviews or raw data into a standardised format to facilitate

a more detail analysis (Babbie 2015, Bowling 2009, Kvale 2008). My transcription of the

data was not arbitrary but an interpretive and selective process (Davidson 2009) which

reflected the research aims and objectives (Duranti 2006). Using an earpiece connection, I

listened to each interview prior, during, and after transcription into Microsoft word

document. The transcribing of the interviews took an average of three hours for a typical

interview of about forty minutes long.

However, the process helped me in becoming more habituated with the data and

checking the accuracy of the transcripts (Richards 2014, Rapley 2011, Dey, 2003). I followed

the same process or approach to transcribe each interview data verbatim to ensure

consistency (Hesse-Biber, Leavy 2010) and to gain accurate transcript content reflecting

participants narrations (Beech et al., 2012). My transcription followed the denaturalised

approach, which captures only the main spoken words and responses (Lapadat 2000, Jaffe,

2007; Oliver et al., 2005). However, I ensured that the context of the interviews and all

memory points were preserved and reflected in the transcripts. My supervisors read samples

of the transcripts but were unable to listen to the interviews and to check for accuracy

because of their lack of familiarity with the local dialect.

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3.22 Open, Focused and Theoretical Coding of the Data

I commenced the coding by reading, reflecting and noting on the transcripts and

throughout the analysis to become more absorbed in the data before the in-depth

analysis (Neuman 2005, Dey 1999, Harding 2013). I identified some initial catchy

codes and impressions that facilitated the subsequent analysis. My initial reflection on

the data was that participants seemed to speak negatively about doctors’ behaviour

and positive about the Traditional Healers behaviour around cultural practices. As the

foundation of analysis, coding classifies or categorises data segments with a label that

stays firmly to the data and concurrently encapsulates the essence of each piece of

data to interpret the accounts of a social phenomenon meaningfully. (Charmaz, 2014,

Dey, 2003, Burgess, 2003)

The methods of constant comparison were used throughout the analysis to

compare codes and categories with each other and with data and preserved more

analytic categories which had fitter and power to subsume more data (Dey 2012, Dey

1993, Charmaz 2014). After the manual line-by-line coding using Microsoft word

tracking and commenting system, I transferred all the data and codes into NVivo

qualitative analysis software which facilitated the sorting, managing and organising a

large amount of data with ease.

Again, the software provided an audit trail of the analysis, my thoughts, and

allowed me to revisit them quickly. I was able to write memos and description of

categories (nodes in NVivo) and linked them to the data. The software also facilitated

my ability to interrogate the data more rigorously through comparison, shifting,

reorganisation, relabelling and word frequency search. The salient line-by-line codes

were transferred to NVivo as nodes and tested against large sums of data.

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Coding focuses on possibilities in the data to define a range of variations in the

phenomenon which is under investigation and not the accuracy of data fit into the

labels or codes (Charmaz 2014). Respectively, I focused on the various dimensions of

the participants' account of their motivations and experiences of using Traditional Healers.

Some of the initial emerging ideas that I saw in the data was how participants referred to

Traditional Medicine as something they share with Traditional Healers because the ancestors

gave it to them all. Participants talked about Traditional Healers as people who represented

their ancestors and could be trusted for their goodwill and intentions.

Although the coding of the data was iterative, it followed a sequential progression

from Open coding, through Focused coding and to Theoretical coding (Charmaz 2014). Open

coding is the initial coding of the data. I used the line-by-line approach for the open coding

(Charmaz 2014) and attached a label to each line of the transcripts using Microsoft Word

commenting and track changes system.

The following are samples of excerpts from 72-year-old male participants who had prostate

cancer and how I coded them using line-by-line open coding.

Line-by-line coding was still guided by the research and analytic interest (Dey 1999; Dey

2003; Harding 2013, Charmaz 2014). I consciously focused on actions and their scope of

encapsulating more data in the next phase of the analysis. Although line-by-line coding

The truth is that I was thinking a lot and even now, I am still thinking, although I have

hope after the herbalist spoke to me (Code: Being encouraged)

They are very free; they joke with me and encourage me to be strong and do (Code: being

jovial).

They did not hide anything from me, they let me know what they are doing and want to do

(Code: Openness)

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usually generates a copious amount of provisional codes, the process ensures the researchers’

thorough engagement, interrogation and submersion in the data. The intense data habituation

was useful for me in identifying and defining new and implicit meanings such as power,

inequalities, emotional management and potential concepts which I later explored

analytically (Charmaz 2014, Dey 2003, Rapley 2011).

I reduced the number of provisional line-by-line codes by re-coding the first

and second codes of each transcript, comparing, evaluating, and combining codes

based on their fit to the data, usefulness and capability to accommodate for more data.

The initial or open coding also involved the incorporation of in-vivo codes which

refer to the terms, language or symbolism that participants used to describe their

experiences (Charmaz 2014). These codes were essential in preserving the views and

meanings of the participants in the coding process. I used in-vivo codes to construct

aggregate terms and statements of participants’ thoughts, beliefs and action. The

following extracts from the interviews provide examples of in-vivo codes.

Both Nyantah and Boasiako used these words to discuss how they protected

their self-image by concealing their health condition from their community and

relatives. I used these In-vivo codes to generate ideas and concepts about how the

“I was afraid that I could not just jump to wash my clothes in public” (Nyantah,

female, 58, cervical cancer),

“I do not think it is necessary to let people know when you are not well. You would be

washing your cloth in public, and this is not a good thing’’ (Boasiako, male, 25, skin

cancer?).

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herbalists related to the participants, understood their concerns and protected their self-

esteem. I integrated in-vivo codes into the coding process and tested for their salience to the

data and theoretical or conceptual significance through constant comparison and analytic

examination.

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Focused coding is the next primary phase in coding after the initial coding

(open coding) to form more conceptual codes or categories and to move towards an

analytic process and advance the theoretical direction (Charmaz 2014). Through the

method of constant comparison, evaluation and coding of the open codes, I was able

to decide which initial codes made the most analytic sense, subsumed more data, and

elevated them to focused codes (Charmaz 2014). For example, I combined some of

the line-by-line codes by Feseini to form the focused codes or categories. The

following is an example of how I developed focused codes from the initial line-by-

line codes.

Figure 7 example of Open line-by-line codes

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Developing focus codes from Line-by-line codes

Furthermore, through constant comparison, I was able to test how these codes were fitting to

the data, understand their properties, refined and used them to interrogate, examined and

categorised extensive data (Holtslander, Duggleby 2009, Charmaz 2014). Equally, I

combined some Focused codes and dropped those that did not have much fit or relevance to

the data. I elevated the most salient Focused codes into higher categories which had more

conceptual or abstract power to create the theory (Charmaz 2014). For example, raising the

Focused code “Sense of Community’’ to a conceptual category in this study meant paying

attention to why participants talked about their familiarity with the Traditional Healers and

how they lived in the same community or neighbourhood and shared ancestry and traditions.

Comparing this focused category with participants’ description of the cultural divide,

power difference and foreign-like attitude of the conventional doctors, I was able to raise the

category to a more conceptual level, i.e. “Placing trust in one's community and identity''.

Focused coding was followed by theoretical coding to analytically raise the substantive

categories to a higher conceptual or abstract level (Charmaz 2014). Theoretical coding is an

emergent process of conceptualising the relationships between the substantive categories

Line-line codes

Always funny,

always laughing with me,

being jovial,

encouraging friendship,

making jokes

Focused code (Category)

Being Friendly and Jovial

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(Glaser 1992) or the application of analytical patterns to substantive categories to

augment their conceptual abstraction (Glaser 2005, Stern 1980, Dey 2003, Charmaz

2014). These substantive categories are linkable to existing theories.

In practice for me, theoretical coding was an intellectual exercise which I

achieved by reading related literature, having a discussion with supervisors and

thinking analytically about the data. I was cautious to avoid any theoretical imposition

on the study, and this was facilitated by my supervisors to continually emphasising

the need to allow the data to dictate the theoretical direction. Hence, I remained open

to change and to refine the theoretical codes.

The application of axial coding was not suitable for the Constructivist

Grounded theory. I did not employ the rigid application of an analytic frame around

the data as that would have limited or constrained my ability to exercise flexibility,

tolerance to ambiguity and innovation (Charmaz 2014). The application of such a pre-

set structure limits the emergence of categories and exploration by forcing the data

into a specific paradigm. However, I still developed sub-categories and properties of

categories and showed the conceptual relationship or links between them by following

emergent leads from data collection, analysis and experiences that the categories

represent.

Right from the onset of the analysis and throughout the analysis, I applied

constant comparison by comparing codes and categories with themselves and with

data. The use of constant comparison ensured that my analysis started from specific

instances in the data and remained close to the data while moving to a more general

abstract category (Urquhart 2013; Charmaz 2014; Creswell 2012). By continually

asking the theoretical question of the data, I was able to engage and interrogate the

data thoroughly. For example, the codes: we are one, respecting the culture, cultural

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training, reputation, ancestral connection, lacking cultural communication and hoping in the

Traditional healers were compared with each other and with codes of other interviews.

It was identified that these codes had similarities in their expressions of trust in the

Traditional healer and contributed to developing the theoretical code of trust. The constant

comparison helped in identifying commonalities and differences in the manner the

participants constructed or talked about their experiences. Also, such a comparative

evaluation of codes and categories with each other and with the data helped to unearth their

analytic distinction and fit (Glaser, Strauss 2009, Charmaz 2014). I remained theoretically

sensitive to facilitate theoretical comparison but ensured that any existing theory that came

into mind was tested for their fit and not imposed on the data.

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Box 3, Comparison of the focused codes of Fuseini and Yamoah and how

they developed into Substantive Categories

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3.23 Memo Writing

Successive writing of memos encourages engaging with the data, generating current

ideas, analytical codes, and increasing the level of abstraction (Charmaz 2014, Lempert

2007). A memo is the notes of the rational conversation or interrogation with the data where

researchers find their voice and facilitate an analytic jump (Charmaz 2014, Gibbs 2015,

Lempert 2007). Analytical memos were used to express ideas about the data and to track the

patterns and emerging categories and concept. Using NVivo software facilitated memos

writing on the interview, codes and categories. Also, memos were used to describe the

meaning and boundaries of categories and how they related to each other. For example, I

used a memo to describe the category of quality time as not being rushed, giving enough time

for consultation, allowing time for questions and involving participants in the discussion.

Although the centrality of memo writing is in building theoretical categories or

concepts (Charmaz 2014, Glaser 1992), memo writing is encouraged throughout the research

process. I wrote down my thoughts, momentary idea, feelings, challenges, setback and

feedback. Some analytic insights occurred to me randomly, even in the middle of the night.

Also, sometimes while driving, and they were written down as soon as it was possible.

Theoretical insights can arise at any time, even away from the data, and the researcher should

document them as soon as possible (Goulding 2001, Lempert 2007, Gibbs 2015, Charmaz

2012). Although memos ideally should have a caption reflecting a category or a concept

(Lempert 2007, Charmaz 2014), it was not practical for me to write memos neatly and

promptly always. The important thing was to ensure that ideas and reflections were noted

down so that I could visit them in the analytic or research process.

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3.24 Developing Categories

Categories are conceptual ideas which help in categorising or classifying and

comparing essential differences and similarities (commonalities) of the phenomenon

through abstracting of salient features from the immense details and complexity of the

data (Dey 2003). A category must have an analytic context, relate to other categories

and have broader conceptual relations while at the same time reflecting the empirical

material or data (Dey 2003, Charmaz 2014). The categories that I developed were

assessed for their abstraction power while at the same time, ensuring that they link

closely to the data and the context of the study using the constant comparison method.

The approach of constant comparison allowed me to compare categories continuously

to themselves and to the data to access their emergent or fit and relevance to the data.

Constructivist Grounded theory categories encourage the explanation of categories

concerning their contextual or socio-environment origin (Charmaz 2014).

Hence, the categories for the study needed to reflect the socio-cultural context,

environment and the phenomenon that I was investigating. For example, the central or

analytical core categories of “Placing trust in one’s community and identity”,

“Finding Solace in Therapeutic Hospitality and Conviviality” and “Aiming to Avoid

Upset and Manage Emotions” closely aligned with the context of the indigenous

communities and practices in Ghana and the phenomenon of Traditional healing or

medicine. The process of category formation is an analytical process which allowed

me to assess how the data support or contradict the initial codes and their theoretical

contribution to the findings of the study (Dey 2003, Glaser 1992, Strauss,

Corbin,1990).

Using iterative coding and constant comparison, I identified commonalities

and divergences and created core properties fitting to all categories that I lifted from

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the initial open and focused coding. In practice, the formation of categories was using the

method of constant comparison and elevating some focused codes that had more conceptual

or analytical power. These codes also had fit to the data (able to subsume more extensive

data) and relevance to context and phenomenon of the study. The focused codes were lifted

to the next higher level called categories.

Again, using constant comparison, memo writing and conceptual thinking, I

developed core or analytic categories and generated various aspects or patterns of the core

categories from the data but with conceptual relevance and power to compare to extant

theories for theoretical contribution (Glaser 1992, Charmaz 2014). Moreover, the approach is

evident in Strauss and Corbin (1990) through the concept of unifying all categories around a

central core which explains other categories in more detail through relationships with the core

properties (See Figure 8 for analytical core category and subcategories). Charmaz (2014),

underscores involving in the process, creating a balance between core categories and

theoretical statements about the categories, including memo integration. For example, in the

main category of trusting communities, I wrote the following description or statements.

Participants see themselves and the Traditional Healers as one community with a collective

identity. They expressed these identities in a shared language, community relationship and

accountability to each other, shared tradition and shared reputable values or sensibility.

Although most participants trusted the Traditional Healers and thought the Traditional

Healers provided a hospitable service, there was an unusual case in which a participant spoke

unfavourably about Traditional Healers. This participant was disappointed by paying money

to a Traditional Healers and not seeing an effective treatment outcome, which may explain

his dissatisfaction. Although the participants trusted the institution of Traditional healing, he

felt that charlatans had infiltrated the system.

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3.25 Theory Development

From the interpretive perspective, a theory is a conceptual interpretation and

understanding of the relationships (pattern and connection) in an investigated or

examined phenomenon instead of seeking causality (Thornburgh, Charmaz 2012,

Charmaz, 2014). The Constructivist Grounded theory focuses on generating a theory

outside of a theoretical framework through iterative inductive and constant

comparison data analysis. Constructivist Grounded theory allows researchers the

flexibility and freedom to gain knowledge about any aspects of participants

experience and life (Charmaz 2014). The use of iterative, constant comparison and

coding led to the development of the analytical categories and their sub-categories.

Through data interpretation and comparison of the analytical categories to existing

theories and concepts, I developed a theory of abstraction that was not initially

explicit or obvious in the data.

In this study, the broad theoretical categories that I developed were Trust and

Hospitality. I focused my attention on how these categories explained the participants’

motivation to use Traditional Healers. In the process, I developed a theory of the

Figure 8 Sample of analytical core category and subcategory

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intricacies of the relationship between participants and the Traditional Healers. The theory

also shows how these relationships influence the participants’ trust and perception of

hospitality in herbal clinics. I analysed hospitality through the process of analysing

participants’ language about how Traditional Healers created a welcoming atmosphere at

their clinics, exhibited friendliness, listened with attention, lifted participants spirit, boosted

their hope, provided quality time to participants and managed participants’ emotions. These

practices were what the participants appreciated the most, and hence, the practice of

hospitality encourage participants to use Traditional Healers.

Also, I analysed trust and how it forms the foundation of the relationship between

indigenous Ghanaian communities and Traditional healers, and how trust influences

participants’ preference to use traditional healers instead of Conventional doctors.

Participants justified their trust in the Traditional healers based on the universal language,

tradition and the Traditional healers’ reputation and accountability towards their community.

The theory of “ Community of Us’’ which I developed represent the fabric of identities and

subtilities of trust in most Ghanaian indigenous communities and how they influenced

participants’ motivation to use Traditional Healers.

3.26 Post field Reflexivity

In general, the post field phase involves reflexivity about the processes that usually

occur after the data production (or collection) period (Neumann, Neumann 2015). While

Neumann and Neumann (2015) describe this phase as textual situatedness, Mauthner, Doucet

(2003) and Mauthner et al. (1998) emphasise post field reflexivity in the analysis,

interpretation and conclusions of a study. Researchers decisions on the method of analysis

and process of interpretation is a reflexive exercise through which they make sense and find

meaning (Mauthner et al. 1998, Mauthner, Doucet 2003). The decisions that I continued to

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make on the study after the fieldwork were not arbitrary but reflected the institutional,

departmental, supervisory and personal perspectives. These included the books and literature

that I read, the analysis software that I used, feedback and recommendation from

supervisors, colleagues and other academic staffs and how I used them.

Moreover, decisions were made on the portions of data selected and

interpreted as evidence to support the line of argument. Devine (1999) was right to

mention how researchers enter the post-field or analysis phase wearing blinders of

pre-conceived ideas, assumptions, and the planned trajectory of the research. Many

authors argue for openly acknowledging and discussing elements that may have

influenced their post field activities as part of strengthening the validity and

credibility of the study (Mauthner, Doucet 2003, Neumann, Neumann 2015, May

1998). Some elements influenced and directed my thoughts and actions directly or

indirectly in the post field activities.

3.27 Considerations for Rigour and Credibility

A qualitative researcher should not consider or assess the rigour of their work

base on reliability, validity and generalisability, typically required for quantitative

research (Yardley 2000, Noble, Smith 2015). Instead of directly applying these

assessments to judge qualitative studies, we should explain the terms within the

framework of qualitative studies or use equivalent terminologies (Yardley 2000,

Noble, Smith 2015, Charmaz 2014, Glaser, Strauss 2009 ). The credibility of a

qualitative study is vital in assessing its rigour and quality (Noble, Smith 2015,

Corbin, Strauss 2008; Beck 1993, Glaser, Strauss 2017). Credibility is an indication

that the findings of a study are trustworthy and believable by reflecting the

participants’, the researcher’s and audience’s experience and a product of credible

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interpretation of data in a manner that stands out as one of the many possible and plausible

interpretations from the data (Corbin, Strauss 2008).

Also, the credibility of a study is a measure of its reliability and validity, which we

should address more appropriately in qualitative studies as true value, consistency and

confirmability (Noble, Smith 2015). Similarly, these elements can be addressed as sensitivity

to context, commitment and rigour, and transparency and coherence (Yardley 2000). It is

essential for qualitative researchers to openly acknowledge multiple realities, and their

personal and subjective biases (true values) (Noble, Smith 2015) and remain sensitive to

participant perspective, socio-cultural settings and ethical consideration (sensitivity to

context) (Yardley 2000). Reflexivity is critical in boosting consistency, conformability or

traceability and overall credibility of a study (Beck 1993, Noble, Smith 2015, Yardley 2000).

Using reflexivity, I was able to openly recognise existing background preconceptions,

professional and academic experiences and asked questions of emerging codes or categories.

I maintained objectivity by being aware and situating myself throughout the collection and

analysis of the data.

The use of Constructivist Grounded theory approach meant the study was a version of

my story about participants’ account of social processes, social actions and situations

(Charmaz 2014). By following and documenting the analytic process of grounded theory and

ensuring transparency, I amplified the credibility of my study (Watson 2000). I ensured

transparency in the research findings through the acknowledgement and documentation of

interactions and dynamics, challenges, and the possible influence of my background and

empathy with participants and their potential influence on both the data collection and

analysis. Moreover, I maintained transparency by thoroughly documenting observational

field notes, audio recording interviews, keeping interviews transcripts and revisiting them for

clarity and accuracy, attending monthly supervisions and writing of memos (Beck 1993).

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Also, I maintained credibility using constant comparison approach to unveiling

similarities and differences in how participants constructed their experiences and

identified an unusual case.

Furthermore, instead of reliability, a qualitative study should aim to achieve its

equivalence such as dependability, consistency or trustworthiness, and commitment

and rigour ((Morse 2015, Noble, Smith 2015, Yardley 2000). The dependability of a

study is concerned with the ability of another researcher to obtain the same or

comparable results if they retrace the study (Morse 2015) which is achievable through

the ‘trustworthiness’ of the appropriate use of methods, transparency and clarity of

researcher’s decision and audit trail (Noble, Smith 2015). The Constructivist

Grounded Theory approach does not strongly recommend the notion to achieve

reliability or dependability on the basis that we examine phenomenon with regards to

participant’s context, making it unlikely for another researcher to achieve the same

results (Charmaz 2014).

However, qualitative research should have some level of dependability or

consistency to make the findings usable to guide changes in behaviour or health

literature used by third sector organisations. Charmaz (2014) prefers the term

resonance, which focuses on whether the analytical categories portray the full reality

of participants and offer a more in-depth understanding or explanation into their world

of experience. I achieved dependability through in-depth engagement and interaction

with my study through methodological awareness, data collection and detail analysis

of data. Also, I used multiple methods (interviews and observations) and sites

(hospitals and herbal clinics) to collect data and thoroughly engaged in the study

context during both visits. The dependability of Constructivist Grounded theory

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depends on how close, relevant, and reflective the theory is to the context and phenomenon of

the investigation.

The categories and the theory development were relevant and closely related to the

context and the phenomenon that I studied and derived from the accounts or data from

participants. Again, I achieved dependability in the study through the conducting, listening

and transcribing the interviews, painstakingly reading and annotating transcripts and carefully

scrutinising the data through the analysis and coding process. These activities helped me to

be more immersed and habituated with the data. Qualitative research attracts criticism for

lacking transferability or generalisability due to small sample sizes and lack of control over

individual variables (Blaikie 2010). However, the quality of a study corresponds to be

applicability. If the study is accepted to meet the test of quality, then equally, it should be

considered applicable as well (Corbin, Strauss 2008). The findings of such a study should fit

the context, provide enough insight, understanding and work in various situation or

populations to bring about a preferred outcome (Noble, Smith 2015, Yardley 2000).

However, some qualitative researchers often argue against generalisation as pointless

and impractical because of the complexities of social environments which do not operate with

consistency (Guba, Lincoln 1989). Such a view is congruent to the Constructivist approach,

which rejects the thought of predicting human experience with one universal set of ideas

(Guba, Lincoln 1989). The aim of my study was not to achieve generalisation but to generate

a theory that is relevant to a phenomenon and its context (Charmaz 2014, Yardley 2000,

Noble, Smith 2015).

However, such a theory can serve as a useful guide for studies with similar

characteristics. Using both purposeful and theoretical sampling in this study produced a depth

in the data and thick findings (Guba, Lincoln 1989, Noble, Smith 2015). Thick data and

description of findings enable interested parties to judge the degree to which the finding

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would transfer to their area of interest (Morse 2015). I purposely selected participants

who had relevant experience in using Traditional healers and in a context where the

Traditional healers are predominant and interwoven with the socio-cultural traditions.

Also, the categories and sub-categories that I developed were relevant to the

phenomenon and the contest of participants experience.

3.28 Summary of Chapter

I have described theoretical paradigms that underpin Grounded theory or

Constructivist Grounded theory and how they influenced my methodological

orientation. I have described Grounded theory and Constructivist Grounded theory

and my justification for choosing it. I have discussed the fit of the research design and

methods for my study objectives and research questions to be answered. Moreover, I

have described the Constructivist Grounded theory method, its key concepts, and how

I applied them in my study. I also discussed Constructivist Grounded theory

methods’ relationship with literature pre-data and during the analysis. Also, I

described the recruitment process, participants selection, negotiation of various

accesses (formal and Informal), and how I sustained them throughout the data

collection period.

Furthermore, I described the procedures and methods that I employed to

analyse the data that were suitable for Constructivist Grounded theory approach and

how that led to the developing of categories and the substantive theory. Moreover, I

talked about how my study achieved the standard of credibility, dependability and

applicability.

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CHAPTER FOUR: FINDINGS

4.1 Chapter Overview

I have divided the findings chapter into three main sections which provide evidence

from participants interview accounts and observation of their context of interaction with

Traditional Healers and doctors to substantiating the core categories developed from the data

analysis. These categories are: 'Placing trust in one's community and Identity'', ''Finding

Solace in the therapeutic hospitality'' and conviviality'', ‘‘Aiming to avoid upset and manage

emotions''.

''Placing trust in one's community and identity'' presents participants' accounts of how

they identified with their community, shared socio-cultural values and interaction with

Traditional Healers and how these elements facilitate participants trust for the Traditional

Healers. The category of ''Placing trust in one's community and identity’’ also shows how

participants' accounts generally signified a lack of trust in the conventional doctors. The lack

of trust in the doctors was because of the participants perceived that the doctors were

dissociated from the local communities and represented a cultural divide, power, and

inequality. The category of ''Finding solace in therapeutic hospitality and conviviality''

describes participants encounter and experience with the Traditional Healers in the herbal

clinics against their experiences with doctors and nurses in the hospitals. The third section on

''Aiming to avoid upset and manage emotions'' reports on participants’ description of their

feeling of reassurance that the Traditional Healers would protect their privacy which enabled

them to trust the Traditional Healers than the conventional doctors. Also, the participants

obtained emotional security and comfort that the Traditional Healers will keep their

information safe.

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4.2. Power Disparity and Lack of Trust

Many participants' accounts indicated a lack of trust in most doctors and

hospital institutions because of the perception that their practices brought a cultural

divide and revived distant colonial memories. Although most participants were

unlikely to have had a direct experience of colonial administration, they know of it

through oral history. A typical example is the Cape Coast and Elmina Castle, which

are sanctuaries of some appalling memories of the slave trade. Many participants

opposed the colonialist idea and did not trust many things they considered as colonial

legacy or representation. Most participants were concerned with the colonialist era

legacies such as cultural adulteration, the impact of western education, and the power

of the elite. They perceived these colonial depictions to be present in the hospital

environment and their interactions with the Conventional doctors.

Many participants viewed these legacies as the causes of the power difference

between themselves and the doctors. Such participants perceptions about doctors

hindered the formation of trustful relationships between participants and doctors.

Although many participants expressed a lack of trust for the doctors, they continued to

use their services, possibly because they were dependent on the doctors. Yamoah and

Kisiwaa perceived the conventional doctors to endorse everything “white’’ or

“Whiteman’’: related as superior to the indigenous as indicated in the excerpts below.

“The problem with the doctors is that they are very proud and think everything White is right

and everything Black is wrong’’ (Yamoah, male, 31, liver cancer?).

“What I want to say is that you people with White education should not think the herbalist is

not good. The hospitals do not like it if you come to the Traditional Healers; they think you

are stupid or something. The doctors always think they are superior to everyone, and that is

not a good thing’’ (Kisiwaa, female, 50, cervical cancer).

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Most participants used the words “White’’, “Whiteman’’ or “White medicine’’ as a

metaphor to describe some doctors as symbols of power, superiority, control, elitism and

wealth. The word in general also defines behaviours and practices that are foreign and

differing to the Ghanaian culture and identity. Most of the unprivileged population think the

rich and powerful do not respect the culture, and local norms and values because of their

education and expensive lifestyle, a symbolic reflection of colonial influence (Mathiot et al.

2011).

In Yamoah’s view, some doctors exalted everything that originates from Europe and

America over anything local. These may range from simple products such as food and

clothing to more advanced products and institutions. These products or institutions are

coincidentally mostly accessible and affordable to the higher class. Some people of such

high calibre or rank do not usually identify themselves closely with the indigenous culture

and people. Instead, they prefer to identify themselves with modern and sophisticated

European culture and life. My observations in both the hospitals and the Traditional Healers

clinics highlighted the notion that the doctors were interested in European and American

products and lifestyle than the local ones.

I observed in the hospitals that all the doctors usually dressed in cute shirts, trousers,

dresses, shoes, expensive watches, and a white coat. Such a manner of dressing up was

different from the way most of the patients and the local community dress up. The local

community and most of the patients wore something made from the locally produced tie-and-

dye material. Also, all the doctors that I met had beautiful and big vehicles and had parking

spaces allocated to them. Some of the doctors frequently travel to Europe and America for

holidays and enthusiastically shared their experiences with other staffs in the presence of

patients.

In contrast, I observed that the Traditional Healers, their staff, and patients dressed in the

local apparel. These include “tie-and-dye”, “Fugu”, ‘’ahenema’’ (local slippers made from

goatskin) which mean the children of a king. There were a few staff and patients dressed in

what others would consider as European dressing but remained moderate and showed no

sense of extravagance and wealth (OFN, CP, HC,2015/2016).

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From the observation, we can see why patients felt that the hospital doctors

were not interested in what happens in the local community or considered them less

relevant. From my experience of growing up and working in Ghana as a nurse,

doctors and nurses generally do not use the locally produced costume or cultural

regalia. Also, some doctors import brand-new cars from Europe and America and use

items that people have imported from these countries. The ownership of a private

vehicle is a sign of wealth in Ghana, and doctors are usually able to afford some of the

most expensive cars. Hence, most people in Ghana see doctors as members of the

upper class who are apathetic to indigenous items. However, it is difficult to know

with certainty whether the doctors’ interest, acquisition and use of foreign items were

by necessity or just luxury. For example, although the use of a white coat by doctors

is an adoption from the European culture, it has become part of the doctors’ uniform

in Ghana and possibly necessary for identification.

Although it is unlikely that all doctors in Ghana have such attitude in them,

most participants expressed such feeling about them. Such a feeling is also generally

prominent among most of the ordinary Ghanaian population, who are usually rural or

agrarian with low education and low income.

Kisiwaa’s quote above commenced with a note of caution to doctors and

people who receive western education or in the position of power not to undermine

Traditional Healers recklessly:

“What I want to say is that you people with white education should not think

the herbalist is not good.”

My experience and observation at both the hospital and the herbal settings

indicated strong power dynamics between doctors and the Traditional Healers. Most

Traditional Healers expressed outrage at what they perceived to be a shift in power

against them in favour of the doctors. Some Traditional Healers spoke to me about

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how they felt that the doctors had always undermined them and the socio-cultural traditions

of their communities. My observation field notes express some of the contentions between

Traditional Healers and the doctors. Sometimes, the tension between the Traditional Healers

and the doctors was shown in how some Traditional Healers had a suspicion that I was a

doctor or connected with doctors and had the ulterior motive of exposing their practices. At

one of the herbal clinics, the Traditional Healer asked me to show evidence that I was a

student and had no affiliation with any conventional institution or not a doctor in Ghana.

Some herbal clinic staff told me how they feel doctors are arrogant and think that they are

more important than anyone. They also talked about how doctors pretend that they can cure

all illnesses. Some Traditional Healers and their staffs expressed concern about how the

doctors undermine the community traditions and ancestral legacies. The following was an

observation note from one of the herbal clinics that I visited:

Sometimes, the Traditional Healers expressed their tension with the doctors through their

reaction and suspicion towards me. Some of the Traditional Healers had the suspicion that I

had links with doctors at the local hospitals. In one of the herbal clinics, the staff asked me to

wait to speak to the herbalist for permission before I could do anything in the clinic or speak

to any patients. The staffs were not prepared to discuss anything with me until the herbalist

had established my identity and had permitted them to allow me to operate in the clinic. A

member of staff described how they (clinic staff) could only trust people who trust them or

believe in them. The staff was upset and mentioned that the doctors should stay away from

the clinic and not attempt to defame their name. At that time, I sensed that the staff thought I

was a doctor or affiliated to the local hospital. The herbalist asked me ‘’ How do I know that

you are a student and just doing research? These days we must be careful about doctors as

they just want to tarnish our image to our people”. I reiterated to him that I was a student

from the UK and doing the research as part of my studies and not in any way linked to the

local hospitals or doctors. The herbalist asked me to show some evidence that I was a student

and not a doctor. I showed him the recruitment materials and the introductory letter from my

supervisor as they had the university logos on them to prove that I had come from the UK

(OFN, HC, June 2016)

The Traditional Healer and his staff showed their resentment to doctors and how

doctors were not welcome to their premises. Possibly, the Traditional Healer may have

instructed his staff not to discuss any issues with potential doctors or hospital staff until they

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could ascertain their identity. Traditional Healer only allowed me to operate in his

clinic when he was satisfied that I was not a doctor. Initially, the staffs in the clinic

identified me as a doctor. Hence, they saw a perfect opportunity to show their

bitterness and dislike to me in response to their perceived general behaviours of

doctors towards Traditional Healers. The staff felt the doctors do not trust them, and

hence they should also not trust the doctors. The clinic was on the lookout for any

undercover work from the doctors that may expose how they work and pitch it against

Conventional Medicine.

Traditional Healers see the resentments from doctors as a real threat to their

very livelihood, survival, and dignity in society. In this respect, some Traditional

Healers exercised caution to validate my identity and to establish that I had no links

with the doctors before allowing me access to their facilities (see Chapter 3.9, 3.15 for

indications of distrust). Equally, the doctors openly expressed their concerns about the

Traditional Healers during my interactions with them and reported that the Traditional

Healers have no education or understanding in treating illness and are preventing

people from using conventional medicine.

Some doctors expressed anger about the fact that some Traditional Healers

addressed themselves as doctors. The doctors thought the Traditional Healers were

undermining their arduous work to become doctors. Similarly, some doctors spoke

openly with me that the herbalists do not have the requisite knowledge or

qualifications and are 'charlatans. Such a powerful language of condemnation

emphasised the level of resentment that doctors had for Traditional Healers. Most

doctors mentioned how they could not understand why some patients would visit the

Traditional Healers. In their view, the herbalists' assurances to the public that they can

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treat illnesses were false. Kisiwaa's accounts suggest the doctors sometimes criticised the

Traditional Healers in from of the patients.

However, Kisiwaa felt that the doctors’ assessments and criticism of the Traditional

Healers were not fair as the Traditional Healers do much work in the community and care for

the vulnerable people. Furthermore, Kisiwaa found it unacceptable that some doctors criticise

patients who visit the herbalists instead of the hospital. Some participants saw such doctors as

oblivious to the cultural practices in the indigenous communities. Moreover, many

participants viewed the doctors’ behaviour of using inaccessible language and perceived lack

of sensitivity to tradition, whether deliberate or from ignorance as culturally inappropriate,

suggesting their socio-cultural disconnect and power inequality.

Possibly, the participants, through their narratives, were addressing the power balance

by telling stories about their bad experiences with Conventional doctors. Some participants

came across during the interviews as wanting to pass a message to the doctors. These

participants expressed their resentment and dissatisfaction to the inequality and cultural

detachment that the doctors represent. This category of power and lack of trust shows how

most participants lacked trust in the doctors because they perceived the doctor to have

westernised standings and detachment from the indigenous cultural values.

Most participants felt the doctors exercised and reflected colonial supremacy over

ordinary people because of the power and privileges they enjoy in society. Many participants

viewed western culture and education as features of a cultural divide, the revival of colonial

memories and the creation of power imbalance between the average population and the elite.

On the contrary, most participants trusted the Traditional Healers because they saw the

Traditional Healers as people who shared a similar identity with them and have the necessary

cultural sensitivity, humility and understanding required in the community.

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4.3 Placing Trust in One’s Community and Identity

“Trust shapes all aspects of human life. Whatever matters to human beings,

Trust is the atmosphere in which it thrives… When it is damaged, the community as a

whole suffers, and when it is destroyed, societies falter and collapse” (Bok 1979,

page 69).

One cannot overstate the importance of trust in all dimensions of human life

and activity, and the functioning of society depends on trust to a greater extent (Bok,

1979). Tradition and strong familial and community bonds give clear moral

guidelines for the development of good character and smooth functioning of most

Ghanaian communities (Utley, 2016). Most Ghanaian communities require trust as a

fundamental character or value from their members or institutions. However, the

problem in societies or communities is more of trustworthiness than trust as even the

person who is most willing to trust will still look for signs of trustworthiness in others

before placing trust in them (Gambetta 2008, Hardin, 2006).

Socio-cultural identities, and relationships and appropriate standard

behaviours are the essential fabric of the Ghanaian indigenous communities. This core

category, ‘Placing trust in one’s community and identity’, encapsulate the

fundamentally shared community values, relationships, and the Traditional Healers

behaviours’ that made them trustworthy amongst most of the participants.

4.3.1 Tradition: Participants shared Ancestral and Cultural Connection with Traditional

Healers

Most participants reported trusting in the Traditional Healers because they shared the same

traditional identities with them. Participants trust in the Traditional Healers generally

appeared to be part of the way they showed conformity to their traditional identity and

revered the community's ancestral authority. Most Ghanaian communities consider people

who distance themselves from indigenous traditions and moral values as arrogant and

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disrespectful. This interview extract from Barwuah identifies the importance of ancestral

heritage and how community elders sustain and perpetuate it to future generations:

''Our ancestors gave the Traditional Healers to us for the benefit of the community and all of

us. Our ancestors and grandfathers pass on Traditional Medicine to the Traditional Healers

when they are about to die. When they are about to die, they would call someone in the

family, and they [grandfathers] would hand over their herbal knowledge to them'' (Barwuah,

male, 74, prostate cancer).

Barwuah highlighted how the elders or grandparents would call on a family member

that they consider apt and then pass on the healing knowledge to them. The approach

establishes the notion that people do not gain herbal knowledge through personal merit but as

a favour from their ancestors and elders. The elders can transfer their knowledge and power

to their successor before they die. Also, the elders can gradually transfer their power to their

successor by training them. The elders usually train their successor when they sense the

possibility of death due to age, ill-health or communication from the ancestors of their

intention to take them home. A common belief in most communities in Ghana is the notion

that elders can see the spiritual world and communicate with ancestral spirits.

Fremah's narrative below reflects the importance of cherishing the Traditional Healers

because of a shared historical connection with the ancestors who usually are responsible for

passing on traditional healing as a gift to families and community members. Participants

cherishing of the Traditional Healers leads to placing trust in them.

''I believe that we should never throw away Traditional Medicine. It is our past (our history)

and a gift from our ancestors so I will continue to use it” (Fremah, female, 31, cervical

cancer).

Fremah's beliefs in Traditional Medicine represent trust in Traditional Healers and

the ancestors who are responsible for the Traditional Healers’ knowledge. The expression 'we

do not throw away' is part of a famous Ghanaian axiom that implores people to avoid

distancing themselves from their traditions and native identity. In this sense, Fremah saw

Traditional Healers as part of her tradition, history and represented a gift from the ancestors.

Fremah emphasised her commitment to continuing to trust the Traditional Healers and use

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their services. Most Ghanaian indigenous communities broadly encourage their

members to honour what the ancestors have left behind for the good of their

communities. These communities believe that the ancestors have preserved their

character in the Traditional Healers, which earn the Traditional Healers the credibility

of trust.

Some participants felt that they could trust the Traditional Healers because the

Traditional Healers receive training that reflected the society’s tradition and moral

standards. Thus, the community values and traditions instilled in the Traditional

Healers through training conferred to them a positive reputation which people can

trust. Both Boampong and Abrafi described how the Traditional Healers receive

community-based training and learning of ethical values:

“Somebody can start learning from a very young age and get all the wisdom before he or she

can work as herbalist’’ (Abrafi, female, 41, cervical cancer).

“Well, my experience is that the herbalist is very well trained. They have not trained abroad,

or in any institution, they are trained in the community and know the people in the

community. They are outstanding’’ (Boampong male, 76, prostate cancer).

Abrafi described how the training of the trainee Traditional Healer continue

until the elders are satisfied that they have acquired the required wisdom to practice as

Traditional Healers. Most Ghanaian believe that the training of the Traditional

Healers involves a rigorous personality, identity and character training. Abrafi's

description about the Traditional Healers acquisition of wisdom before commencing

their practice has a link with the Ghanaian adage that says ''efie nyansa nko, ena

sukuu nyansa nko.'' The literal meaning of this idiom is that the wisdom obtained

from home is different and better than the wisdom obtained from the school.

The elders usually use this idiom to caution those who have detached or are

contemplating to detach themselves from their culture because of academic prowess

and primarily encourage people to seek relevant soft cultural values. Boampong used

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the word outstanding in describing the Traditional Healers character and reputation.

Traditional Healers appear to epitomise respect, selflessness, community solidarity,

humility and equality, which are all necessary building blocks of most Ghanaian communities

(Utley 2016). The training of the Traditional Healers in the local communities meant the

Traditional Healers receive first-hand knowledge of their community values and a buffer

against cultural adulteration. Also, the community training of the Traditional Healers

enhances their integration, building of community bonds and learning of the skills that

prepare them for community life.

On the contrary, most participants reported the lack of trust for doctors because of the

western system of education that doctors receive. Many participants felt that the medical

education system does not provide doctors with culturally rooted or relevant training. Instead,

most doctors were reported to receive knowledge and medical training that is devoid of

compassion, character and traditional values that the local community espouses:

“I agree that the doctors know about drugs (medical knowledge) and they are trained in

medicine, but they can learn something from the herbalist. They can learn about our culture

and how to behave appropriately (Buruwa, female, 30, cervical cancer?).

Buruwa acknowledges the importance of the expert medical knowledge of doctors but

implores them not to let that knowledge become detrimental to their behaviour. Given these

concerns, some authors have argued that the governments of Africa should ground and tailor

Africa's teaching and education in its culture and values (Ocheni, Nwankwo 2012).

4.3.2 Participants Shared Language with the Traditional Healers

Most participants expressed trust in the Traditional Healers because they shared a

common language with them. Many participants described how they could understand and

communicate satisfactorily with the Traditional Healers, in contrast to the conventional

doctors who often used English. Majority of the participants did not speak English and

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signalled their preference to speak in “Twi’’ which is a familiar local language that

everyone could speak in the community.

Aborampah showed the difference between the languages used by the doctors and Traditional

Healers and how they influenced trust and power relations:

“Sometimes, you may not even understand what the doctors are saying. For example, I do not

understand some of the languages that they use. They speak the White man's language

because they have all become ‘, White men and women’. The herbalist speaks our language,

and we can understand each other. If you understand what someone is saying, then you can

also contribute or feel you have power” (Aborampah, male, 73, prostate cancer).

Aborampah expressed the lack of trust in the doctors because he could not

understand what the doctors discussed with him in the hospital. Furthermore,

Aborampah felt he was powerless in doctors’ presence and unable to identify with

them and contribute to the clinical encounter. Many authors describe how language

can be used as a power dynamic to distance others from an interaction (Luhmann

2018, Garrett 2010, Giles, Ogay 2013). Most doctors often used English and medical

terms which were unfamiliar to the local population. Aborampah’s used of the

statement '' the doctors’' language'' as a way of distancing himself and the local

population from such a language. It seems Aborampah expected to be involved in the

exchange of communication with doctors but felt unable to do so because of his lack

of understanding of the doctors' language.

Many Ghanaians refer to English as the ''White man's language'' and those

with European or American cultural attachments as ''Whites''. In a profound sense,

Aborampah was expressing his lack of trust in the doctors because of their use of a

foreign language which he interpreted to illustrate power inequality, elitism and loss

of cultural attachment. Aborampah felt that the language barrier between himself and

his doctor meant he was unable to ask questions or have a full picture of his situation

and what he needed to do.

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Contrary, Aborampah's account unveiled his trust in the Traditional Healers because

of his ability to understand and identify with the Traditional Healers in a common language.

Aborampah called the local language ''our language'', thus invoking a sense of collectiveness,

inclusiveness, and trust for the Traditional Healers because of the shared language. Some

studies have shown how people who are fluent with a common language were more likely to

be accepted and trusted by their intra-groups and have a personal sense of identification with

the group (Sanchez et al. 2012). Similarly, ethnic communities perceive someone who speaks

the ethnic community's language as showing respect to them.

Such respect can lead to substantial interaction and bonding, which are essential to

trust. Aborampah described how his shared language with the Traditional Healers provided

him with a sense of power and ability to contribute to the therapeutic discussions. Other

participants (e.g. Akomeah, female, 28, cervical cancer; Aboagyewaa, female, 56, breast

cancer; Asabia, female, 41, cervical cancer? and Kisiwaa, female, 50, cervical cancer)

expressed a feeling of frustration at their inability to understand the language that the doctors

used. They expressed a profound lack of parity between themselves and the doctors because

of the language barrier, and hence they found it challenging to trust the doctors.

In Akomeah’s view, the doctors’ use of English during the therapeutic encounter and

interaction was deliberately designed to prevent her from understanding her situation.

''The herbalists speak to you in your language so that you can understand. They do not

behave like the doctors who sometimes do not want you to hear or understand them.

Traditional Healers do not speak to you in English” (Akomeah, female, 28, cervical cancer).

The Traditional Healers spoke to participants in a common language in contrast to the

doctors who spoke an unfamiliar language. Most participants thought the doctors used the

English language and complex medical expressions deliberately to sabotage and alienate

them from the discussions about their illness. Most participants thought the doctors used

English to maintain their power, inequity and exclusivity over them.

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The following is a sample of my observations in a Gynaecology-Oncology

clinic in one of the hospitals

I usually spent part of my day in the Gynaecology clinic where doctors and nurses will

introduce me to potential participants for recruitment. Since I was not a member of staff, I

usually sat outside the main consultation room. At about 13:00 hours, a porter brought a

patient in a wheelchair from the emergency room. During the consultation, the doctors

shouted to me “This case is vulvar cancer, would you be interested?” I answered yes, and the

doctor continued to speak to me in English across the room in the presence of the patients.

He told me that the condition had spread to most of the patient’s private parts because the

patient does not always come for review. The doctor expressed his suspicion that the patient

may have been visiting a herbalist for treatment and only comes to the hospital in an

emergency (OFN. 19 October 2015 Hospital Clinic).

Such a conversation can cause anxiety to patients as they are not familiar nor

understand the English language which the doctor used. Equally, the patient could be

uncomfortable because she did not understand what the doctor was discussing with me.

Probably, the doctor may be aware that it was not appropriate to be telling me in more detail

about the patient’s condition and potential behaviour. Hence, the doctor’s' use of English

could be an attempt to stop the patient from understanding the conversation. The observation

substantiates why most patients reasonably believed that doctors sometimes do not want them

to hear the contents of their discussions. This observation was in contrast with the herbal

clinic where the herbalists spoke to the patients in the local language (Twi). Also, the

herbalists usually conducted a consultation with the patients alone. They did not speak to any

staff or others about the patients’ condition.

However, it appeared that many of the participants had accepted the culture of

disempowerment. They were unable to ask the doctors to speak in the local dialect during the

consultation. The doctors' training focuses on enhancing their medical and academic

knowledge and not the dynamics of local communities. Hence, doctors may not always be

aware and sensitive to how their behaviour may contradict the socio-cultural environment in

which they practice. However, it is not clear whether patients would hold the same

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unfavourable views about doctors if they were able to speak English and understand the

medical terminologies, or if the doctors were to speak in the local language

4.3.3 Perception of Familiarity, Goodwill and Accountability

“Whoever wants to win trust must take part in social life and be in a position to build the

expectation of others into his self-presentation’’ (Luhmann 2018, page 69).

The quote suggests how familiarity forms the basis of trust, and hence those interested

in a trust must show themselves as a social identity and interact with their communities.

People who isolate themselves from their communities are not in the position to build trust

since they do not make themselves available for others to know them. Most Ghanaian

communities have close familiarity and a sense of mutual help, collective responsibility and

reciprocal obligation (Utley 2016, Uzzell et al. 2012). The familiarity and close social

relations in these communities strengthen the members' sense of goodwill and accountability

towards each other.

Many of the participants indicated that they trust the Traditional Healers because they

had relationships, interactions and neighbourhood bond with the Traditional Healers. Most

participants trusted the Traditional Healers because of familiarity; for example, Fremah

conveyed how she lived in the same village as the Traditional Healer

“I know about the man because he lives in the village with us for many years and has always

treated people who are sick. He is part of our community” (Fremah, female, 31, cervical

cancer).

In this account, Fremah trusted the Traditional Healer because he was not a stranger

but a member of the community. In the Ghanaian context, to know somebody denotes a

knowledge about their character, behaviour, and whether they are trustworthy. Fremah's

cohabitation in the same village with the Traditional Healer gave her the confidence to trust

him. The expression that the Traditional Healers are part of ''our community'' broadly means

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the Traditional Healers are more than mere residents of the community. The local

expression is ''Kuromane papa'', which means a genuine and engaging community

member. The implication is that Traditional Healers are part of the everyday routine

life and cultural practices of the community.

Most Traditional Healers in Ghana fulfil their community's expectation for its

members and contribute to community life through their participation in ceremonial

activities. These include funerals, marriages, festivals and practical community

improvement activities. Most participants trusted the Traditional Healers because of

the Traditional Healers active interaction and engagement with them ordinarily on a

day-to-day basis in the community. Fremah described how the Traditional Healers

had always shown goodwill towards the people in the community by treating their

illnesses. Participants' seemed to have an implied assumption that the Traditional

Healers have goodwill and responsibility towards them. Communities in Ghana

usually label people who have apathy and lack involvement in the communities as

‘‘Kuromane bonee'' which broadly means non-engaging or lousy community

members. People perceive such members of the community to have ulterior motives

or hidden agendas and lack goodwill and accountability towards their community.

Akoto described her relationship with the Traditional Healers as one “like a

family’’, an indication of familiarity and relationship, accountability and goodwill.

“The thing is, your farm maybe next to the herbalist farm, and you always say hello to each

other and share a boundary. We are like a family to them'' (Akoto, female, 47, cervical

cancer).

Akoto compared the extent of her relationship with the Traditional Healers to

that of family. This comparison is an indication of trust based on good personal

knowledge and frequently repeated interactions. These interactions included living

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and farming in the same locality and routinely greeting each other and promoting the feeling

of being part of a family.

Most Ghanaians may consider people who may not share blood relations with them as

family, based on sound and trusting relationships. The sense of family is an indication of

trust, security and accountability to each other. Hence, Akoto, in a profound sense, was

perhaps implying that the Traditional Healers were worthy of trust and would behave in a

manner that considers her best interest.

In both the account of Akoto and Fremah, there was a perception of trustworthiness

and goodwill in the Traditional Healers' behaviour which are an essential aspect of the

Traditional Healers image in the community (McCroskey, Teven 1999, Choi, Stvilia 2015).

Goodwill is the participants’ perception of the Traditional Healers intention towards them.

There is an implicit assumption that the goodwill of health professional towards patients

should always primarily be caring (McCroskey et al. 2006). Most participants appeared to

know the Traditional Healers at the community or neighbourhood level and had the

confidence that the Traditional Healers have goodwill towards them. Other participants

(Aboagyewaa, female, 56, leg ulcer/skin cancer?; Abrafi, female, 41, cervical cancer;

Yamoah, male, 31, liver cancer?; Boampong, male, 76 prostate cancer and Akoto, female, 47,

cervical cancer) shared similar views of how they could trust their Traditional Healers

because they knew them in the community.

Aboagyewaa felt the Traditional Healers have a mutual responsibility for the kindness

and support that the communities had given to them and would reciprocate them.

''The Traditional Healers remember all good things that people in the community have done

for them, the things that others have given to them and want to pay back and show their

gratitude” (Aboagyewaa, female, 56, leg ulcer/skin cancer).

Most Traditional Healers benefit from support, prestige and status as part of their

quintessence of the traditional and ancestral moral values in their communities.

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Consequently, the communities require the Traditional Healers to show some

responsibility to abide by specific moral standards of behaviour and honour some

obligations to the community. Many participants trusted the Traditional Healers to

reciprocate the privileges they received during their training and show some gratitude

to the community. Thus, the privileges and respect that the Traditional Healers enjoy

required them to behave ethically towards the community. Aboagyewaa was

convinced that the Traditional Healers would try their best to show some appreciation

to the generosity that they receive from their communities.

In contrast, the participants described the conventional doctors negatively. For

example, Opambuor gave a displeasing description of the doctors' lack of connection

with the communities in which they worked:

“Doctors come from many places in the country or anywhere in the world to work in our

communities. They do not know us because they are not from here and hence everything to

them is about business or transaction that will earn them money” (Opambuor, male, 68,

prostate cancer).

Opambuor found it challenging to trust the doctors because of his perception

that the doctors lacked lineage, accountability and goodwill towards the local

population. In Ghana, most doctors are non-natives of the communities in which

they work and have the flexibility to transfer to another community or hospital or look

for opportunities elsewhere. Based on the lack of lineage or strong bonds to these

local communities, Opambuor felt the doctors had no sense of moral responsibility

towards them or equally did not have any incentive to show goodwill towards the

population. Opambuor felt the main ambitions of doctors were to acquire wealth, and

they lacked the credibility of committing to the local communities as the Traditional

Healers do.

Most participants’ perception of the doctors' lack of credibility may

influence how they relate and listen to doctors. Some participants may not see the

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need to listen to doctors if they perceive the doctors not to have goodwill towards them or

interact with sincerity (McCroskey, Teven 1999, Choi, Stvilia 2015). My experience of

practising in Ghana as a nurse was that most doctors lived in exclusive and expensive

locations from the average population, making the doctors inaccessible to most people apart

from the usual brief interactions in the hospitals. Equally, most doctors did not seem to

respect the local community’s moral standards or show secure moral attachment to the

communities. Doctors acted on a simple matter of legal and professional principles which

did not agree with the local traditions regarding the therapeutic encounter.

Most participants described how they could trust the Traditional Healers because of

their goodwill. The Traditional Healers’ goodwill was seen through the acts of compassion,

which corroborated their credibility and trustworthiness (Choi, Stvilia 2015, McCroskey,

Teven 1999). Most of the participants (e.g., Fremah, Boasiako, Akoto, Fuseini, Abrafi,

Nyamekye and Husain) believed that the Traditional Healers motive for serving their

communities and reaching out to the vulnerable was compassion without any ulterior

motives. These participants described how the Traditional Healers demonstrated their

compassion through the willingness to assist the rural population. Some Traditional Healers

also visit patients who cannot attend the clinic at home to provide them with the support that

they need. Boasiako emphasised the vital role of the Traditional Healers in supporting the

vulnerable in their communities.

“As for them, they are ’our own’ people; they go everywhere to help our mothers and fathers

who are in remote villages. Therefore, I think it is good’’ (Boasiako, male, 35, skin cancer?).

Boasiako was convinced that the Traditional Healers would do everything in their

capacity to attend to the remote communities to support the vulnerable. The context in which

Boasiako used the word ''our own'' in the local dialect entails a sense of oneness and shared

identity between himself and the Traditional Healers. Such a conception of oneness with the

community possibly motivates the Traditional Healers to have the compassion to attend to the

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places where doctors usually would not go. Husain described how some Traditional

Healers show compassion by visiting and supplying treatments to their patients at

home:

“If you are very sick and cannot even go out, the herbalist will come to your house to treat

you or give you the medicine; they will come and see how you are getting on because their

aim is you becoming strong again” (Husain, male, 56, liver cancer)

In Hussain’s view, the Traditional Healers do not work for profit gain but are

motivated by seeing the sick person become healthy again. Moreover, most

Traditional Healers usually would go to the remote communities where there are no

doctors or doctors would not usually visit or stay. By implication, Husain had

concerns about the lack of such practices of compassion in conventional medical

institutions or from doctors. Most doctors usually prefer to work in cities where they

can access more opportunities and career progression. However, it is also possible that

most doctors have the restrictions of regulation and professional codes which may

limit their flexibility to offer low-level services such as visiting patients at home. It is

unknown whether the Traditional Healers will still offer such a soft and flexible

service if their relationships with participants were guided and regulated by law and

professional codes like doctors.

4.3.4 Participants Perceptions of the Traditional Healers Reputable Virtues

“A good name is better than riches’’. Proverbs 22:1, Bible

Most participants trusted the Traditional Healers because of the impression

that the Traditional Healers have reputable virtues. These essential virtues included

how Traditional Healers showed dignity and respect to patients, demonstrated

reliability to their communities and the successful treatment stories of the Traditional

Healers. Majority of the participants' trusted the Traditional Healers because of the

dignity that they showed them (e.g. Asenso, Ohemaa, Kyeremaa, Pinaman, Assifuah

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and Abrafi). For most participants, respect and dignity included the health professional

acceptance, tolerance and consideration to their cultural values and identities when

interacting with them. Pinaman described how the hospital treated her with lack of respect

and dignity; she believed such behaviours would not happen in the traditional setting:

“I was lying on a trolley with no cover, the room was cold, and they will not even bother to

give you something to cover your nakedness while men were coming in and going out. In the

same manner, the doctor will take your clothes without even saying sorry or minding who is

around, and they would be looking at your whole body. Our fathers, the traditional healers

have manners, and their eyes are opened; they will not expose people nakedness. They have

respect for our culture and us. It is very disrespectful to look at someone nakedness”

(Pinaman, female, 40, Vulvar cancer).

Pinaman felt the doctors treated her with ignominy, leaving her on a trolley

uncovered. Similarly, Pinaman was concerned about the doctor's behaviours of sometimes

exposing patients without asking permission or taking precaution for dignity. Pinaman

perceived such behaviours of hospital doctors as disrespectful and entirely against the cultural

prerogatives. Contrary, Pinaman described how Traditional Healers have manners and treated

patients with respect and dignity. In Ghana, covering and protecting one's private parts is a

crucial cultural imperative: a moral high ground. Hence, most participants perceived

Traditional Healers of showing show respect and dignity by not exposing patients' body or

doing it with precaution. Pinaman felt the Traditional Healers would not look at someone's

nakedness or expose their bodies. Kyeremaa expressed her trust that the Traditional Healers

would not put their hands inside her or do any of the uncomfortable and invasive procedure

that the hospital doctors carry out:

“They do not put things inside you or call people to see what they are doing’’ (Kyeremaa,

female, 32, cervical cancer).

Kyeremaa described her confidence in the Traditional Healers that they would not

intrude, people, intimate privacy, expose their intimate body parts and would always treat

patients with dignity. Most participants perceived the Traditional Healers as sensitive to their

needs around dignity and took the necessary precaution to maintain them. However, the

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Traditional Healers do not usually conduct the invasive procedures, and hence it was

not possible in this study to know how the Traditional Healers would behave if they

had to carry out such investigations. According to most of my study participant,

Traditional Healers seem to consider dignity during examinations and did not invite

others to the room. The Traditional Healers not calling others to come into the room

when they are dealing with patients, may not necessarily be adherence to patients'

dignity. Traditional Healers do not usually have many trainees at any one point in

time who may need to be around during examinations of patients. The participants in

this study may have been shocked by conventional practices in modern medicine.

Most participants gave the impression that they trusted the Traditional Healers

because of their reliability and continuity of care. Majority of the participants felt they

could depend on the Traditional Healers most of the time to act on their interest

irrespective of prevailing adverse conditions. Most participants expressed the feeling

of an existing implicit ''moral contract' in the community between them and the

Traditional Healers.

“The man used to live a bit far away from my house but used to see me every day or at least

every other day no matter what the weather conditions were. On the days that he could not

see me, he will tell my husband to call and tell him how I am doing’’ (Fremah, female, 31,

cervical cancer).

Noticeably, Fremah could always count on the Traditional Healers

unconditional and continuity of care. The symbolism 'weather conditions' as used by

Fremah is like ''rain or shine'' which was used by Barwuah. Ghanaians use both

allegories to express the commitment to do something even in an uncomfortable

situation.

“You can call them in the night or anytime and if you need them then they would come to you

in shine or rain’’ (Barwuah, male, 74, prostate cancer).

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Primarily, Fremah and Barwuah emphasised the Traditional Healers loyalty and

commitment to honour their obligation to their patients even under challenging conditions.

Patients or relatives could request to see the Traditional Healers at any time, and the

Traditional Healers would usually respond favourably. Such a practice is not different in my

experience of residing in Ghana where it was common to call the Traditional Healers in the

night to see a sick person in the community. In contrast, both my experience of previously

living and working in Ghana as a nurse and during the data collection for this study at the

hospitals showed that most encounters between patients and doctors were transitory and brief

without recurrence. Most doctors kept their contact and address private and have little or no

interaction with patients outside the hospitals or working hours.

Also, there was a lack of continuity of care, as most patients saw different doctors at

each visit. The responsibility of the doctors to patients was usually a legal contract, ending at

the hospital with no long-term moral attachment. Most participants demonstrated the lack of

trust in doctors because of the perception of the doctor’s unreliability to provide continuity of

care, a representation of the lack of ‘moral contract’ between doctors and patient. Most

participants primarily trusted the Traditional Healers because of the perception that the

Traditional Healers were reliable and committed to them no matter the situation. The

following observation is a reinforcement of the concerns that some patients had about the

lack of continuity of care.

I observed in the hospitals that different doctors conducted consultations on different days.

Hence, patients had to see any doctor who was available or scheduled to review patients on

the day of their visit. Some doctors in the hospitals were student doctors on rotation and

followed a rota system which required them to move between wards and clinics. Also, some

doctors moved between hospitals as part of their orientation program or because they were

doing locum work. I observed how sometimes the patients spoke among themselves trying to

ascertain which doctor was on duty at the clinic. The patients appeared to prefer some

doctors. However, they had no control on consistency on which doctor would see them.

In contrast, the herbal clinics were managed by the same herbalists with a few other staff.

Some of the staff have worked in herbal clinics for many years. Most of the patients appeared

to see the same staffs at every visit and hence felt familiar and comfortable with them (OFN,

CP, HC, 2015/2016).

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The frequent moving and changing of doctors made it impossible for patients to see

the same doctors regularly or form a therapeutic relationship with them. The patients

interpreted the situation in the hospitals as a lack of care towards them. Also, the patients'

inability to see the same doctors regularly may force them to repeat to the doctors what they

may have already discussed or said before. However, most herbal clinics had been managed

by the same herbalist and staff for many years, and the patients had formed long term

therapeutic relationships with them.

Some participants trusted the Traditional Healers because of the widespread success

stories from their own experiences or other people's encounters. Many of the participants had

experienced a successful treatment of some illnesses from the Traditional Healers or were

aware of the Traditional Healers reputation in treating certain illnesses. In the excerpt below,

Abrafi described the success story and experience of her sister’s treatment with a Traditional

Healers:

“I remember that my sister was playing volleyball and had a fracture of the left leg. It was an

herbalist who put it together, and within two weeks, she was out of bed” (Abrafi, female, 41,

cervical cancer).

Abrafi expressed trust in the Traditional Healers for swiftly and successfully

treating her sister when she fractured her leg. Most Ghanaian indigenous communities

think the herbalists are competent and would successfully treat fractures or chronic

diseases than the doctors (Aries et al. 2007, Solagberu 2005). The chronicity of cancer

for most of my study participants may have contributed to their choice for the

Traditional Healers. However, there was no evidence of the Traditional Healers

successfully treating cancer in Ghana. Furthermore, some participants (e.g. Yamoah,

Benewaa and Akoto) trusted the Traditional Healers for their ability to treat the

conditions which were perceived to have supernatural dimension to them.

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“Traditional Medicine helps us regarding these things, diseases that the doctor has no

medicine or are not caused by physical [causes]” (Benewaa, female, 43, cervical cancer).

Most participants trusted the Traditional Healers for their inherent recognition of supernatural

influence on human endeavours and the possession of spiritual authority to treat both the

physical and spiritual aspects of an illness. Some studies in Ghana and other parts of Africa

found that the perception of a spiritual association with cancer influences patients to choose

Traditional Healers (Yarney et al. 2013, Ezeome, Anarado 2007, Bazzano et al. 2008).

Although many participants were not specific that their condition had spiritual inference,

many of them assumed the possibility since they did not see a favourable treatment response

from the hospitals. Most Ghanaians have received successful treatments from doctors, but

this does not form part of the community discourse as people do not generally look for

testimonies before attending the hospital. However, some participants trusted the doctors in

emergencies. Barwuah, for example, thought the doctors were useful in dealing with acute

and life-threatening conditions:

“The hospital medicines are good when you want something to happen immediately. They are

suitable for only emergencies. In an emergency, they stop the problem quickly but leave it

there and do not cure it’’ (Kyeremanteng, male, 70, prostate cancer?).

Kyeremanteng trusted the hospitals and doctors’ ability to treat emergency conditions.

Although they were unable to provide a long-term solution, consequently, some participants

mentioned how they would go to the hospital to get a diagnosis and subsequently go for

treatment from the Traditional Healers. For example, accident victims immediately attended

the hospitals for doctors to stop their bleeding and later left for the Traditional Healers (Aries

et al. 2007). Also, in an emergency, the sick person may not necessarily have many choices

apart from going to the hospital accident and emergency department.

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4.4 Finding Solace in Therapeutic Hospitality and Conviviality

The paradigm’s shift within the healthcare industry to emphasise on patient

experience and perspective makes customer service a logical partner and complementary

resource for healthcare providers (Steele et al. 2015, Suess, Mody 2017). Therapeutic

hospitality and conviviality describe the amicable between participants and

Traditional Healers within the herbal clinic context. Most participants described how

Traditional Healers treated them respectfully and established friendly relationships

with them. Many participants thought the Traditional Healers showed interest in them

by listening to them, giving them the necessary attention and providing

encouragement to them. Thus, the Traditional Healers created the right atmosphere

for the therapeutic interaction by focusing on the social aspects of the therapeutic

encounter and treating the participants as whole human beings rather than as diseased

bodies.

4.4.1. Being Reassured by the Friendly and Jovial Manner of the Traditional Healers

Most participants recognised the importance of their health professional being

friendly towards them and not being rigidly and overly professional. In the following

excerpt, Akomeah described how the Traditional Healers treated him like a friend:

“As I said earlier, the herbal practitioners or clinics treat people or me well. They are jovial

and treat you like their friend. You may not have visited them before, but they treat you in a

friendly way before attending to you” (Akomeah, female, 28, cervical cancer).

Akomeah described how the Traditional Healers exhibited hospitality and

conviviality towards her during the therapeutic encounter with an array of functional

interactions. Most participants thought the Traditional Healers presented themselves

as cheerful, humorous, friendly and informal. Traditional Healers may create a joke

and laughter to relieve any anxiety and tension that their patients may be

experiencing. Akomeah described the hospitable and convivial behaviours of

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Traditional Healers as being treated well. Akomeah’s quote shows how the Traditional

Healers friendly interaction was indiscriminate and extended to all patients, including those

visiting for the first time. Likewise, other participants (e.g., Nkrumah, male, 70, prostate

cancer & Boasiako, male, 35, skin cancer?) shared similar experiences:

“Even the receptionist told me that. Oh, brother, you look worried is everything ok and I said

yes. She smiled and started talking to me about yesterday’s football and what team I support,

and before I realised, I was in a good mood and cheerful. When I went to the out-Outpatient

Department, they talked and smiled at me, and I even forgot that I was sick. Everyone was

friendly, so there was no stress. That was my experience” (Boasiako, male, 25, skin cancer?).

The receptionist pleasantly and informally addressed Boasiako as a brother and

consequently lowered the threshold of any real or perceived hierarchical protocol in their

relationship between herself and Boasiako. Equally important, the receptionist smiled and

discussed everyday activities with Boasiako. The behaviour of the receptionist was like what

some researchers have termed as 'symbiotic niceness'. Symbiotic niceness is a situation in

which both nurses and patients construct therapeutic relationships in psychosocial palliative

care with mutual niceness (Li 2004). The concept describes how nurses and patients

presented themselves as friendly people to facilitate therapeutic relationships (Li 2004).

Also, Boasiako described how the receptionist smiled and commenced discussing an

everyday subject with him to allay his anxiety. The introduction of casual discussion on

mundane life occurrences is an essential part of friendliness that can progress to a more

significant discussion (Hunt 1991). Consequently, Boasiako figuratively was able to take his

attention away from his illness and stress because of the receptionist friendly behaviour.

Being friendly and informal is a necessary manoeuvre in creating the prospect for health

professionals and patients to form appropriate therapeutic rapport that can foster useful

therapeutic encounter (Jarrett 1998). Through the friendly and jovial relationship, Traditional

Healers and participants built a trusting relationship for their mutual benefits. However, the

Traditional Healers friendliness and happiness may also be a way that the Traditional Healers

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induced compliance and exerted power over their patients. Some participants co-

constructed the friendly encounter or therapeutic hospitality by either responding to

the Traditional Healers or sharing their jokes. The excerpt below from Yamoah serves

as an illustration:

“I was even practically making jokes with them, and they did not take it as an offence’’

(Yamoah, male, 31, liver cancer?).

Yamoah felt comfortable and at ease to make jokes in return to the clinic's

staffs' behaviour and was astonished that they did not become offended. Hence, the

initial impression or behaviour of a health professional can influence the therapeutic

relationships and encounters by encouraging a positive response from the patients

(James 1986, Jarrett 1998)

4.4.2 Participants perception of Traditional Healers interest in them

Most participants thought the Traditional Healers were interested in their lives

and hence conversed with them about a wide range of social and personal matters of

importance. In the data extract below, Nkrumah, a 70-year-old man with prostate

cancer, shared his experience:

“Also, some of the herbalists, you become their customer, the moment they see you, they treat

you as if you have gone to them many times. Even if it is your first time, they take their time to

find out more about you and the diseases and even the places you have visited before unlike

the nurses and some of the doctors” (Nkrumah, male, 70, prostate cancer).

Most participants described the Traditional Healers by discussing conventional

doctors or drawing the comparison with the manner of them. Some authors refer to

this as contrasting rhetoric in which the participants try to reveal the positive aspect of

Traditional Healers or Traditional Medicine by simple discussing their negative

feelings about the conventional doctors (Hargreaves 1981, Coffey 1996, Mylonas

2014, Titley 2013). According to Nkrumah, the Traditional Healers casually showed

interest in participants routine activities and previous encounters. Traditional Healers

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wanted patients to feel at home and genuinely cared about their entire personhood and

welfare. Also, Nkrumah described how the Traditional Healers find out in more detail

about the patient's condition and concerns and any places they have visited for treatment.

In contrast, Nkrumah viewed the doctors and nurses as uninterested in their patients'

previous therapeutic encounters, whether in another Conventional or Traditional Healers

setting and focus on the now. The following data extract from Aborampah, a 73-year-old man

with prostate cancer echoes Nkrumah’s view:

''Oh, you do not have to queue, they talk and chat with you as because they have known you

for a long time or you are from the same village. Traditional Healers do not talk only about

the disease to make you feel you are sick. Instead, they welcome you well and explain

everything to you’’ (Aborampah. male, 73, prostate cancer).

Strategically, the vivacity of the Traditional Healers preceded the discussions about

the patient's sickness. Most participants valued simple warm-up interaction, such as receiving

culturally specific greetings on their arrival at the clinic or encounter with staffs. Exchanging

of wellbeing greetings is very much part of the initial proceedings of social encounters in the

Ghanaian culture. From this perspective, the Traditional Healers may be adhering to the

cultural requirements of their communities. Perchance, they know how to talk to patients and

put them at ease and to deliberately divert their patients' attention from the disease and

anxiety. In either case, most participants felt that the Traditional Healers showed that they

have an interest in their entire wellbeing.

Notably, participants desired their health care professionals to show interest in the

entirety of their life. Such a desire did not appear to preclude participants fundamental

objective of getting a cure for their illness. Most participants preferred the process and the

trajectory to cure to be considerate of their broader needs and feelings. Aborampah wanted

the health care professionals to recognise him as a person not treat him like a disease. The

following field note observation explains how the Traditional Healers welcomed and initiated

a conversation with their patients as part of their hospitality.

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Traditional Healer: Welcome Madame (Mother).

Patient: Thank you.

Traditional Healer: How are you?

Patient: I am fine, thank you.

Traditional Healer: Where have you come from?

Patient: I came from [name of the village]

Traditional Healer: Oh, I know that place very well because my sister lives there with her husband. I am

visiting them this weekend.

Patient: you are coming at the right time because of the season; you can bring a lot of food and fruits

back with you. ….(OFN, HC, 17/06/16)

“I observed most Traditional Healers having chitchat with their patient at the

beginning and the end of their encounter as a matter of standard routine. Such

behaviour or practice appeared to help the Traditional Healers to introduce to patients

their planned transaction steadily and bring it politely to a close. Other participants”

(Duffie, female, 42, cervical cancer; Boasiako, male, 25, skin cancer; Yamoah, male,

31, liver cancer; Ohemaa, female, 71, cervical cancer) shared similar experiences of

the herbalist talking to them on routine matters and showing interest in them.

In contrast, many participants did not think that such was the case in the

conventional medicine settings, as shown in the extract from Ohemaa:

“Hahaha, I cannot read, I cannot write, I did not go to school, they give you a paper and say

go to the pharmacy and get drugs or buy and you do that. They do not ask you a question

because they cannot spend their time talking to you alone, so you must do what they say’’

(Ohemaa, female, 71, cervical cancer).

Ohemaa's described her interaction with the doctor at the hospital as brief and

one-way precise instructions (Berry 2006) in which she had to obey without

questioning. Interestingly, Ohemaa blamed herself based on her lack of education, and

the situation in the hospital, which may have contributed to the doctors’ lack of

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interest and engagement with her. In contrast, Traditional Healers or staff showed interest

through their compassionate manner and consideration to the needs of most participants.

E.g., Boasiako described the support that he received from the Traditional Healers:

“I do not know what kind of training he gives to his people, but they are very

hospitable and helpful. They understand everyone, or at least I can only speak for myself that

they showed understanding and empathy” (Baosiako, male, 25, skin cancer).

Boasiako felt that the Traditional Healers or staffs were supportive to him and

described the elements of this support as hospitable, helpful, understanding and empathy. It

seems Traditional Healers responded to their patients’ emotional or psychological needs by

showing warm, tolerance and empathy with them. Equally, the Traditional Healers or staffs

provided physical assistance to their patients, such as getting them a seat to sit on; getting

them water to drink and making sure, they were comfortable. I observed in the herbal clinic

that the staffs showed willingness and promptness to help both visitors and patients:

A man got out of a taxi with her daughter and headed towards the clinic entrance. He

was indicated that they were coming to the clinic. The man appeared weak and strolled. The

daughter, however, could not support him because she was carrying two full big bags, which

appeared heavy. The security person got up to help immediately he saw the man and the

daughter. He took the bags from the daughter and asked them to wait where they were. The

security man took the bags to the clinic and came back to support the man also to the clinic.

The daughter was very grateful and commented on how the staffs are always helpful during a

casual conversation at the communal area (OFN: HC, 10 June 2016).

“The security person acted responsively and offered to help the patient to carry her

bags to the clinic. The patient's daughter shared her gratitude to the security staff with me and

indicated that the practice was common in the clinic”.

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4.4.3 Being Listen to and Giving Attention

Most participants felt the Traditional Healers showed hospitality to them by giving

them attention, listening to them and engaging them in dialogue. Additionally, most

participants thought the Traditional Healers could see them within a reasonable time of their

arrival to the clinic, allocate to them enough consultation time, and did not make them

feel rushed. Majority of participants feel they do not receive such hospitality or

attention in the conventional medical facilities.

In the following excerpts, Yamoah shared his experience with the Traditional Healer as

commendable.

''When I went there, they took their time, no rush. The herbalist asked me all

the necessary questions and allowed me to ask questions, and he answered them. The

doctors in the hospital should learn to listen when we ask the question even if they are

stupid because that is the only way you can help somebody, the only way you can help

me. The herbalist had the time for all my questions. Here or any herbal clinic that

you go, the truth is that they care about you, their medicine may not even be good,

but you would love to go there because they listen to you as human beings'' (Yamoah,

Male, 31, liver cancer)

The Traditional Healer allocated enough time to listen and asked questions to

gain an understanding of Yamoah's disease and concerns. Yamoah felt the Traditional

Healer did not judge his intellectual capacity but allowed enough time and opportunity

to talk regardless of whether what he had to say was pertinent or not. Yamoah

highlighted the need for doctors or conventional health professional to listen to their

patients even if what they may be saying is not medically plausible. In Yamoah's view,

the only way one could help with his condition appropriately was for that person to

take the time to listen to his concerns.

Yamoah does not view health-seeking to be influenced by the quality of

treatment alone but also how one is made to feel like a human by health care

professionals. Yamoah described how the medicine that the Traditional Healers

provide may be less effective but would still attract the visit of many people because of

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the kind of the human experience that they may receive. Other participants, (e.g., Duffie,

female, 42, cervical cancer and Abrafi, female, 41, cervical cancer) described similar

experiences with the Traditional Healers of how they take their time to listen.

Data from Abrafi draws a clear distinction between the situation in the hospital and the herbal

clinic:

‘They have time for you (emphasised). Until you are ok and have asked your entire questions

or talk about anything, you want they would engage with you. There is no rush at all.

Sometimes the herbalist would take about 30 minutes to one hour to see one person. In the

hospitals, it is very different, you queue, and you are just part of the numbers or statistics.

Sometimes you would go at 8 am and would only see the doctor at say 3-4 pm. nobody would

even tell you what is happening. You could sit there like a tree while people walk pass you up

and down. The doctors would not explain anything to you. They would only tell you to take

this take your prescription and go. They have no time or interest in you. It is whom you

know’’ (Abrafi, female, 41, cervical cancer).

Again, in this quote, Abrafi used contrastive rhetoric to discuss her experience in the

herbal clinics and the hospital. Abrafi described how the herbalist gave her enough time to

exhaust all her questions and discussed any issues she wanted by drawing a comparison with

the doctors' behaviour. Although it might be a hyperbole that the herbalist allowed between

thirty minutes to one hour for consultation, my observations back the reported fact that the

Traditional Healers in this study gave time and attention to their patients. I observed that the

Traditional Healers did not seem to work under pressure or fast pace. In contrast, Abrafi

characterised the hospitals with longer waiting times, short section times, lack of attention to

patients and lack of information or updates about the doctors' schedule. In my experience of

working in Ghana, doctors are very autonomous and have a limited sense of accountability to

any subordinate or associate staff.

It appeared in the hospitals that most doctors did not inform the nurses or health care

assistants of their schedule. Hence, the nurses were unable to update patients of the doctors

whereabout or what time they would be coming to the clinic. They leave patients unattended

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or ''walk past'' them and avoided interaction, interruption or questions. Therefore,

patients usually must wait until anytime the doctors arrived.

Moreover, Abrafi mentioned the idea of '' whom you know'' to symbolise how

the privileged few, e.g., those who know the staffs, have wealth or rank high in

society do not encounter the same challenges. In the hospitals, I observed that people

with the right class or connections had due attention and were prioritised by the

doctors and usually bypassed others. The following observations substantiate the

assertions of most participants about the difficulties they encountered in the hospitals.

“I arrived at the hospital at 8 am, and the corridor to the clinics and

consulting rooms were already full of patients. At 10 am, I asked the reception when

the doctors would be coming to see the patients. The reception told me that she does

not know. Sometimes they come at 10 am, sometimes at 11 am and sometimes at noon.

It all depends on which doctor is on duty. Nurses and other staff are moving around;

some would go to the clinic rooms and come out. Patients were anxiously waiting, but

no one tells them anything’’ (OFN, CP, 2015)

There was no specific clinic schedule as it was dependent on the doctor on

duty. Most doctors came to the clinic late and had limited time to see patients, which

could explain why they were straightforward in their approach and avoided

conversations or questions that might delay them. The following is an illustration of

how the doctor discounted Yamoah's question and the suggestion.

“The doctor said he was going to do a malaria test, and I asked him why he was not going to

add typhoid test. Instead of him explaining to me why he does not want to add typhoid test, he

asked me whether I am the doctor” (Yamoah, male, 31, liver cancer).

Unfortunately, the doctor saw Yamoah’s suggestion for other investigations

to be carried out as unequivocally challenging his authority and expertise. The doctor,

instead of explaining things to Yamoah, quickly curtailed Yamoah’s suggestion and

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asserted his authority as the one who makes all the clinical decision. From my personal

experience and field observations, most conventional doctors in Ghana view any quizzing

from their patients as a lack of trust or a challenge on their expertise and authority. Doctors

and the Biomedicine turn to see themselves as the repository of medical knowledge and

hence monopolise and influence most medical decision and policies (Nettleton 2013, Rose

2007). The sequel of such a notion in Ghana is that most of the indigenous population and

participants of my study felt they had no legitimate right to question what the conventional

doctors perceived as the best treatment or cause of action.

However, the situation is transforming, especially for the population who have had

western education and culture. Yamoah was a teacher, and hence, it was not surprising that he

wanted to contribute to the decision about his care. However, the situation in Ghana differs

from developed countries where patients have more power, choice, and input into their care.

Such behaviours between the conventional doctors and the rest of the population is not a

social contract, instead is a facsimile of power and knowledge dynamics in the society. On

the other hand, most participants explained how they felt comfortable and able to converse

freely and asked the Traditional Healers questions without feeling intimidated.

4.4.4 Feeling Relaxed

Most participants gave an account of experiencing a friendly atmosphere at the herbal

clinics. They described the herbal clinics as loose and lacking rigidity and restriction. Most

participants associated the Traditional Healers clinics with softness, easiness and a homely

ambience where they could relate to both the staff, other patients and freely express

themselves naturally without the fear of judgment (Parr 1997). Most participants considered

the herbal clinic staff as open-minded people who allowed them to be spontaneous and

natural. Authors describe such liberal environments of social relatedness and sense of safety

as “effective sanctuaries’’, “haven of sociality’’, “shelter’’, and “convivial space’’ (Nayak

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2017, Butterfield, Martin 2016, Moore et al. 2013, Glover, Parry 2009). The interview

excerpt and observation below are illustrations of the prevailing atmosphere in the herbal

clinic:

“Well, you can see for yourself, there is the music playing with a calm atmosphere. I could

not complain in any way. They are real community people, and I enjoy it here. I am not

saying this because I am here, I am an elder and I cannot lie, I say it as it is. Sometimes you

look at the way the nurses handle some people or patients in the hospital; you are sure such a

person would not come back again if they had the choice” (Boampong, male, 76, prostate

cancer)

“I observed that radio was music; some patients and relatives were sitting outside around

some tables with a parasol. Some people were playing the “Oware game’, some were

chatting and laughing, while others were enjoying the music and relaxing’’ (OFN, HC,

2016).

The people around the clinic seemed happy from their facial and outward

expressions. Some of them were laughing and talking with each other while others

were playing the local game “Oware .’ Boampong’s instant reaction when I asked him

to share his experience of using Traditional Healer was to point to the open

interactions that were taking place around him. He referred to the people around him

and the clinic as ‘’community people’’. Boampong was implying that the people in

the clinic, both staff and patients were free and got on well with each other. Although

Boampong mentioned that he enjoys coming to the clinic, it is unlikely that he meant

this be literally. Quite contrary; he may be referring to the feeling of liberty and

hospitality that he receives at the clinic not feeling tense about visiting the clinic.

Boampong mentioned his age to substantiate the credibility of his views. There is a

general conception in Ghana that the senior citizens have experience, wisdom, and

character, and they would always tell the truth. In effect, people can trust or believe

them, to be honest.

Contrary to the experience in the Traditional Healers clinic, Boampong

expressed dissatisfaction with the rigidity, atmosphere of surveillance and

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judgemental attitude in the conventional hospitals. Indeed, the sophistication of conventional

health facilities may require structuring, monitoring and controlling of some of their practices

and environments from patients for safety purposes (Curtis et al. 2009). Most of these

hospitals did not offer much hospitality to their patients; instead, they focused on procedures

and processes, leaving most patients frightened and unable to be themselves. Boampong

believed that most people are unlikely to go back to the hospitals if they have a choice.

Nearly, all participants (e.g. Akoto, female, 47, cervical cancer; Fremah, female, 31, cervical

cancer; Fuseini, male, 72, prostate cancer; and Nyamekye, female, 29, uterine cancer) uttered

similar concerns about the tense hospital atmosphere and their inability to be themselves or

voice their opinions for fear of repercussion such as not being treated by the doctors.

4.4.5 Feeling of Lifting the Spirit and Boosting Hope

Most Traditional Healers offered another aspect of welcoming attitude and

atmosphere to their patients by giving them hope and encouragement that their situation is

under control. As part of hospitality and excellent customer care, some professionals

exercise emotional labour of presenting themselves as enthusiastic, capable and having things

under control all times (Hochschild 2012). Similarly, as cultural practice in Ghana, elders and

healers are required to maintain their composure and show emotional strength under

challenging circumstances to offer hope and support to the rest of the populace.

Consequently, healers are usually careful to avoid the sick person or their families, perceiving

them as weak or negative.

The following observation in a herbal clinic was a demonstration of how the

Traditional Healers gave hope to their patients through conversation.

I observed that the Traditional Healers appeared very calm in their demeanour and

approach to patients and seemed to not talk about the severity and potential consequences of

patients’ condition. Instead, they seemed to downplay the illnesses of their patients and offer

them hope and encouragement. While I was in one of the herbal clinics, a woman brought her

father for treatment. The receptionist asked the older man to sit down. The receptionist told

the older man that his facial appearance was not good, as he appeared worried. The older

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man said to the receptionist that he has been suffering from the disease for a long time. The

receptionist then informed the older man that he would recover soon. The receptionist

reassured him that all the other patients that he sees around were once in comparable

situations, and now they are all doing very well. The herbalist told the older man that he

would do everything possible for him so he should not worry. In a brief time, the older man

appeared cheerful from his facial expression and demeanour (OFN, HC, 2016).

The herbalist and his staff appeared to focus their conversation on the positive

outcomes and testimonies of others and not on the current situation or what can go

wrong. Most herbalists gave their patients hope and encouragement by talking about

their achievements and their ability to treat illnesses. Some of the herbal clinic staff

also pointed to other patients to emphasise the herbalists' ability to treat illnesses. I

was a bit surprised that the herbal clinics did not appear to tell patients about the

severity of their conditions or discussed the potential or possible adverse outcomes.

Although most participants accepted that they were very unwell and current

condition was severe, they maintained some optimism within their heart: light at the

end of the tunnel. Even those at the advanced stages of their illness appeared to keep

their hope and optimism alive and welcomed the Traditional Healers reinforcement of

their hopes and aspirations. Most participants reported that Traditional Healers

provided them with inspiration and expectation by using encouraging and uplifting

words and maintaining the right demeanour of reassurance. Fordjour expressed how

he maintained his hope because of the hopeful presentations of the Traditional

Healers.

“I am hopeful because they gave me hope. They have not given up on me; they keep

encouraging me that it would be ok, so I also have the hope that it would be ok. If the person

looking after you have not declared you hopeless, then it means you are not going to die. If

you are not supported but made to feel that your condition is worse, then you will die

tomorrow’’ (Fordjour, male, 61, prostate cancer?).

Health professionals have the power to influence the moods and motivations

of patients through their interactions and choices of words (Fallowfield 1993).

Fordjour's feeling was that the Traditional Healers had not relinquished their

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positivity towards him or declared his condition as dismal, and hence there was no reason for

him to give up. The attitude of the Traditional Healers influenced Fordjour to have

confidence in himself and hoped for a favourable treatment outcome. Similarly, the assurance

from the Traditional Healers positively affected Fordjour's wellbeing, security and recovery.

In contrast, patients can misconstrue any nihilism from a health care professional as a sign of

doom or impending death. Fordjour believed that people would die sooner or have their

condition deteriorate if they get the signal that their condition is hopeless.

Perhaps, this is one of the reasons for most Traditional Healers maintaining a positive

attitude, at least in the presence of patients. Other participants (Yamoah, male, 31, liver

cancer; Adomako, female, 80, cervical cancer; Abrafi, female, 41, cervical cancer and

Ohemaa; female, 71 cervical cancer) shared similar experiences that the Traditional Healers

spoke to them in a way that gave them the impetus for the future. Adomako described how a

receptionist in an herbal clinic offered her hope that her condition would improve:

“The woman at the reception perchance thought I was anxious and said mama, now that you

have come here you will be ok. Many people with significant problems come here and see

their lives change. You must be hopeful that you will get better (Adomako, female, 80,

cervical cancer).

The receptionist may have observed Adomako’s possible expressions of the feelings

of worry and anxiety and spoke to her hearteningly. The receptionist was strikingly aware

that most of the patients who come to the clinic could be worried and anxious because of

their vulnerability and situation. Therefore, she appears to watch out for signs and facial

expressions of anxiety and intervenes appropriately. The receptionist comforted Adomako

that her case was minor compared to the severe conditions that the herbalist can treat. Most

participants shared similar experiences in their accounts. They described how they became

uplifted because of the words of encouragement they received from the Traditional Healers.

The Traditional Healers thus provided a positive mood stimulus for their patients.

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4.5. Aiming to Avoid Upset and Manage Emotions

’Words are singularly the most powerful force available to humanity…. Words have energy

and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate and to

humble’’ Yehuda Berg (Toler 2019, chapter 1, page 9)

The theme “Aiming to avoid upset and Manage Emotions “describes the

participant’s perception of how the Traditional Healers negotiated within the socio-cultural

conventions to avoid upsetting or exacerbating their feelings and manage their emotions.

Many participants described how Traditional Healers discussed their condition and sensitive

issues with them by using a euphemism to protect their emotions. For example, “Yade bɔne’

which means a deadly disease. In a more profound sense, the term is a description of a

deadly disease and used usually to discuss diseases such as cancer and HIV/AIDS by most

people in Ghana. In parallel, most participants themselves used nondisclosure and secrecy as

a way of avoiding upsetting themselves, their families, and protecting their self-image.

4.5.1 Euphemising: Softening and Placating Participants Situation

Euphemising was most participants’ description of how Traditional Healers

used the appropriate moments and culturally acceptable words to discuss participants’

situation to avoid upsetting them and managed their emotions. Most Ghanaians

believe that openly discussing death, misfortunes or severe illnesses or referring to

their actual names can upset the victims. Also, this can lead to the illness or condition

occurring, reoccurring or perpetuating. Most participants felt the Traditional Healers

understood the socio-cultural requirements and complexities around severe or

terminal illnesses and their emotional impact on people, as shown in the excerpt from

Serwaa.

’The herbalist would know how to tell you when there is something wrong with you so that

you do not become upset. Some of the doctors are so blunt’ (Serwaa, female, 52, breast

cancer ).

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Serwaa felt that the Traditional Healers were mindful of the time, place and moments

to deliver tragic or unpleasant information to their patient to prevent upsetting them or at least

curtailing the impact on them. Most Ghanaians consider some severe diseases as misfortunes;

hence, they treat such sicknesses with the same weight of spirituality and use indirect or

subtle words to discuss them.

Discussing these diseases softly and at the right moment, diffuses their intensity and

manages and protects the emotions of the people affected. Furthermore, identifying the right

moment to deliver shocking news is a cultural imperative in Ghana. For example, messengers

of sad news would usually hold off until the right time, and the setting is ready without

rushing. Such people are usually skilful and would sometimes behave as if their visit is

routine, ensuring that the recipients of their message have eaten, have had their shower and

are comfortable before sharing the shocking news. Serwaa’s analogy emphasised how

Traditional Healers choose the right time and environment to discuss sensitive and disturbing

issues to safeguards participants' emotions.

On the contrary, most participants described doctors as causing upset to them by

being abrupt and direct with their language. In the following excerpt, Nana Hussain, a 56-

year-old man with liver and lung cancer, became upset and expressed grievance with the

doctor for not adhering to the socio-cultural decorum;

“When I met him, he said Nana, there is a problem, I said to him, but the other doctor said

there was no problem. He kept quiet and said I am afraid you have your liver and lung

damaged. You have liver cancer, and you must reduce smoking and drinking; otherwise, it

will kill you soon. He was very blunt, and I do not think a doctor should say things like you

will die, that alone can kill me’’ (Hussain, male, 54, liver and lung cancer).

Hussain was concerned that the doctor was forthright with him in discussing the

possible negative outcome of his disease. Death and dying have acute sensitivity in most

Ghanaian communities. Respectively, people handle a conversation about death and dying

with extreme sympathy and compassion. People use subtle words such as ''Wawhire

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Akwa/kra'' (he has lost his life or soul), Wafiri Mu (he has left or gone), and ''Wadane

atɔ’ (he has turned away) to talk about dying or say someone has died as a way of

respecting and showing empathy.

Therefore, Hussain did not find it promising for the doctor to say to him that

he would die, although the doctor was merely stating the obvious. Instead, Hussain

expected the doctor to appreciate that directly referring to death was inappropriate

culturally and showed disregard to his sentiment. Hussain wished the doctor had

ensured that their conversation was not charged emotionally or caused nervousness to

him. Most participants found conventional doctors to be too direct in dealing with

daunting issues with their patients. The doctors appear to consider the legal and

professional implications of their communication more than the culturally agreed

ways of breaking the unwelcome news.

However, precisely and indifferently delivering sad news have distressing and

abiding consequences on the recipient (Fallowfield 1993). Unfortunately, weak

sensitivity to cultural practices hinders most doctors from managing such situations

appropriately (Fallowfield 1993). Given the manner that the hospitals were busy, it

may be possible that the doctors bluntly delivered terrible news because they do not

have enough time to spend with each patient and prepare them gradually for the sad

news.

4.5.2 Concealing: A Non-Disclosure of Participants Illness

Another way in which participants tried to avoid upsetting themselves and

others was through demanding concealment from health professionals, keeping their

condition to themselves, and not disclosing it to their families or relatives.

Concealing, in most contexts, involves the notion or elements of silence and secrecy

(Carlisle et al. 2013, Brennan 2017, Lavers 2012). Hence, my study participants

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primarily wanted their health care professional to keep their situation secret and not expose it

to others. Urging or adhering to secrecy was a way in which most participants tried to protect

their image, avoid being a burden on loved ones and not causing upset to themselves or close

family.

Most participants described their ardent desire for health care professionals to keep

their information confidential and not to pass them on, even to their partners without their

permission. The following extract illustrated the unhappiness of some participants when

doctors discussed their information with others without their approval.

“They do not care who is there or what would happen when they have said told them about

your illness. You see, I could come to the hospital with my wife, but it does not mean I want

my wife to know what is wrong, so the doctor should check with me before passing

information to them. However, for them, they talk without consideration to your feelings”

(Yamoah, male, 31, liver cancer).

Yamoah expected the doctor to conceal his illness and became upset that the doctors

did not observe such confidentiality. Instead, the doctor shared Yamoah’s information with

Yamoah’s wife without getting permission or considering the possible consequences of such

an action. In this case, the doctor may have presumed that it was right to tell Yamoah’s

spouse about his condition without Yamoah’s permission. In my experience of working in

Ghana as a nurse, caring for patients was a collective family responsibility. Most health

professionals considered it acceptable to give some degree of information to families to

enable them to carry out their duties or care for their loved ones.

Regardless of what may have motivated the doctor to share the information, Yamoah

deemed such a practice unseemly in certain situations. Yamoah, for some personal reasons,

did not want his wife to know of his situation. Maybe, Yamoah wanted to protect his wife’s

emotions or avoid upsetting her. Granting the current legal liberation and proliferation in

Ghana and heightened awareness of western practices, at least in theory, adhering to patient

confidentiality and seeking consent concerning sharing of patients’ information is essential.

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However, my observation suggests that the doctors sometimes unintentionally and

unconsciously discussed patients with their colleagues without cautiousness.

In my observation, the doctors always saw their patients in a room and sometimes allowed

relatives in the room but not strangers. The relatives turn to be in the consulting room on the

doctor or patient’s request o because of a need for a relative to support the doctor physically

or offer language interpretation. Also, most consultants share their clinics or consulting

rooms with their associates, subordinates, and nurses (OFN, CP, 2015/2016).

The hospitals were busy and had limited spaces compared to traditional

settings. It was, therefore, difficult to conclude whether both the Traditional Healers

and Conventional Medical Practitioners were acting based on resources they had or on

their understanding of the local culture. Yamoah felt that the Traditional Healers’

stealth their patient's condition and information and unlikely to discuss or share the

information with other people. A portion of Boasiako’s interview expounds this

assertion;

“When you see the herbalist, I think everything is kept a secret, so you are free to discuss

your feelings and whatever that you want. The doctors would be discussing your disease with

staffs, and when they are talking to you, they do not care who is around they talk and before

you know a healthcare assistant or a nurse is taking your problem to people that you

probably do not want them to know” (Boasiako, male, 25, skin cancer?).

Boasiako felt that the herbalist would keep his information secret, giving him

the confidence and security to discuss his feelings and concerns freely. In contrast,

Boasiako shared his concerns about the possible lack of confidentiality to his

information with the doctors. He feared that his information with the doctors might

end up in the public or wrong domain. Moreover, most participants regarded non-

disclosure or concealment as part of the process of minimising their shame and

gaining control over managing their self-presentation and personal identity (Golthan

2009).

Majority of participants kept their situation to themselves to avoid

disconcerting themselves from the possible attitude and reaction from other people.

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Some participants were afraid that people whom they may discuss their situation would cause

them upset by stigmatising or treating them with contempt. The following quote illustrates

the dilemma of patients about their condition. However, they resolved to keep their condition

to themselves, as much as possible and as long, as necessary.

“I was afraid that I could not just jump to wash my clothes in public. We are in Ghana, and

you must be careful and sure whom you discuss your disease or situation. Some people will

even laugh at you or take advantage of you trusting them to isolate or stigmatise you. As it

was stated earlier, it was not supposed to be shared with anyone. It was to be kept personal.

It was not supposed to be on the news or the topic of discussion at a gathering or in people's

home. The next day the blood was coming, was yielding in clots. Therefore, I had no choice

but to tell someone which I did, and they brought me to the hospital” (Nyantah, female, 58,

cervical cancer).

Although Nyantah did not feel settled about her condition, she wanted to keep it

secret from others. She used the metaphor of washing one’s clothes in public to imply

making public of something that should be private. Nyantah felt that one should avoid or

exercise caution in disclosing their illness because of the possible undesirable upshots and

upset. Nyantah described some of the possible ramifications of revealing her condition to

others to include ridicule, isolation, stigmatisation and becoming the topic of discussion in

the neighbourhood or people’s home. Nyantah thought that people could take advantage of

her susceptibility to treat her abysmally if they were aware of her illness.

As a result, Nyantah was determined to keep everything to herself at least until it was

no longer possible. Most participants (e.g., Boampong, male, 76, prostate cancer, Boasiako

male 25, skin cancer? and Nyamekye; female, 29, uterine cancer) strongly felt that they

needed to keep their situation to themselves to protect their own emotions and image.

In the excerpts below, Boasiako was concerned that others might patronise and consider him

inadequate if they know of his troubles:

“I put specific barriers sometimes between my friend and me so that they do not go

and tell people that maybe I am going to die or something like that. I do not think it is

necessary to let people know when you are not well. You would be washing your cloth in

public, and this is not a good thing. Also, some people would even look down on you.

Because they think you are inadequate in some way, you are sad and suffering, that is the

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way they will treat you. I do not want to be pitied because that can be patronising”

(Boasiako, male, 25, skin cancer?).

Boasiako kept some secrets about his illness from friends for the fear that his

friends might tell others about his illness or assume that he was going to die and lead

to people treating him with contempt. Also, Boasiako did not want people to pity him

or think he was suffering. He felt that people who view him in this way were likely to

treat him with pity. Boasiako felt that some form of commiserating could be a

cunning way in which people may belittle and make him feel defective. Boasiako kept

things secret to avoid feeling distressed and upsetting from his friends’ potential

behaviour or reaction and that of others who may get to know of his situation.

Furthermore, most participants tried their sickness to themselves and not tell

others, especially their significant others as they did not want to inconvenience or

burden them. They felt that their relatives or families would feel obliged to look after

them once they know the situation.

“I did not tell anyone because I did not want to be a burden on my family. The thing is that

when you tell them then, they feel obliged to help because they cannot look at you to suffer.

You end up letting them stop their own business. They may not be able to tell you that you are

a nuisance, but you know it yourself that you are becoming a burden to them” (Nyantah

Female, 58, cervical cancer).

Nyantah expressed the fact that he did not want to upset her family by

becoming a burden on them. She did not want her family to feel the onus to support or

care for her. The Ghanaian society regards supporting a sick relative as a moral and

cultural responsibility. People consider families who fail to meet such an expectation

as spiteful. Hence, families usually feel the pressure to honour the duty of supporting

their sick relatives to maintain or earn their reputation in society. Offering such

support sometimes require families to adjust or halt their commitments. In effect, the

socio-cultural contract leaves families with no option other than to provide support

once they are aware of the situation, and Nyantah did not want to put her family under

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such pressure. Nyantah described how she felt her relatives or families might consider her as

a nuisance and offer their help reluctantly. Nyantah seemed very perceptive to such family

frictions and dynamics that can arise. Nyanta’s account reveals the tension that patients go

through in negotiating for family help and trying not to upset them.

4.6 Chapter Summary

The findings chapter has described and conceptualised how the study participants articulated

their motivations to use Traditional Healers and their experiences with the Traditional

Healers in contrast to their lack of trust in conventional doctors. The chapter has shown how

shared community and socio-cultural identities formed the foundation of participants’ trust in

Traditional Healers. Also, the well-established reputation of the Traditional Healers served as

a motivation and influenced participant help-seeking behaviours. In contrast, participants

expressed the lack of trust in conventional doctors as they perceived them as a symbolism of

power, inequality and cultural detachment. The chapter described how participants found

solace in their experience of the therapeutic hospitality and conviviality in using the

Traditional Healers or Traditional Medicine. Besides, the chapter shows how Traditional

Healers used euphemisms to protect the participant’s emotions and how participants

themselves tried very much to conceal their illness and expected their health professional to

do the same.

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4.7 The theory of “Community of Us.”

Figure 9 The Developed Substantial Theory

The theory of ''Community of Us'' shows community identities and tradition as the fabric of

trust in indigenous communities in Ghana. The Theory explains how the placement of trust in

one’s community and identity underpinned the motivation of people living with cancer to use

Traditional Healers and influenced their therapeutic encounter in the herbal clinics or the

traditional health sector. The trust that people living with cancer had for the Traditional

Healers was enshrined in the notion of ''Us', which represents people living with cancer,

Traditional Healers and their community identities. The shared identities create a sense of

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oneness between the people living with cancer, the Traditional Healers and their

communities. People living with cancer shared identities of trust with Traditional Healers

include the shared traditional or ancestral connection, local language identity, familiarity in

community and neighbourhood interaction, and perception of goodwill and reputation of

Traditional Healers. The '' Us'' is also a sense of collective moral sensibility or rightness

which is inherently known to those who share in the common identities and confer trust to

them on the basis that they will act according to the known standards. Traditional Healers

are members of the ''Us'', and hence people living with cancer could trust them to do the right

thing and act in their best interest.

The'' Us' 'excluded ''Them'' or ''They'' as doctors or conventional medical practitioners who

did not share in the trusting identities or ''Us'', and hence could not be trusted by people

living with cancer. Doctors spoke in English, had wealth and power and did not interact with

the local traditions. They were considered as ''White'', a symbolic representation of cultural

detachment, elitism, and colonial or post-colonial supremacy or influence. People living with

cancer did not see doctors as people who have the sensibility and goodwill towards them and

excluded them ideologically as outsiders who could not be trusted.

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CHAPTER FIVE: DISCUSSION

5.1 Chapter Overview

Congruous with Constructivist Grounded theory approach, the participants'

accounts were analysed against the backdrop of the social construction of knowledge.

The focus of the analysis was on people living with cancer’ motivation and

experiences of using Traditional Healers in Ghana. Also, the focus was on how the

motivations and experiences influenced participants health-seeking behaviours

concerning their current diagnosis. The literature review showed that socio-economic

elements such as affordability, availability and accessibility to Conventional Medicine

influence the use of Traditional Healers in Ghana

My study highlighted the subtleties of trusting communities and identities and

the importance of relationships and convivial interactions. These elements

underpinned the trust which formed the foundational motivation of people living with

cancer for using Traditional Healers in the Brong-Ahafo region of Ghana.

This chapter discusses the key findings of my study and how they influence

participants’ motivations to use Traditional Healers for help-seeking regarding their

illness in response to the research question. The findings of the study are also situated

in the broader theoretical context of literature. I demonstrate how my study advances

and to add to the existing body of knowledge around patients use of Traditional

Healers in Ghana. The following are the synopsis of the key finding of my study.

My study findings identified how people living with cancer in Ghana

conceptualised their motivation and experiences for using Traditional Healers as a

relationship of trust. The relationship of trust was significant and comforting to

participants in their help-seeking behaviour concerning health. Participants trusted the

Traditional Healers because of how they saw and experienced the Traditional Healers

as members of their local communities. The Traditional Healers were well-integrated

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into the socio-cultural and historical traditions in the community, with collective community

identities and understandings. People living with cancer and Traditional Healers shared these

community and socio-cultural dynamics of trust. These sociocultural dynamics include

ancestral connection shared everyday language, familial goodwill and local accountability,

and the known reputation of Traditional Healers in the community. Participants local

interconnections of shared identities and trust with the Traditional Healers gave them the

perception of the equal footing of power and equality. These smoothed participants

relationships with Traditional Healers and influenced their preference to use them

[Traditional Healers].

In contrast to the trusting relationships with Traditional Healers, most of my study

participants were left feeling they could not trust the hospital doctors. Most participants

reported little or no trust in these doctors. Most participants felt the doctors were detached

from their patients and sometimes expressed contempt to the socio-cultural and indigenous

values or identities of trust. Some participants described doctors as “Whites ‘or their

behaviour and practices as “whiteness’’. The description designate inequalities, power

imbalance, lack of cultural attachment and lack of respect for socio-cultural prerogatives.

These characterisations of doctors reported by my participants were broadly a symbolic

representation of colonial and post-colonial incursion and adulteration of local customs.

Similarly, many participants in my study did not trust doctors because they found the

doctors' behaviour was culturally and even medically inappropriate. These culturally

inappropriate behaviours include how they treated patients with a rush during consultations

and insensitivity to their dignity. Also, the participants reported a lack of continuity of care.

Most participants saw different doctors each time they visited the hospitals. I did not recruit

conventional doctors to my study or explored their views. Hence it is not possible to explain

their behaviour and whether they feel this is an accurate reflection of themselves.

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Moreover, my study identified people living with cancer and how they

conceptualised their interactions and experiences with the Traditional Healers as one

of therapeutic conviviality and hospitality. My interviews and observations found that

the interaction between participants and Traditional Healers during the therapeutic

encounter was informal and friendly. Also, many participants described the provision

of human and quality time in which participants felt the Traditional Healers did not

rush them in consultations. Instead, many participants felt the Traditional Healers

listened to them and manifested interest in the entirety of their being. Equally, many

participants felt the Traditional Healers created a relaxed atmosphere in their clinics

or consultation. The relaxed atmosphere allowed participants to be open and have the

freedom to be themselves without any anxiety.

Although trust appeared in the study as an element in participants' community

and a source of influence on their health-seeking decisions and behaviours, there are

certain inherent risks which may not always be immediately apparent to the

participants. The trust in Traditional Healers could prevent participants from seeking

appropriate or advanced medical help early or not doing so at all (Helman 2007).

Such a failure to seek help promptly from appropriately trained professionals can lead

to worsening or deterioration of patients' condition and treatment outcome. Moreover,

there is the risk of harm from the treatments from Traditional Medicine as most of

them are not standardised or regulated and lack records of efficacy and safety (Davis

et al. 2012, Langlois-Klassen. 2007).

In Ghana, most patients turn to use both Conventional and Herbal treatment

without any communication with their doctors. The lack of dialogue can lead to

potential drug interaction and danger to patients' life (Langlois-Klassen et al. 2007).

Furthermore, there had been many documented instances across the globe regarding

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the contamination of Traditional Medicine with metals and dangerous minerals with toxicity

and harmful effects on consumers (Garvey et al. 2001, Obi et al. 2006, Ernst 2002, Annan et

al. 2010, Au et al. 2000, Adewale et al. 2016, Teschke et al. 2014). Hence, the whole concept

of Traditional Medicine and Traditional Healers need more research and regulation. Such

attention would ensure that patients who use these medications and services receive the right

protection from potential harm and abuse.

Furthermore, trust potentially played a role even in how participants interacted with

the researcher during the data collection and responded to the interview questions. It is

possible that some participants behaved and responded in a manner that would safeguard the

trust that they had for their communities, Traditional healers and their ancestors. Equally,

some participants could potentially use the interview as an opportunity to express their

general dissatisfaction with the doctors and not give a balanced view or responses (Cook,

Hardin et al. 2005, Hardin 2006, Luhmann 2018, Misztal 2013).

Despite the awareness of the risk, safety, and ethical implications, the researcher

intended to represent the views and voices of the participants as accurately as possible. At

the same time, the researcher acknowledges that the findings of the study were not a

comprehensive reflection of every context.

Conviviality and hospitality also involved the feeling of hope and the lifting of spirits.

Many participants felt that the Traditional Healers offered them encouragement and

reassurance that their condition is under control. Traditional Healers were reported to offer

reassurances through their talk and cultural demeanour of calmness, softness and apparent

resilience. In contrast, most participants described their unhappiness with the judgemental,

regimented and potentially punitive experience in the hospitals. My study found that

participants were mostly anxious and cautious about what they said and how they behaved for

fear of potential repercussions with hospital staffs. Also, participants felt the doctors and

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nurses were unfriendly, unhelpful and did not engage with them in a meaningful

manner and therefore engendered a sense of distrust.

Furthermore, people living with cancer experiences in using the Traditional

Healers also embodies the Traditional Healers’ ability to negotiate within the

indigenous culture. Traditional healers achieve this through appropriateness in

behaviour, management of participants’ emotions, and avoiding upset of participants.

The study found that most participants faced a substantial emotional challenge from

their illnesses and felt the traditional healers had the skills, cultural knowledge and

sensitivity to manage and support them emotionally. Traditional Healers were

reported to achieve this through their method of indirect delivery of sensitive

messages.

Most participants described how the Traditional Healers knew how to tell

them and inform them about sensitive situations. Traditional Healers were able to

choose the right environment and suitable conditions to deliver crucial information

using the appropriate euphemisms, indirect and softer language (cultural telling).

Most participants described positive feelings towards such behaviour and considered

the Traditional Healers as showing thoughtfulness and sensitivity to their emotions,

congruent with the local cultural norms.

Similarly, as part of managing the emotions of participants was the practice of

keeping things to oneself or concealment. Concealment was a complex dynamic in

which participants reported how Traditional Healers sensitively avoided upsetting

participants by keeping participants information secret. Most participants wanted to

keep their illnesses secret from family, relatives and the community, and expected

their health professional to do the same. Most participants reported trust in the

Traditional Healers to keep their illness secret and not disclose to others compare to

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the doctors or hospital staffs. Many of my study participants trusted the Traditional Healers

because they believed and had experienced from them the cultural understanding of keeping

their information about their illnesses secret from family and the public.

Some participants described this as ''keeping to oneself” or “not washing one's clothes

outside in public'' to avoid stigmatisation or ridicule from people. Some participants also kept

their illness information secret to avoid burdening the family. They did not want to put

unintended pressure on their family to provide support for them. However, the participants

did not address their illness like cancer. Hence, their fear of stigmatisation related to their

general condition, appearance and symptoms.

In contrast, participants described doctors as insensitive to their emotions and

disclosing sensitive information about their illnesses bluntly and directly. I observed how

some doctors delivered information to patients in the presence of other doctors, nurses and

healthcare assistants. Such behaviour of doctors appeared as a very grey area as some of

these staffs who were usually present when the doctors shared patients’ information were

staff in the hospitals or clinics. It was not clear whether it was necessary or in patients’

interest for the doctors to share the information with these staffs. However, most doctors also

delivered the news to the patient in front of relatives or partners. Many participants perceived

such behaviour by doctors as hurting their emotional well-being and causing them a great

deal of upset.

The following is a discussion of the key findings concerning people living with

cancer’ construction of the complexities of trust, hospitality and emotion management. The

discussion also includes how these shaped their help-seeking behaviour concerning their

symptoms and health condition and motivations for using the Traditional Healers and their

subsequent experiences of the therapeutic encounters. I begin the discussions by looking at

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the term “White’’ or “Whiteness’’ as used by most participants to denote power,

inequality and cultural detachment and how participants showed distrust toward

''whiteness''.

This chapter also discusses the importance of traditional and community

identities as elements of trust espoused by participants and as their motivation for

using the Traditional Healers. Also, I discuss the critical elements of the interaction of

conviviality and hospitality that explain participants' motivation in using Traditional

Healers services. Furthermore, I discuss the dynamics of emotional management and

avoidance of upset and how both participants and Traditional Healers achieved it. I

discuss these critical findings alongside the contrast of what happens during the

medical encounter with the hospital doctors.

5.2 Trusting Identities: People Living with cancer’ Relationships and Motivations for Using

Traditional Healers

In the study, participants described their motivation for using the Traditional

Healers services based on their relationships and perception of trust in the Traditional

Healers and identity. The participants reported socio-cultural relationships and

perceptions of trustworthiness as a cornerstone of their motivation to use Traditional

Healers. Social trust is the barometer for the perception or level of trustworthiness of

people or an institution (O'neill 2002, Sztompka, 1999, Heckscher, 2015, Mackie,

2001). Social trust forms the foundation and stability of indigenous Ghanaian

communities and their smooth functioning.

In most Ghanaian indigenous communities, social trust, and the general

community’s opinion about the character and performance of health providers

influence the relationships that the community members or individuals usually have

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with these providers. My study identified that most participants had positive views about

Traditional Healers and trusted them. Participants trusted the Traditional Healers as they

matched up to the socio-cultural signals of trust in their indigenous communities. Hence, my

study participants primarily had social trust for people and institutions in their communities

who shared in these identities of trust. In most Ghanaian communities, members are

encouraged to trust community members, the traditional institutions and values that form the

fabrics of the communities. My study participants considered Traditional Healers as part of

the traditional institutions and members of the local communities. Consequently, most

participants perceived the Traditional Healers to be trustworthy and were willing to trust

them regarding medical help for their illness.

In contrast, most participants could not place trust in the doctors because they did not

form part of the community or social circle of trusting identities known to most participants.

My findings are consistent with Mackie’s (2001) analysis of the Eurobarometer data on trust,

a European community survey. In this survey, he observed that people always rated their

country and populations as more trustworthy than the other countries or people of other

nationalities. However, this study did not explain the reasons why its participants selected

their countries population as more trustworthy over other countries. My study was unique or

different in the sense that participants did not base their social trust indiscriminately on

simple physical or sociological membership of the local communities. Instead, my study

participants trusted the Traditional Healers based on the Traditional Healers active and

meaningful engagement and membership, attachment and submission to the socio-cultural

traditions and values of the communities.

Although beyond the scope of this PhD, social psychology has long been concerned

about how social categorisation or dynamics function to accentuate inter-category or in-group

similarities and intra-category or intra-group disparities (Kruglanski, Higgins 2007, Brewer

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2007, Turner et al. 1979, Tajfel, Turner 1986, Tajfel 2010). Generally, people have a

preference for their in-groups or a group in which they share a similar identity. Such

preference can lead to in-group favouritism or acceptance and often distrust and

dislike of out-groups which leads to out-group derogation or rejection (Kruglanski,

Higgins 2007, Brewer 2007, Turner et al. 1979, Tajfel, Turner 1986, Tajfel 2010).

The doctors’ exclusion from the social trust by participants of my study was

both an ideological and practical sense. Most doctors were reported to not come from

the local communities. Also, they lived in expensive and isolated and secluded parts

of the towns from the rest of the local communities. Hence, participants did not

consider them as community members. Ideologically and in a more profound sense,

doctors were not considered as part of the local communities because they had

minimal or no interaction and contact with the local people. Doctors were not seen to

be engaged with the socio-cultural traditional and values. Interestingly, some

conventional doctors were in-group members, either Ghanaians or community

residents. Nonetheless, they were still perceived as out-group members by many

participants because they did not speak the local language or abide by the local

customs and had elite statuses.

Many researchers emphasise the importance of trust in healthcare

professionals and how trust influences the effectiveness of therapeutic encounters and

relationships (Lagenspetz 1992, Rhodes, Strain 2000). The therapeutic relationship

between most of my study participants and their health care professional was

influenced by social trust.

Many of them appeared to report an excellent therapeutic relationship with the

Traditional Healers and expressed satisfaction with their services. In contrast, there

was a note of dissatisfaction regarding their relationship with the doctors. Trust

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influences patients’ behaviour and attitude towards treatment reception, adherence and

sharing of sensitive information that can affect treatment outcomes (Lagenspetz 1992,

Rhodes, Strain 2000, Hall et al. 2002, Hall et al. 2001).

A trusting relationship prevents patients-physician disputes and leads to increased

satisfaction and continuity of care, as patients usually stay longer with the physician they

trust (Lagenspetz 1992, Rhodes, Strain 2000, Hall, et al. 2002, Hall, et al. 2001). Most of my

study participants were vulnerable because of the nature and the stage of their illnesses. Their

accounts reflected a preference for the Traditional Healers whom they could trust to have

their holistic interest at heart and to give them a loving and continuous care. Many

participants in my study knew their Traditional Healers. They had lived in the same

community with them for many years. Hence, they had experienced continuity of care by the

same Traditional Healers.

However, as noted above, the social trust or trust in individual and institutions in

indigenous communities are not arbitrary but based on trusting identities and identification to

specific socio-cultural requirements. In the following sections, I discuss the participants’

expressions or conceptualisation of trust in the findings. These are broadly linked with

theoretical concepts of trust and how they influenced and motivated participants to use

Traditional Healers services.

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Figure 10: Participants model of placing trust in their communities

5.2.1 Whiteness: Power, Inequality and Lack of Trust

Most participants reported distrust in the hospital doctors they visited or

encountered during their current condition and treatment for cancer. Most participants

described their lack of trust in the doctors because of their experience of the doctors’

behaviours and practices. The attitude of doctors was described as representing of

power, contempt and detachment from the local sociocultural standards. These

behaviours and practices included the doctors’ use of the English language as the

primary mode of communication, their western education and perceived attachment to

European or western culture. Most of my study participants, therefore, referred to the

doctors and their practices as “oburoni’’. The term is translated as “white’’ or

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“Whiteman’’ to denote power, economic and class inequalities which were intrinsic to

colonialism in the colonial era with a strong history within Ghana.

The symbolism was also universal in most participants’ accounts to describe the elite

in a society whose behaviours and practices were discordant with the local culture and

identity. Foucault conceptualises power as a social relationship or relational dynamics

(Foucault 1988, Foucault, Rabinow 1991). Luhmann (2018), sees power as a communication

medium that in addition to language can transmit and regulate choices in society. Both

conceptualisations contradict the traditional discourse or perspective of power which involves

one’s ability to impose their will on others or exercise a sovereign or absolute control over

them (Nunkoo, Gursoy 2012, Stein, Harper 2003, Luhmann 2018).

My study participants’ use of Traditional Healers in conjunction with conventional

medicine signified empowerment as they were able to make treatment choices and demand

more respectful patient care. Many of my study participants had the freedom to choose

between the Traditional Healers and the doctors. They could avoid the hospitals if they were

dissatisfied with their treatment or the behaviour of the medical staff. These dynamics were

reflections of power as sociocultural therapeutic interactions and relationships or a medium of

engagement.

In this sense, power exists and functions in a set of relationships, the medium of

communications and social institutions (Luhmann 2018, Stein, Harper 2003). Power has its

expression in these relationships and institution through dependency or interdependency and

inequalities created by social and functional stratification (Luhmann 2018). Doctors and the

medical profession enjoy institutional and professional power because of the vital services

they provide to the public and the unique set of skills and expertise they hold. Hence, the

power of doctors outweighed the power of my study participants as their condition or

sicknesses made them dependent on the hospitals and the doctors. Also, the hospitals

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participating in my study were public or government-funded hospitals where doctors'

pay did not relate to any specific performance. Hence, doctors during my observations

did not seem to have incentives to raise their standards of behaviour and interactions

with my study participants to encourage the continued use of their services.

It was observed that most doctors came to the clinic late and gave little

attention to patients. Some of these were related to doctors performing other duties in

the wards and working under pressure. However, there were some occasions that the

other clinical staffs did not know why the doctors were not in the clinic or know what

they were doing. There was a common knowledge that most doctors worked in private

clinics or hospital and considered that a priority over their work in the public sector. It

is not clear whether data from private hospitals where doctors are more dependent on

the number of patients and their experience for their remunerations would have

altered the power balance in the doctor-patient relationship.

Equally, there is a possibility that the Traditional Healers provided excellent

service because they depended on my study participants for their reputation, income

and existence. Some authors acknowledge how power disparity and dependence

undercut trust as the trustor may not have any hope of influencing the trustee or the

power holder (Hardin 2001, Bachmann 2001, Cook et al. 2005). Some authors argue

that trust and power tend to operate concurrently and hence any theoretical analysis of

trust amongst social actors should be considered simultaneously with power and

inequality (Bachmann 2001, Hardin 2001, Cook et al. 2005, Stein, Harper 2003,

ÖUberg, Svensson 2010). Using Goldthorpe analysis of social class and occupation,

doctors will fall into the category of the upper echelon of society, giving them wealth,

opportunities, and power over my study participants (Goldthorpe, McKnight 2006,

Giddens, Sutton 2013).

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Most doctors in Ghana have affluence and access to the best opportunities in contrast

to my study participants who were at the lower strata of the socio-economic scale. Most

participants were unable to trust doctors because of the socio-economic inequalities, which

they associated with the influence of western education and practices. Such inequalities were

a symbolic representation of the power of the colonial past and cultural contempt or

detachment. Many of my participants described how the doctors have contempt for anything

local and assume superiority for things that originate from the ‘West or America’ (e.g.

Kisiwaa, female, 50, cervical cancer and Yamoah, male, 31, liver cancer, see details in

chapter 4.2 power disparity and lack of trust).

Although it is unlikely that all doctors in Ghana have such attitudes, participants’ lack

of trust in the doctors was prominent and widespread. However, participants continued to use

both traditional and conventional medicine in parallel to meet their needs. Perhaps, the lack

of trust in the doctors was not a rejection of western medicine but a rejection of its cultural

disconnection and seemingly reported contemptuous attitude towards traditional standards.

5.2.2 Trust as a Traditional Identity and Shared Sensitivity

The study found that most participants shared traditions or traditional identities with

Traditional Healers formed the basis of their close relationships, a bond of trust, and

motivation to use the Traditional Healers for therapy. Many participants trusted the

Traditional Healers and had the confidence that the Traditional Healers understood or were

part of the local socio-cultural values and will behave in a manner that was matching with

these values. Some authors conceptualise trust as the confidence or believe that people or

institutions will act rightly or appropriately even in a future situation and broadly in the best

interest of the trustor based on a common established standard (Misztal 2013, Heckscher

2015, Luhmann 2018). Most of my study participants believed that the Traditional Healers

would act in their best interest because of the Traditional Healers understanding of a shared

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rightness or sensibility. Shared rightness is a collective understanding of what both

the trustor and the trustee inherently consider as appropriate behaviour towards each

other (Heckscher 2015).

The mutual understanding provides both the trustor and the trustee the

assurance that each party will act according to an acceptable standard (Heckscher

2015, Giddens, Sutton, 2013). Although my study participants did not pinpoint, or

they were unable to say what precisely this shared sensibility was, they found its

expression in the local traditions and values. Thus, the shared traditional identities of

values and practices reinforce most participant’s perception of a shared rightness with

the Traditional Healers. Most of the participants of my study and traditional healers

lived in orthodox communities or neighbourhoods. These neighbourhoods had

traditional collective identities as the basis of rightness, morality and framework of

behaviours. Equally, the Traditional Healers and my study participants were

normatively bounded by this common tradition or socio-cultural morality as the

foundation of their behaviours in the communities. They, therefore, had the basis for

trusting each other as in any trusting relationship, both the trustor and the trustee

should have a collective understanding of what is right to form the basis of a

reasonable demand and expectation in the relationship (Heckscher 2015).

Many participants of my study displayed their confidence and trust in the

traditional healers because of the Traditional Healers attachment and understanding of

the local cultural and traditional values. These traditional values formed the basis or

framework of appropriate behaviour. Hence, they demonstrated and expressed a sense

of shared rightness in the notion that they and Traditional Healers have the same mind

as the ancestors and will help each other per the ancestral instructions. An example of

such expression is the excerpts from Kyeremeh below.

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“We are one people with Traditional Healers. It is like we have the same mind from the

ancestors to help each other. They will always obey the ancestors who gave them their gift to

help their people, and that is why I believe them’’ (Kyeremeh, male, 44, prostate cancer?).

Most of my participants acknowledged the ancestors as the providers or basis of

traditional or socio-cultural identities and framework for moral behaviour or rightness.

Primarily, they perceived the Traditional Healers to have the same mind as the ancestors and

hence will act or behave appropriately as intended by the ancestors. In contrast, there was a

complete cultural dissonance or lack of any shared traditional framework as the basis for my

study participants to trust doctors in the hospitals. Most participants expressed the lack of a

sense of common ancestry or tradition and consequently lacked any basis of shared rightness

for doctors to act appropriately.

In other words, many participants could not be confident that the doctors will behave

appropriately because of their perceived lack of understanding of the inherently shared

accepted standards of the local community or socio-culturally expected behaviour. Some of

the participants for my study thought the doctors had ulterior motives or motives of

accumulating wealth and not necessarily the welfare of the local communities. Many

participants thought doctors were not morally bound or have the obligations to behave per the

ancestral instruction and therefore had the versatility in how they chose to behave. Durkheim

(2012, 2013) described social-cultural rightness as a normative obligation in which trust

emanates from shared values and faith that communities or societies reaffirm through rituals

and ceremonies.

Most indigenous Ghanaian communities achieve traditional morality or rightness by

inculcating in their members and encouraging them to believe and submit to the ancestors or

their symbolic traditions as the supreme authority and moral consciousness. My study found

that most participants trusted the Traditional Healers as a matter of showing their

commitment and deference to the ancestral or traditional authorities, which the Traditional

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Healers symbolise. In this case, participants were motivated to use the Traditional

Healers for therapy. Many participants felt the Traditional Healers were linked to

traditional ancestral identities or authorities. Such a motivation echoes with the

concept of trust as a commitment and deference to traditional authority and identity

(Tyler, DeGoey 1996, Tyler 2001, Braithwaite, Levi 2003).

The participants showed their identification or validated their identity with the

authorities and the indigenous communities where they belong. Generally, people

trust authorities established from their culture, families or communities and assume

that such authorities will do what is right for them (Tyler, DeGoey 1996, Tyler 2001,

Braithwaite, Levi 2003). In Ghana, deference trust and commitment to ethnic

authorities is prominent and reflect many aspects in society, including voting patterns

and voters’ behaviour in which people vote along their ethnic lines (Adjei 2013,

Hoffman, Long 2013).

Possibly, deference trust in authorities may change when the authorities fail to

live up to the required standards or fulfil their promises. However, my study is

different in the sense that the relationship between participants and the Traditional

Healers have a strong and unwavering anchorage of the ancestors who are the

ultimate authority that the participants must respect. Hence, my study participants

deference to the Traditional Healers motives equals to the motives of the ancestors,

which is the bedrock of the trust that the participants had for the Traditional Healers.

Also, many participants appeared more concerned about expressing their

identities or identification with the ancestors whom the Traditional Healers symbolise

and not focused on any tangible rewards from the Traditional Healers. Although most

participants did not focus on tangible results, they were convinced of the general

goodwill of Traditional Healers towards them. They expected the Traditional Healers

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decisions and actions to broadly be favourable to their best interest by reflecting the

community and ancestral values. Most of my study participants used the Traditional

Healers or continued to use them even when they were not getting any cure or treatment

benefits. Such participants behaviour suggest that their motivation was not on treatment

outcome but deference and identification to their traditional identities and authorities. Such

insight contrasts with the traditional notion that treatment-seeking only focus on the possible

treatment outcome.

Most of the participants reported seeing traditional healers as part of their ingroup and

embodiment or representation of traditional morality and authority figures. Even participants

who were not regularly using the services of the traditional healers expressed a generalised

trust in the Traditional Healers and described how the Traditional Healers would not falter in

performing their moral responsibilities. Most of my study participants gave the impression

that they were committed to holding on and continuously trusting their traditions and

traditional values. Participants used idiom such as “Yento Amamre Nkwene’’ (“we do not

throw away tradition”) to emphasise the importance and pride in trusting and sticking to

one’s traditional identity.

In describing their experiences with traditional healers, most participants pointed to

the trustworthiness of the ancestors who are the real source of the traditional healers’

knowledge. Most participants took pride in their ancestral origin and trusted their ancestors

because they believe the ancestors fought in the past against the enemies and preserved the

local lands and identities. Also, many participants thought it was honourable to continue to

trust the Traditional Healers as the symbolism of the ancestors who used herbal medicine for

centuries before the advent of conventional medicine.

Equally unique to my study was the suggestion from the participants that any act of

distancing or showing contempt to the Traditional Healers was tantamount to condescension

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towards ancestral or traditional authorities and undermines participants own identity.

Durkheim (2018), used the concept of mechanical and organic solidarity to describe the basis

of trust for traditional authorities. While mechanical solidarity is usually the result of

fear of punishment and pressure of conformity or identification, organic solidarity or

trust is a function of societal roles, responsibilities and a shared moral decorum

(Durkheim 2018). In this study, participants’ accounts and my observations did not

suggest that participants’ trust for the Traditional Healers was because of fear or

pressure to conform. Instead, my study participants felt proud of their traditions and

willingly submitted to the Traditional Healers who are part of its symbolism of the

ancestors and local traditions.

However, this does not rule out the possibility of at least an implicit pressure

on my study participants to positively appraise Traditional Healers in conformity to

trusting and respecting tradition. Some authors describe how indigenous communities

can sometimes use pressure and the possibility of severe punishment to inculcate their

values into the people (Heckscher 2015, Sztompka 1999). Generally, the traditional

healers and the healing service they provide in Ghana, even in the indigenous

communities, are continuously transitioning from their original premise of serving the

community interest alone to a means of livelihood (Yeboah 2000).

These changes make it difficult to take at phase values that all Traditional

Healers were serving the interest of participants. Few participants expressed concern

about the lack of control, monitoring and supervision of Traditional Healers and the

possible infiltration of fake healers who may have selfish motives from the traditional

moral standards. Perhaps, my study participants’ trust for the Traditional Healers

provided comfort to participants and helped simplify the complexities involved in

participants seeking treatment for their serious illnesses

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On the contrary, most participants of my study did not feel they had a shared sense of

rightness or subscribe to the same moral principle with the hospital doctors and hence did not

express the same feeling of trust about them. Although doctors in Ghana may not be so close

to their communities or take an interest in the traditional standards, this alone may not be

enough to suggest that they will or do not act in the interest of patients. At least, in principle,

doctors vow to care and to act in the interest of their patients' and communities following

their professional code of ethics. In the Ghanaian context, doctors need to be aware of the

cultural and community dynamics of care to avoid both the direct and indirect criticisms and

clash with the social-cultural expectation.

Almost, all the participants had low socioeconomic status and education and found it

challenging to communicate with highly educated doctors. These could influence the

participants’ ability to feel trust for doctors whom they considered as upper class. It was not

possible to compare my study participants behaviour or accounts with the rest of the

population who may have higher education or better access to conventional medicine. In

other words, my study did not uncover the extent of the influence of socio-economic status in

participants’ behaviour and whether wealthy participants would have had a different level of

trust in doctors and Traditional Healers

5.2.3 Trust as a Shared Language and Identity

Here, the study discusses another way that my study participants conceptualised trust

as a shared language identity and how it influences the relationships and motivations of

participants in using the Traditional Healers services. The study found that the participants’

trust for the Traditional Healers were anchored in the identity of a common language and

understanding. Most participants mentioned that they could understand what the Traditional

Healers told them and felt they were able to contribute to the therapeutic discussions and

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conversations with Traditional Healers in contrast to hospital doctors. Many authors

acknowledge the critical role of a common language and understanding in the formation and

development of trust (Bacharach, Gambetta 2001, Gambetta 2008, Sanchez et al.

2012, Saha et al. 2000). Most of my study participants identified with the local dialect

“Twi’’ which served as one of the critical elements of trusting identity that connected

them with the Traditional Healers and their communities. I observed in the hospitals

that even doctors who understood and spoke “Twi’’ fluently did not speak it routinely

or regularly and found it comfortable to speak in English.

The accounts of my study participants suggested that they considered

communication or a shared language with the traditional healers as a resource or

something more than just a medium of exchanging words or handling the therapeutic

encounter. Instead, the language signified participants’ identity and identification with

the local socio-cultural or ancestral traditions, belongingness and empowerment,

which the Communication Accommodation Theory supports (Garrett 2010, Giles,

Ogay 2013). In my study, most participants perceived their shared language (Twi)

with Traditional Healers as an expression of identity and identification to their

indigenous groups, communities and values that can be trusted.

In other words, language forms the foundation of expressing collective

identities, trust and conveys a more profound sense of familiarity and belongingness

(Garrett 2010, Giles, Ogay 2013). The Communication Accommodation Theory

acknowledges the importance of sociocultural and sociohistorical context in which

communications or individuals embody. According to this theory, our personal and

sociocultural identities are inherent in our communications and not just the immediate

situation. The theory emphasises the notion that communication or language is not

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just an exchange of facts, information or even emotions but a salient category of identity and

membership negotiation and validation to a group (Giles, Ogay 2013).

In this respect, language is a code, abstract or a systematic knowledge base that is

deeper than just the ordinary instances of expression (Giles, Ogay 2013). For most

participants, language formed a fundamental part of their collective identity and whom they

could trust. Most participants expressed a shared identity around the local language using

inclusion words such as “Omo Ka Ye Kasa’’, meaning “they [Traditional Healers] speak our

language”, to invoke collectiveness and how language connected them with the traditional

healers. In contrast, most participants’ inability to understand and smoothly communicate

with doctors led to their expression of lack of trust in the hospital doctors. Ghana was a

British colony, and English is an official language and continues to dominate in public and

academic life or institutions. For my study participants, the use of English was an expression

of power and socio-cultural demarcation or distancing and served as a means of alienating the

lower class.

The Communication Accommodation Theory and Luhmann’s conceptualisation of

power as a communication medium emphasise power as robust language code which can

create identity or identification, set criteria for inclusion and exclusion and defines power and

limitations for people (Giles, Ogay 2013, Luhmann 2018, Garrett 2010). Many participants

saw the doctors’ dominant use of English for interaction as barring, disempowering and

undermining or disrespecting of their linguistic identity and that of the local communities.

Similarly, people can use language as the means for creating, projecting or reflecting,

harmonising or concentrating and routinising or normalising power in society (Reid, Ng

1999).

Many doctors in Ghana use the English language in clinics and from my observations,

even when patients are present. Doctors’ dominant use of the English language may not be

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intended to exclude participants but a matter of convenience and blindness to cultural

values. Peculiar to my study is participants perceived extension of the use of the

English language by the doctors as an emphasis on “whiteness’’ or reflection of

colonial representations in the form of power, inequality and detachment from the

locally shared identities. Superficially and in practice, as reported by participants, at

least in the hospitals, it appeared that doctors used language to exclude my study

participants. However, one can construe that the participants also used the criteria and

power of language to exclude doctors from the local identity and to define doctors’

level of trustworthiness based on how they related to the local dialect. In other words,

both my study participants and the reported behaviour of doctors was an exercise of

power and identity of languages in diverse ways.

5.2.4 Trust in the Familiar and Habits in Communities

Most of my study participants conceptualise trust in their accounts as

familiarity and habits. Many of them and their use of the services of the Traditional

Healers was based on the relationships of familiarity, habits and perceived Traditional

Healers accountability and goodwill. My study identified a connection between the

participants’ trust in the Traditional Healers and their communities and local

neighbourhoods’ relationships of familiarity and the principles of accountability and

continuity. Familiarity can develop into an encapsulated self-interest account of trust,

which is the notion of the trustor that the trustee will act favourably towards them as it

is within their interest to do so (Hardin 2006). Does familiarity breed trust? Gulati’s

(1995) assessment of the relationship between familiarity and trust found that

familiarity increases with repeated encounters and interactions and leads to trust in

which parties suspend equity as the basis of forming alliances.

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In such repeated encounters and close working relationships, the interest of each party

builts into the other. Hence it becomes necessary and comfortable for the parties to act

appropriately without any legal or written commitments (Gulati 1995). Many authors in their

conceptualisation of trust identified the tendency for people to trust a familiar person,

situation or environment than a stranger (Hardin 1993, Luhmann 2018, Sztompka 1999,

Hechter, Kanazawa 1993, Heckscher 2015).

Similarly, most of my study participants familiarity or active engagement and

community interaction with the Traditional Healers assured them that their self-interest

encapsulates in the Traditional Healers interest. In other words, many participants trusted that

the Traditional Healers would not behave in a manner that would ruin this community

connection and statuses accord to them. However, my study was different in identifying that

the participants tie their interest to the moral framework and goodwill of the ancestors which

the Traditional Healers were inherently required to obey. Most of my study participants

assumed that the Traditional Healers were responsible or accountable to them and their

communities because of the strong relations and community identity bonds that they had with

them.

Also, many of my study participants acknowledged familiarity as a form of security.

Familiarity reduced the complexity and uncertainty and gave participants the incentive to

trust Traditional Healers. Luhmann (2018) in conceptualising trust, discussed the foundation

for building trust as the presentation of the self or groups through social identity and

interaction. In this respect, those who want to be trusted or are interested in the trust must

make themselves familiar through community and social interaction (Luhmann 2018,

Heckscher 2015). Doing so allows the trustee to understand the basis and dynamics of trust in

their environments and build the expectation of others into their self-presentation (Luhmann

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2018). My study participants had opportunities for contact with the Traditional

Healers through networks of local groups and activities through which they built and

developed trust.

Furthermore, trust relationships and accountability are found to flourish in a

social context or structural conditions of relative persistence, re-encounters and

mutual dependence. Some authors refer to these re-encounters and repeated cycle of

events as trust in “habits “ (Durkheim 2012, Misztal 2019, Gulati 1995, Gilson 2006,

Wuthnow 2004, Misztal 2013). My study participants trusted in the protection and

comfort of the reliability of the familiar and predictable stable routines, reputation and

tacit memories of traditions or socio-cultural identities. Trust in the familiar is like

trust in habits which built on past experiences and avoidance of risk in dealing with

the unforeseen situation (Misztal 2019, Misztal 2013). Hence, trusting in habits or the

familiar is a disposition that offers predictability, provides security, continuity and

strength to face uncertainties and complexities of social life, particularly in vulnerable

and unsettled situations (Latour 2013, Misztal 2019).

The community and neighbourhood activities as focus of interaction provided

a repeated cycle of events, familiarity and interdependence for my study participants

and traditional healers. Through these interactions, my study participants and

Traditional Healers had developed predictable expectations, obligations and

accountability towards each other in terms of reciprocity. Perhaps, participants used

this as a mechanism to guard against the desperate situation they were in because of

their advanced cancer with little available treatment and the threatening situation of

the hospital and the doctors. Many participants, therefore, trusted the Traditional

Healers and the more comfortable situation of the ‘habits’ and comfort available at the

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Traditional clinics which provided them with hope and were unavailable in the hospital

setting.

On the contrary, my study participants expressed a lack of trust in doctors because

they felt they did not know the doctors well enough or have a well-established relationship

with them. Most participants in my study considered doctors as mere community residents

and not members of the community because of their lack of lineage or attachment to these

communities. Hence, some participants felt that doctors could leave the communities without

justification. They perceived doctors to have less responsibility towards them and the

community. Doctors unstable behaviour caused a sense of the lack of continuity of care.

Also, most participants had concerns that the doctors, unlike the Traditional Healers, were not

living in the communities to provide continuity of care and interaction.

Conceptualising familiar trust as trust in habit contribute to continuity and stability of

social life and relationship (Latour 2013, Misztal 2019). According to Latour (2013),

predictability of habit helps to create a social order in dealing with the perception of

discontinuity and unreliability. Predictability of situations appeared essential to my study

participants and gave them some level of control, safety, certainty and normality. Habits play

an essential role in fostering trust by increasing familiarity and serving as the basis for

continuity and predictability for my study participants in negotiating the complexities and

uncertainties in societies.

The participants of the study had very little chance of getting to know their doctors,

predict the possible occurrences and prevailing situation in the hospitals. They could not even

guarantee that they would be seeing a doctor that they have previously met and unable to trust

doctors for continuity. Most of my study participants did not attend hospital regularly and

were seen by different doctors who conducted the clinics on different days, making it difficult

for participants to get to know the doctors intimately.

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5.2.5 Reputational Trust: Reputable Characteristics of the Traditional Healers

In this section, I focused the discussions on how participants conceptualised

their trust in the Traditional Healers as reputation. Reputational trust served as a

motivation for participants to use the Traditional Healers for treatment. Collectively,

Traditional Healers or Traditional healing as an institution has built a sturdy

reputation over generations in most Ghanaian communities. Most participants’

accounts showed that they mostly had become aware of and ascribed reputation to the

Traditional Healers based on cumulative community knowledge and the testimony

and experiences of others. Often, authors conceptualise reputation as records of past

deeds (Ensminger 2001, Good 2000, Misztal 2013), perception of integrity and

dependability (Giddens 1991), or evaluation or opinion of others of a social institution

(Goffman 2009).

Hence, reputational trust is usually based on our historical experiences or

knowledge (Sztompka 1999, Good 2000) and involves multiple attestation and events

(Misztal 2013). In this study, some participants expressed trust in the Traditional

Healers reputation or important characteristics without any apparent explanations.

Respectively, some participants ascribed the reputational qualities to Traditional

Healers collectively or as a social institution and not in an individual Traditional

Healers. In this sense, the Traditional Healers enjoyed what some authors describe as

identity reputation or trust in which an individual’s trustworthiness depends as their

identity with a profession or institution (Gambetta 2008, Pettit 1995, Hausman 1997,

Bacharach, Gambetta 2001).

In other words, we select and judge people or events according to

preconceived concepts and reputations as defined by our culture and society

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(Goffman 2009). Possibly, my study participants were biased in ascribing reputation to the

Traditional Healers based on the information and opinions that their tradition and

communities had given them. Equally, some participants were quick to talk negatively about

doctors, even when they have not received any harsh treatment from doctors. Such

behaviours suggest that participants may have formed their opinions about the doctors based

on the wider sociological and cultural discourse of doctors lacking reputation.

Although Traditional Healers or Traditional healing as an institution have established

a reputation that my study participants could trust, there was no guarantee or certainty that

individual Traditional Healers would take this reputation seriously and will act appropriately.

In this sense, my study participants trusted the traditional healers based on the assumption

that the Traditional Healers will remain trustworthy to maintain or keep their reputable image

and moral status. However, many of the participants who had recently visited the Traditional

Healers and those recruited from the Traditional Healers clinic sounded positive about the

individual Traditional Healers. Participants expressed satisfaction of quality of services they

had received or were receiving from the Traditional Healers. Few participants had concerns

about individual Traditional Healers and possibility of infiltration into the profession by those

who had not the genuine call to the profession as in the excerpts below

In most Ghanaian indigenous communities, people consider reputation as a precious

asset, and the process of acquiring it is arduous and protracted. Once people obtain a

reputation, they must work hard to protect and preserve it because of its fragility and ease to

lose. The nature and closeness of most Ghanaian indigenous communities in which people

“Traditional Medicine , there have many benefits, but the only thing is that

a Whiteman will say the proliferation of traditional quack practitioners who

are not real ones’’ (Kyeremeh, male. 44, prostate cancer?).

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know each other and aware of almost all incidents in their neighbourhood suggest

how quickly a person’s reputation can deteriorate. Unsurprisingly, many authors have

the view that trust rooted in reputation requires the relentless and constant effort of

permanent confirmation, through self-presentation in social interaction (Goffman

2010, Goffman 2017).

It appeared that the Traditional Healers are in a web of a reputation built

individually as well as collectively in most indigenous communities. Traditional

Healers cannot afford to breach such a reputation because of the implications it would

have on their profession. The reputational trust dynamics are consistent with Hardin

(2006) encapsulated interest concept of trust. The encapsulated interest concept

applies to healthcare institutions and professionals. The reputation and trust of

healthcare professionals and their organisations depend on how they relate or behave

toward patients. Congruently, my study participants trusted the traditional healers

because they believed that it was in the best interest of the Traditional Healers to

behave appropriately by the community expectation for their reputation.

In contrast, most participants suggested that they did not feel that it was within

the interest of doctors to behave in a manner that warrants trust and reputation. Most

participants thought that the doctors did not stand to lose relations, community

prestige and reputation if they misbehave. Hence doctors had little incentive to act

appropriately. Arguably, doctors also have a reputation, although not based on the

same things as measured in the Traditional Healers and not generally discussed at the

community level to influence popular opinion. Participants’ accounts did not suggest

that doctors lack reputation regarding their professional competence and performance.

Participants concerns were more on the softer side of care or soft interactional skills

which has become paramount in most organisation.

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In this respect, Sztompka (1999) argues against considering reputation as generically

constituting the same elements in every society. In her view, reputation is culturally specific,

and hence the credential or reputable characteristics and their measurements may vary across

cultures and even over time as societies transform (Sztompka 1999). Most participants

considered the traditional healers’ training to be focused on character or behaviour

development, relevant to local requirements and insulated from western influence and

adulteration. Participants equated the training of Traditional Healers to training in wisdom.

Many participants related this wisdom to the socio-cultural traditions and values such as

respect for the elderly, compassion for the vulnerable and the sick, greeting even strangers,

having time for people and participating in local festivals and contributing to community life.

Many participants considered wisdom as more important than academic knowledge

and necessary to navigate through the complexities of communal issues. Traditional Healers,

therefore, earned a reputation from the nature of their training. In contrast, most participants

perceived the doctors’ training as devoid of culturally relevant values, wisdom, and character

development and instead focused on academic prowess. The accounts of most participants

highlighted the importance of grounding and contextualising medical education in Africa and

Africa’s education in its culture. Doing so would ensure maximum acceptance amongst the

public and patients, and thus maximise the benefits and usage (Ocheni, Nwankwo 2012,

Tervalon, Murray-Garcia 1998).

Moreover, participants reported compassionate behaviours from the Traditional

Healers as a form of reputation. As pointed out by Sztompka (1999), reputation required

some level of consistency of past deeds and reliability or commitment to a principled way of

life. The findings revealed that most Traditional Healers did not just count on their past

reputation but committed to continuously supporting the vulnerable in their communities. My

study participants attributed the Traditional Healers’ commitment to charity and respected

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them for that. While it is difficult to ascertain the exact motives of Traditional

Healers’ compassionate behaviour, money cannot be ruled out entirely. Traditional

Healers advertise their products and services with enthusiasm and charge for their

services. Even so, most participants thought the Traditional Healers showed

compassion by allowing flexibility of payments.

In contrast to the traditional setting, many participants expressed a lack of trust

in doctors because doctors were thought to be unwilling to work in remote

communities. However, my study participants may not be aware or appreciate the

professional code of conduct that guides and restricts the work of the doctors. Most of

the time, doctors in Ghana are legally allowed and remunerated to cover a particular

geographical jurisdiction and unable to provide some of the softer care that the

Traditional Healers may be able to provide. Also, an element of my study participants

perceived reputational trust in the Traditional Healers was around the issues of dignity

in a sociocultural context.

The participants of the study expressed satisfaction in the Traditional Healers’

observance of their dignity and privacy and found it inappropriate that some doctors

exposed their intimate body areas. Doctors were more likely than the Traditional

Healers to perform procedures involving probing or exposing my study participants

intimate body parts. Some participants understood the nature of the doctors’

procedures or investigations but thought the doctors could still have maintained some

decorum and asked for permission. Although it was not known whether Traditional

Healers would maintain privacy and dignity if they were involved in specific

procedures, the findings suggest that they were conscious of the cultural and ethical

prerequisite of privacy and adhered to them. I observed at the traditional settings that

most of the Traditional Healers conducted their consultation and clinic activities with

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only the patient in a room and called for an assistant when necessary. It appeared that the

Traditional Healers did not share any therapeutic or ''professional discussion'' they had with

my study participants with even the other clinic staff.

In contrast, it was observed that the doctor's consultation and ward rounds did not

appear private as other doctors and other medical staffs formed part of the ward rounds.

Similarly, doctors sometimes stayed or worked from the same office in which the

consultation may be taking place. A forty-year-old female participant, known as Pinaman,

described how hospital staffs treated her with no dignity and left her naked on a trolley in a

room which was accessible to other members of staff. In conjunction, my findings were

consistent with the notion that the Traditional Healers have an excellent reputation for

treating certain diseases. Most studies identified Traditional Healers as more capable in

treating fractures and other conditions perceived to have spiritual causes (Awusabo-Asare,

Anarfi 1997, Abel, Busia 2005, Bazzano et al. 2008, Aries et al. 2007, Solagberu 2005). For

example, Abrafi described how the herbalist was able to fix her sister’s fracture within two

weeks (Abrafi, female, 41, cervical cancer, details in chapter 4.3.4, Traditional Healers

reputation).

The finding of my study is consistent with studies that show that the perception of a

spiritual link with the manifestations of disease affected patients’ choice for traditional

healers (Yarney et al. 2013, Ezeome, Anarado 2007, Bazzano et al. 2008). Both Helman

(2007) and Nettleton (2013) discussed the cultural and sociological conceptualisations and

understanding of health and illness in contrast to the dominant biomedical approach

extensively. The western biomedical concept of disease is dualistic and reduces the

complexities of human health to a simple organ pathology or bodily malfunction.

Consequently, the biomedical approach to treatment focuses on the alleviating physical pain

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and restoring bodily function (Wade, Halligan 2004; Dick 2010, Hewson 1998;

Nettleton 2013, Helman 2007).

Most indigenous populations in Ghana believe in the concept of misfortune or

a supernatural influence on how certain illnesses occur. Some participants in my study

thought the traditional healers could deal with the supernatural influences on illnesses.

For example, Benewaa described how the doctors could only treat physically caused

diseases in contrast to the Traditional Healers. The latter are capable of treating

diseases which people perceive to have spiritual causation (Benewaa, female, 43,

cervical cancer, detail in Chapter 4.3.4, Traditional Healers reputation). Although not

all participants were specific that their condition had a spiritual cause, many of them

assumed the possibility since they had not received favourable treatment from the

conventional doctors. When it comes to medical emergencies, however, most of my

participants reported trust in the doctors rather than the Traditional Healers. For

example, Nyamekye described how doctors could deal with people who are bleeding

or have collapsed:

Most participants of my study viewed the doctors as lacking the wisdom’’

(knowledge and skill) to continue to treat chronic diseases or make long-standing

conditions. These participants thought the doctors had the requisite skills for acute

cases and saw the hospital as a place with the sophisticated equipment to stabilise the

acutely unwell but not for continuity of care or treatment of chronic diseases.

''If you collapse or something, then they will take you to doctor to fix you. They can stop

bleeding or emergencies, they stopped my bleeding but could not help me, they could

not continue, that is where their wisdom is, so you need ''dunsinii'' (local medicine man)

to look after you. (Nyamekye, Female, 29, cervical cancer).

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5.3 Conviviality Interaction and Convivial Therapeutic Landscape

Conviviality and hospitality describe and answers the research question on the

participants' experiences and interactions during their encounter with the Traditional Healers

or when using their services. The discussions cover the quality of participants interactions

with Traditional Healers. Also, it covers the atmosphere of participants encountered with

Traditional Healers. These are contrasted with participants experience in hospital clinics. For

Gilroy (2004), the phrase convivial culture subsumes the humdrum nature of daily

encounters, the boisterous everyday interaction of the diverse cultural traditions in a location.

The interviews and observation data showed that the Traditional Healers were friendly to

patients, showed interest in them, listened attentively to them, and ensured a relaxed

atmosphere or space for the encounter. These gave my study participants a sense of emotional

and physical security.

The term conviviality is often politicised and identified with various political

implications, aspirations and strategies of fostering multiculturalism, social cohesion and

diversity in the broader society (Wise, Velayutham 2014, Wise, Velayutham 2009, Meissner,

Vertovec 2015, Vertovec 2007), through regular transient social or public space encounters

(Crouch 2003, Karner, Parker 2011, Neal et al. 2013). Principally, the concept is used to

express new forms of urban citizenship in which the deep cultural dynamics, belongingness

and identities of people may be hybridised or neglected for a superficial good (Nayak 2017,

Gilroy 2004, Askins 2016).

Nonetheless, the concept of conviviality or convivial culture has implications on

healthcare indices, patients experience and relationship between patients and health

professionals (Probyn 2015, Hall, 2013). In this study, conviviality is more than a simple

superficial engagement or getting on with people. The experience of conviviality for my

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study participants was essential and symbolic of their sense of identity, security,

belongingness, affection and recognition of their socio-cultural norms which were lacking in

the hospitals. Although Conventional medicine has moved or is moving to a more

patient-centred approach, my study participants could not see this in how doctors

treated them. My study participants described their interaction and encounter with the

Traditional Healers or their clinics with words such as pleasantness, helpfulness and

friendliness.

The friendliness of the Traditional Healers seemed to help with the lowering

and or removing of both real and potential hierarchy between themselves and my

study participants, putting participants at ease and creating the conditions for

participants to co-construct and reciprocate the friendly encounter. My study

participant accounts described how the Traditional Healers and the herbal clinic staff

engaged in-jokes and laughter with them, helping to relax the atmosphere and to take

their minds away from their illnesses. Also, the nature of the herbal clinics

contributed to the pleasant experiences of the study participants as it offered a haven

from severe illness and disability where social relationships and networks are

available for support.

The concept of Conviviality space or Landscape looks at how the nature of the

herbal clinics' environments contributed to the convivial interactions and experiences

of participants. Gesler (2003) first posited the term therapeutic landscape to find an

explanation of why specific environments seemed to support healing or have a sense

of healing effect. He conceptualised therapeutic landscapes as spaces where the

physical environment, social conditions and human perception combine to produce an

atmosphere conducive to healing and promotion of health (Gesler 2003, Gesler1996).

Since then, several authors have developed related concepts of environments or places

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of free social interaction as ''effective sanctuaries'', ''havens of sociality'', ''shelter'' and

''convivial space'' (Nayak 2017, Butterfield, Martin 2016, Moore et al. 2013, Glover,

Parry 2009).

Again, the concept has been broadened to include the relationships and social

networks of interaction that offers security and belongingness or inclusion in a health facility

or social space (Smyth 2005, Wakefield, McMullan 2005). The findings of my study

resonate with studies that found elements of conviviality as an essential element between

health professional and patients or between other professionals and their customers

(Hochschild 2012, Li 2004, Hunt 1991).

In Hochschild (2012), flight attendants were duty-bound to show conviviality during

flights to signal safety and to maintain an accepted interaction and social order. Li (2004)

used the term symbiotic niceness to describe the mutual, reciprocal or co-production of

conviviality between palliative care nurses and patients. Similarly, palliative care nurses in

Hunt’s (1991) study used conviviality to facilitate their communication and work with the

terminally ill patients and their families. However, these studies, (Hochschild 2012, Hunt

1991, Li 2004) had their participants in professions that have explicitly stipulated codes of

conduct for their members, which reflected their behaviours.

In other words, the behaviours of the nurses and the flight attendants may be

components of their professional training which functions to maintain orderliness, provide

reassurance, and advance personal, professional and organisational aspiration (Hochschild

2012, Ashforth, Humphrey 1993, Brotheridge, Grandey 2002, Morris, Feldman 1996). Many

authors describe such professional behaviours as paid emotional labour or impression

management in which conviviality relates to the industry of work (Hochschild 2012,

Ashforth, Humphrey 1993, Brotheridge, Grandey 2002, Morris, Feldman 1996).

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Unlike the previous researches on conviviality, my study focused on the

experiences of patients (participants) in using the traditional healers’ services. The

Traditional Healers were mostly not bound by any strict or explicit professional code

of conduct or standards. Hence, the issue of impression management to comply with

any organisational or professional code in the strictest sense was unlikely. Also, the

participants did not signal any feeling that the friendly behaviours and interactions of

traditional healers were artificial or simulated. My observations of the behaviour of

Traditional Healers and their staff felt very natural and consistent with the

participants’ accounts. Although the Traditional Healers did not have any written code

of conduct for their practice, they were more likely to behave by the socio-cultural

standards of their communities by being friendly or convivial to study participants.

From my observation and as reported by participants, the Traditional Healers behaved

by the shared socio-cultural norms and values.

The Traditional Healers charged a fee for their services, and hence, it was

difficult to rule out their impressionistic behaviour to attract customers. In any case,

my study participants appreciated the pleasant experience that they received from the

Traditional Healers and used it in conceptualising their experiences with the

Traditional Healers. There is always the question of whether the Traditional Healers

were intentionally using their pleasant and friendly manner of interaction as a

distracting technique for participants, and to hide or manage their own emotion.

However, such an essential interactional and enabling skills of jokes and banter

usually happened before the actual clinical or consultation engagement and put the

participants at ease and facilitate the encounter. Both my observation and participants

accounts show that the Traditional Healers listened professionally and attentively

during the consultations, gave advice, allowed questions and double-checked that the

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participants were satisfied and knew what to do or aware of the date for their next

appointments.

From the participants ‘perspective, the convivial spaces have various aspects or are

characterised by looking comfortable and relaxed. Most participants depicted Traditional

Healers or the clinics as discounting rigidity, restriction, surveillance and judgemental

attitude. Instead, participant’s accounts suggested that the Traditional Healers offered an

environment of easiness and homely ambience. Such an environment encouraged

spontaneity, natural interaction and appeared to have a positive therapeutic effect on my

study participants’ total wellbeing. Some participants expressed the sense of freedom and

belongingness in the Traditional clinics using words such as “nipa baako’’ meaning “one

people’’ and “abusua Baako’’ meaning one community or family. Per my observation, most

of the Traditional clinics had local music playing in the background and local games

available as the entertainment for patients who would be waiting.

However, there are concerns that such relaxed and unchecked atmospheres or spaces

can mask addressing the essential therapeutic and cultural needs of patients (Nayak 2017,

Gilroy 2004). There was no evidence in my study to suggest that the socio-cultural dynamics

of interaction in the Traditional clinics compromised care. For example, some of the

participants showed me the treatment or medicines that had been given to them to take home

and mentioned when they had to come back for their follow up appointment.

In contrast, the participants’ thought the doctors, or the hospitals, were inflexible,

judgemental, controlling and tied to procedures and processes. The strict procedural

approaches in the hospital prevented the hospital or doctors from engaging and resolving any

participant’s issues or concerns. Also, most participants could not act naturally and thought

they had to be mindful of their behaviours for fear of negative aftermath. Some potential

participants in the hospitals refused to speak to me or take part in the interviews in case I was

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a doctor or a hospital staff. Many participants appeared and described how they

usually felt anxious and afraid to talk or even ask questions.

There was undoubtedly an elevated level of anxiety and uneasiness for

participants to freely have a conversation for fear that staff would not listen to them,

overhear them and shout at them. Some participants described their inability to

complain or raise concerns as doing so could turn against them and influence the level

of service they may receive from the staff. My observation supported most of my

study participants’ assertions about the nature of the hospital environment. For

example, some participants were sceptical about me because I appeared close to the

clinical staff who were offering me support with recruitment. Understandably, certain

places in the hospital required strict control as regulatory standards and guidelines

(Curtis et al. 2009).

However, my study participants concern was the actual human interaction and

mood or entertaining atmosphere of the environment and not the physical space

limitations. Doctors need to ensure that patients feel comfortable and natural to

discuss or share their feelings in an open, confidential and friendly space as this is not

only of socio-cultural importance but also has a positive therapeutic outcome.

5.4 Holistic Support and Quality Human Time

My participant's accounts indicated how the Traditional Healers showed

interest in their entirety and wellbeing through broadly asking them questions about

themselves and allowing quality human time to listen to them without a rush. The

Traditional Healers allowed the necessary time during the therapeutic encounter to

engage with participants and to demonstrate their interest in all aspects and activities

of participants and not just their medical condition. Per participants’ accounts, the

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Traditional Healers engaged them in discussions that encompassed a wide range of

participants’ social and personal routine life. Such engagement laid the foundation

and facilitated a meaningful therapeutic interaction and encounter between the Traditional

Healers and the study participants (Hunt 1991, Li 2004).

As per the observation and most participants’ accounts, the holistic view of care also

related to the Traditional Healers empathy, understanding and provision material help or

support to participants. It was observed that the traditional or herbal clinic staffs helped

patients and relatives to carry bags, gave them water, seats, and assisted them to walk and

transfer from vehicles. The approach and the manner of interaction and support used here by

the Traditional Healers resonate with the concept of Holism and patient-centred care which

contrasts with the biomedical model of care (Mead, Bower 2000). Both the concept of holism

and patient or person-centred care acknowledge the socio-cultural, psychospiritual and

biophysical context of a person and how this interconnectedly affect their wellbeing

(Kolcaba, 1997, Kolcaba, 2003, Stewart 2003).

From this perspective, supporting patients should not only focus on their medical

needs but all related aspects of their lives. Presumably, many doctors inhabited in the

biophysical and only concerned about treating physical illness or body malfunction. The

Traditional Healers engaged in the therapeutic encounter with cultural greetings, ordinary

everyday conversations, physical support and comfort. The Traditional Healers and their staff

demonstrated an understanding of the socio-cultural context and dynamics of participants and

indicated that they were interested in participants as whole persons. Required and inherent in

the Ghanaian culture is the practice of exchanging in cultural and welfare greeting at the

beginning of any encounter and helping the sick or the vulnerable. Hence, it is difficult to

ascertain the motives of the Traditional Healers behaviour, whether they were merely

adhering to the culture or broadly interested in their patient’s total welfare.

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Perhaps, the Traditional Healers were culturally fitting in their greetings and

therefore created the trusting atmosphere at the start of the interaction. In doing so, the

Traditional Healers created a therapeutic landscape of interaction by ensuring a

trusting atmosphere. The Traditional Healers appropriate interacting practices and

behaviour seemed to consider participants needs beyond their treatment. Hence,

patients felt cared for and safe. The doctors’ approach was in sharp contrast to the

Traditional Healers. The doctors straight away discussed the patient’s illness and told

them what to do next without any consideration to other impacts that their illnesses

may be having on them. Most participants felt that doctors and other hospital staff

were not interested in any aspects of their life and were not interested in allowing

them to discuss anything else. In the hospitals, the provision of physical support such

as transferring, feeding, and cleaning, appeared to be the responsibilities of

participants’ family and relatives.

In conjunction, participants expressed their encounter, and interaction with the

Traditional Healers as quality time in which the Traditional Healers listened, paid

attention and allowed enough time for consultation. The participants described how

the traditional healers did not rush them during the consultation. The participants’

accounts and supported observations showed that the Traditional Healers consultation

and interaction with participants were controlled, slower-paced and took more time

than the hospitals. The Traditional Healers appeared very patient and listened to

participants with undivided attention and allowed questions and showed no hurry

during the consultation. On this basis, most participants thought the Traditional

Healers were in a better position to understand and support them than doctors because

of the attention and time they gave to them. The concept of time: clock time and

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human time, primarily influence the quality of human interaction and therapeutic experiences

(Hall, 1989, Gell 1992, Fabian 2014, Helman 2007).

The concept of time exhibited by the Traditional Healers was more of human or

quality time in which, it would appear the Traditional Healers focused on my study

participants satisfaction and experience of the consultation or the therapeutic encounter. The

Traditional Healers, congruent with most Ghanaian indigenous communities operated in

human times where encounters were not limited or regulated by clock time. The findings

suggest that my study participants preferred their health professional to give them attention

and quality human and interactive time rather than rigid schedules, appointments and rush

that they encountered at the hospital. However, this concept of time may not always be

applicable or appropriate and can cause dissatisfaction for patients who may be required to

wait longer before their consultation time.

Similarly, some Traditional Healers may not appreciate a patient who would be taking

all their time. Although my observation and participants' accounts did not reveal any such

dissatisfaction, it was possible that they were potentially being controlled. On the contrary,

the doctors or hospitals operated with a concept of time in which scheduled clock time

regulated all activities (Hall, 1989, Munn 1992, Gell 1992, Fabian 2014, Helman 2007). My

study participants characterised their experiences of clock time in the hospital or with the

doctors as haste of consultation, longer waiting times, lack of time, lack of attention or

listening. Most participants had to fit their lives into a tight and rigid hospital or doctors’

appointment regimes.

Many participants lived in remote communities and had to commence their journeys

in the early morning. Some of the participants start their journey the day to their

appointment. Equally, the doctors operated with a tight busy schedule, which did not allow

for enough clinic consultation times and flexibility. The question always arises whether it is

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ever possible for the doctors or hospitals to operationalise time in the same way as the

Traditional Healers. The hospitals were far busier with many patients in comparison to the

Herbal clinics and had regulated time activities. While it may not be possible for

doctors to allow the same amount of time for patients in the hospital, it was possible

to make a little time more human and quality for their patients.

5.5 Protecting Feelings and Avoiding Distress

One of the findings of my study is participants expression of how the

Traditional Healers negotiated within the indigenous culture to manage, protect and to

mitigate participants’ emotions. This part of the discussion focusses on the nuances

between participants and Traditional Healers relationship and interactions, which

supported and protected participants’ emotions and intended to avoid distressing

them. The study identified the work of protecting feelings and avoidance of upsetting

participants through appropriate cultural telling or communication. Cultural telling

involved the Traditional Healers use of euphemism or softer language, adoption of

appropriate cultural demeanour and message of hope to interact and discuss

participants’ situation.

Several studies have highlighted the psychological and emotional difficulties

that confront people with cancer and other chronic diseases and the importance of

managing the psychosocial aspects appropriately throughout the disease trajectory

(Yarney et al. 2013, Probst et al. 2013, Lawton 1998, Clegg-Lamptey et al. 2009,

Charmaz 1997, Copp 1999, Wanchai et al. 2010). Cancer and chronic illness can

bring a sense of shame, loss of personal dignity, low self-image or disfigurement and

loss of independence (Goffman 2009). Likewise, patients also suffer from anxiety,

uncertainty, shock and fear of the possible consequences of the illness especially

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regarding cancer (Clegg-Lamptey et al. 2009, Yarney et al. 2013, Wanchai et al. 2010, Miller

et al. 1998).

However, the level of support, if at all, that exists for the emotional needs of people

living with cancer who attend hospitals in Ghana is limited or lacking (Clegg-Lamptey et al.

2009, Opoku et al. 2012, Yarney et al. 2013). Most previous researches in Ghana

acknowledge that the Traditional Healers provide their services in congruence with the

Ghanaian culture which supports the emotions of people with cancer and chronic disease

patients’ better than conventional medicine (Wanchai et al. 2010, Clegg-Lamptey et al. 2009,

Yarney et al. 2013). However, these previous studies did not explain how traditional healers

specifically support the psychosocial and emotional experience of patients who have cancer

and other chronic illnesses. My study reveals some of the behaviours of Traditional Healers

and people living with cancer themselves in preventing upset and managing emotions which

the study discusses

5.5.1 Cultural Telling and Disclosure

Participants’ accounts showed that the Traditional Healers appeared to use softer

languages or words in talking to participants about sensitive issues to avoid distressing them

or exacerbating their existing emotional distresses. Many participants mentioned how

Traditional Healers were knowledgeable and competent in delivering bad news. Most

Traditional Healers understood how, when and where to discuss or tell their patients about an

uncomfortable situation. The behaviour of the Traditional Healers could be seen in the use of

euphemism, symbolism or “softer language’’ to show compassion and understanding to

participants. Most participants preferred the Traditional Healers method of using euphemism

or symbolic language as a coping mechanism in which they were supported to

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psychologically distance themselves from the consequences of their illness

(Mccallum, Mcglone 2011).

Becker (2007, 2010) in expounding on his concept of death and denial, talked

about the trepidations and unpleasant existential threats of illnesses and how people

go through the trajectory by emotionally shunning or disconnecting from the situation.

The nature and possible advanced stages of the illnesses of my study participants

mean they were likely to have a similar sense of anxiety, emotional concerns and

possible existential threats. Most of my participants’ accounts suggested that they did

not want the doom or sensitive aspect of their illnesses repeated or discussed with

them candidly. Also, the indigenous Ghanaian culture generally does not permit the

open discussion or naming of death, misfortunes and certain diseases.

Openly discussing such situations can upset those with the condition and their

families who believe that such conversations may lead to bad luck. Such beliefs

highlight the need to be sensitive to the weight and complexities of discussing severe

diseases such as cancer with patients and family. For example, Yamoah (31, male,

liver cancer, chapter 4.5.1 softening and placating ) was confident that the traditional

healers would deliver lousy news appropriately. In contrast, nana Hussain (54, male,

liver and lung cancer, chapter 4.5.1 softening and placating ) became very upset and

concerned that the doctors told him directly and in plain language about the

possibility of him dying in a not too distant future. I navigated around this complexity

by not asking participants to name or tell me what illness they had or the doctor’s

prognosis of their illness. Most participants described their illness as very unwell,

awful disease or something serious without necessary mentioning the word cancer.

Although I was aware of the exact diagnosis of some participants who were

identified by hospital doctors and nurses, I referred to participants’ illness in the

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words that they chose and to show my respect for them and avoid upsetting them. In other

words, I behaved in a culturally appropriate way with a respectful demeanour which enables

the participants to talk with me despite their worries about who I was initially. The traditional

Healers’ use of euphemisms was consistent with studies that identified the use of metaphors

to discuss sex or sex organs during medical encounters (Mbugua 2007), symbolism to discuss

the progressive disintegration and deterioration of unbounded bodies (Lawton 1998), and

euphemisms to describe tumours and cancers (Abu-Saad Huijer et al. 2009).

Again, the findings of my study are consistent with studies that have emphasised the

importance of using socio-culturally appropriate methods of communication to avoid causing

upset, distress or aggravation (Doumit, Abu-Saad 2008, Levine 1966). Doumit and Abu-

Saad’s (2008) termed such an approach as tactful communication, while Levine (1966)

referred to it as double layered communication which allows for vagueness, ambiguity and

interpretation. However, there are concerns that the use of euphemisms can become a

superficial strategy for impression management, avoidance, displacement or denial from

reality (McGlone, Batchelor 2003, Liszka 1990, McGlone et al. 2006).

Additionally, euphemisms or metaphors may serve the purpose of saving or

preventing the loss of face of the Traditional Healers and not the patients’ (Keith, Burridge

1991, Allan, Burridge 2006). In other words, the style of vague communication may afford

the Traditional Healers some latitude to avoid blame and not be held responsible in case there

is an unsuccessful treatment outcome, or something goes wrong. While these criticisms are

valid, there was no suggestion from my findings or participants’ accounts that the traditional

healers’ behaviour in managing participants’ emotions were simulated or intended for this

purpose. Instead, the Traditional Healers appeared to acknowledge the cultural necessities,

language traditions and the immediate contextual environment in breaking or discussing

important news.

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The timings and method of delivering sad news or discussing sensitive issues

are paramount in most Ghanaian indigenous communities. For example, supposed

wise people who can gauge the right moments and use euphemistic or symbolic

languages are usually sent to deliver shocking news such as death and misfortunes to

diffuse the intensity and impact of the message for the receivers of such news. Many

authors agree to the relevance of such a communication approach and its implications

on patients’ emotional experience, treatment satisfaction and outcomes (Arora 2003,

Beck et al. 2002, Ong et al. 1995, Stewart et al. 2000, Baile, Aaron 2005, Tayler,

Ogden 2005, Mccallum, Mcglone 2011).

On the contrary, the account of most participants of my study showed

dissatisfaction of how doctors used the direct or straight-to-the-point approach in

discussing or breaking sad news (Mccallum, Mcglone 2011, Tayler, Ogden 2005).

Most of my study participants considered such an approach unacceptable, insensitive

and culturally inappropriate. However, several authors acknowledge that achieving

the skills of cultural communication to manage emotions is a complex process which

cannot take place in a vacuum (Ackerson, Viswanath 2009, Demers, Viswanath 1999,

Simpson et al. 1991, Tayler, Ogden 2005).

Hence, such awareness cannot be expected to arise from theoretical

knowledge in the classrooms of medical schools without continuous and intentional

community engagement (Simpson et al. 1991, Tervalon, Murray-Garcia 1998).

Broadly, the Traditional Healers have an advantage in this sense of having their

training in the communities and learning the community values and acceptable

behaviours. Similarly, the approach of cultural telling and disclosure involved the

Traditional Healers hopeful and encouraging communication to participants. My

study participants described how Traditional Healers offered them hope and not used

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pessimistic or despondent words. The data shows that some Traditional Healers reassured

participants that their illness was not beyond redemption, even in the most advanced disease

stage.

Although superficially, most study participants may appear to believe what the

Traditional Healers told them, it cannot be taken at face value that they believed the

Traditional Healers could heal them. Most Traditional Healers did not explicitly tell the

participants that they could heal them, and hence, most participants expressed their hope in a

general and immeasurable sense. Such behaviour could also be a way in which my study

participants exercised their denial of the seriousness of their illness. Traditional Healers use

of hopeful and encouraging word helped the participants to live in a state of denial. Hence,

they did not question the Traditional Healers about their illnesses as they preferred remaining

in the dark as a coping strategy. The quote below is an example of how the Traditional

Healers offered hope to the participants;

Most participants expressed how the Traditional Healers gave them hope and

discounted the gloomy and pessimistic information they received from the doctors. The

traditional healer's language offered most participants a sense of hope, confidence, security

“He (Traditional Healer ) told me that I would not lose my life. The doctors said

that because they (Doctors) do not know how to treat such disease, all they know

is”kukuku’’ (inpatient or lack of patience). He (Traditional Healer) said it was

good that I have brought it to him. He told me that there is sore in my womb and

under and hence, he was going to give me some treatment that would help to

resolve this, so I should not worry’’ (Nyantah, female, 58, cervical cancer)

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and positive emotional outlook although participants’ reports of treatment outcomes

were primarily of symptom relief and appetite boosting rather than of actual healing

of their illness. In my experience of living and working in Ghana, tradition required

elders to demonstrate both emotional and physical composure in a challenging

situation and not to show weakness. Although there was no suggestion from my study

participant’s accounts or my observation that this was the case for the Traditional

Healers, it is conceivable that the Traditional Healers were acting superficially to

appease and validate their status and function in society. Possibly, the Traditional

Healers were required to reassure participants and to hide the truth of the seriousness

of their illness.

The findings of my study echo the view found by previous research, e.g.

Fallowfield (1993) that health professionals are vital in motivating patients through

their choice of words, composure and actions. My findings suggest the traditional

healers understood the impact of their attitude on the emotions of participants. The

caution is that such a community or cultural demands, although they enhance the

reputation and sense of control of Traditional Healers, can be unhelpful to their

patient's mental health and wellbeing (Hochschild 2012, Brotheridge, Grandey 2002).

Although the traditional healers’ behaviour may be a cultural prerequisite, there was

no hint that they were under pressure to behave in the manner that they did. Indeed,

the traditional healers in my study appeared to have a genuine sense of care and

support to ensure that participants remain positive and hopeful in their situation. The

study observed in the herbal clinics that the Traditional Healers appeared to not be

under pressure and had things under control through their facial expression of smile

and demeanour of soft calm and gentle approach.

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5.5.2 Keeping It to Oneself and Not Washing One’s Clothes in Public

Keeping it to oneself and non-disclosure of information by both the

participants and the traditional healers was a means of protecting participant’s emotion. My

study participants expressed their confidence and trust in the Traditional Healers to keep their

information secret and not upset them. Most participants themselves concealed their

condition from their families to avoid upsetting their families and themselves. Studies support

how a culture of emotion control and awareness in the form of non-disclosure helps to protect

the image and emotion of patients and families (Copp 1999, Glaser, Strauss 2017).

In both studies (Copp 1999, Glaser, Strauss 2017), the dynamics of information

sharing, and control was used by patients and other stakeholders as protection or power to

protect and define the status of the terminally ill. Most participants referred to the information

secrecy as “not washing one's clothes in public or outside’’, “Yensi ntoma wo abonten’’.

Hence, most participants wanted a health professional to keep their condition secret and not

reveal it even to families to avoid indignity, emotional distress and loss of control or

independence (Probst et al. 2013, Charmaz 2002). Many participants had concerns about the

doctors’ lack of confidentiality and protection and the assumption that it was accepted to

share information with participants’ family or other staff members.

Many participants, therefore, expressed confidence and openness to disclose and

discuss their feelings in more detail with the Traditional Healers because of their culturally

appropriate behaviour regarding the confidentiality of information about the illness. Also, the

Traditional Healers offered a safe place for participants to discuss issues which are so

sensitive for participants and needed handling with the utmost delicacy. The practice of non-

disclosure protected the participants’ emotions by shielding them from potential public

ridicule, judgment and opprobrium. The socio-cultural concept of helping or supporting a

sick relative is a massive moral responsibility in Ghana to the extent that the society regards

people who fail to meet such obligation with contempt.

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Although such a cultural practice can be helpful, it can equally put pressure on

participants to suffer in silence, to remain independent and not be a nuisance or

inconvenience to their family. Some participants felt that telling their families about

their illness would put the family under enormous pressure to adjust their life routines

to look after them. Most participants appreciated the invaluable support from their

partners or families but had legitimate concerns that their physical and economic

incapacity and dependency may put their relationships under strain. My study

participants’ feelings highlighted the adverse effects of chronic illnesses and their

significant impact on relations and social interactions, sometimes leaving divisions

even within families (Charmaz 2002).

My study found that the participant's decision to hide their situation from

families came with difficulty and involved some participants changing their life

routines and social relationships which radically impacted on their very self, life and

financial situation. Managing and protecting emotions was an essential cultural

prerogative for both the traditional healers and the participants.

5.6 Summary of Chapter

In this chapter, I have discussed the main findings of the study and how they

compare to relevant theories and findings of other studies. I have shown how trusting

identities of participants and Traditional Healers influence participants motivation to

use the services of the Traditional Healers. I have discussed the experience of

participants in seeking Traditional Healers as one of conviviality, hospitality and

emotional management through the perspective of socio-cultural understanding and

standards. The discussion has helped to answer the research question or fulfilled the

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study objective of exploring participants ‘motivations and experiences of using Traditional

Healers.

The chapter has highlighted the contrast of the lack of trust for the conventional

doctors because of their lack of “ shared identity’’ with the participants and how they

symbolise power and inequality in society. “Community of Us’’ the grounded theory from

this study encompasses participants share of identity, trust and convivial interaction with

Traditional Healers and how that affects their motivation and experience in using Traditional

Healers in Ghana.

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CHAPTER SIX: CRITIQUE OF STUDY AND CONTRIBUTION TO KNOWLEDGE

6.1 The Study Contributions to Knowledge

This study has shown the complexities and subtleties of community identities

of trust and relationships and how they influence participants health-seeking

behaviours. The research has shown that the motivations of people living with cancer

to use Traditional Healers or Traditional Medicine in Ghana are more profound than

we currently know through other researches as lack of availability, affordability and,

accessibility to conventional medicine. Instead, the study establishes that the socio-

cultural community dynamics of trust which have their expressions in a shared

tradition or ancestry, language, familiarity and established reputational characteristics

influence the motivation of people living with to use Traditional Healers in the Brong-

Ahafo region of Ghana.

In other words, people living with cancer have a shared community identity

with Traditional Healers or saw Traditional Healers as an active integral part of their

socio-cultural history and values. These shared identities formed the basis of the trust

that people living with cancer had for Traditional Healers or their motivation to use

the Traditional Healers. These add to the existing body of knowledge.

Equally, the study has shown that some people living with cancer in the

Brong-Ahafo region of Ghana have a generalised lack of trust in hospital doctors.

Most people living with cancer had the perception that the doctors did not share in the

local communities’ trusting identities. Instead, they were detached and sneering to the

local community trusting identities. This finding reflects and may explain why most

Ghanaian indigenous population use the Traditional Healers for their health-seeking

regarding illnesses.

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Moreover, the study explored the experiences of people living with cancer in their

therapeutic encounter with Traditional Healers in the Brong- Ahafo Region of Ghana. The

research has shown that people living with cancer conceptualised their therapeutic contact

and interaction with the Traditional Healers as friendly, informal and relaxed following their

community socio-cultural propriety. Therefore, the study highlights the importance of good

patient-health professional relationships and interaction, which is based on community socio-

cultural understanding. The study has shown that such relationships enhance patients’

experience, openness and feeling of liberty to discuss their condition and concerns health

professional.

The study adds to the current literature by showing that people living with cancer are

not only interested in the outcome of their treatment but also how their health professional

related to them in the therapeutic encounter and illness trajectory. The study has shown how

patients’ socio-cultural identities impinge on the perception of health and health-seeking

behaviours for illness and symptoms. Most people living with cancer in the study wanted

their health professionals to recognise their broader socio-cultural identity needs during the

therapeutic encounter and treat them with respect, dignity and friendliness. The study has

highlighted how patients and health professionals trusting relationship in indigenous

communities is linked with shared identities. The study adds to the knowledge that health

professional should endeavour to understand the cultural environment in which they practice

and align their practices and behaviour to it.

Furthermore, the study has shown how people living with cancer received emotional

and psychological support from Traditional Healers in the Brong Ahafo region of Ghana. The

pieces of literature had already demonstrated that chronic disease patients prefer Traditional

Healers to conventional doctors because of the emotional and psychological support they

receive from Traditional Healers. However, there was no evidence of how Traditional

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Healers provided such psychological support. The study adds to the body of

knowledge by emphasising the importance for health professionals to be sensitive and

adopt a culturally appropriate language of communication in speaking to people living

with cancer. The study has also shown how important it is for health professionals to

maintain their patients' information confidential, even from close relatives. The study

has shown that the legal and professional requirements for conventional doctors to be

straight and direct to their patient is not generically applicable to indigenous

communities. Some indigenous communities have different understanding and

manner of dealing with sensitive and complex issues. The study has shown how the

perception and understanding that some indigenous communities in Ghana have about

certain illnesses are associated with heightened emotions for both patients and their

families, which require additional skills from health professionals to handle. The

study shows the vital role or potential role of Traditional Healers in maximising

psychological care for patients in Ghana.

Moreover, the study adds to the body of knowledge that chronic disease

patients prefer to seek help from Traditional Healers for symptom management and

palliative care. Thus, Traditional Healers are better in managing chronic diseases,

while conventional doctors are competent in managing emergencies or acute

conditions. Most participants appeared happy with the manner that the Traditional

Healers managed their condition over a prolonged period and revisited the Traditional

Healers on a regular occasion. Even those who attended the hospitals still attended the

Traditional Healers for long term or palliative management of their illness.

The principal aim of the study was to develop a substantive theory or

conceptual understanding of people living with cancer’ motivation and experiences of

using Traditional Healers in the chosen context. The theory of “Community of Us”

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developed from participants accounts explains how people living with cancer see themselves

and the Traditional Healers as “Us’’, or people who share a standard traditional or ancestral

connection and community identities of trust. The study has shown how most patients trusted

health professionals whom they considered as part of the “Us’’ identity as they believe such

people would act towards them according to a shared rightness or sensibility. The study

shows how community identities formed the basis or measure of one’s trustworthiness in

indigenous communities

On the contrary, the concept shows how people living with cancer excluded the

hospital doctors from the ’Us’’ identities and categorised them as detached from the

community and showed distrust to them. The study has shown how people merely residing in

a community does not make them members or part of the ‘’Us’’ unless they share in the

community identities of trust.

6.2 Strength of the Study

The use of constructivist Grounded Theory (CCG) methodology has led to the

development of in-depth participants’ knowledge and understanding of their motivation and

experiences in using Traditional Healers in the context of the Brong-Ahafo region of Ghana.

The transparency of the researcher was important in this study as the researcher pre-field

biography, and clinical experience had the potential to influence the interview or data

collection and its analysis (Li, Arber 2006; Jack 2008).

However, the use of pre-field, in-field and post-field reflexivity was a strength to the

study by allowing the researcher to openly acknowledge and examine his own bias and deal

with them in a balanced manner. The potential biographical and professional, and academic

reflection allowed for the appropriate scrutiny of all the research thoughts and activities and

ensured they were not imposed on the process or outcome of the study. These provided a

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balance to ensure that my decisions were not based on preformed ideas. Instead, they

were based on the context and the participants' view.

Furthermore, my understanding of the local culture and fluency in the local

dialect helped in navigating the complexities of the setting and asking the interview

questions appropriately to sustain participants engagement and honest responses.

Hence, the dialogue between myself and the participants reflects the phenomenon and

the context of the study. Also, the study has the strength of interviewing patients from

both the herbal clinics and hospitals which provided a broader perspective and a

balanced view of patients who have used or were using Traditional Healers. The

multiple data sources ensured that the findings were a more representative view of the

phenomena.

6.3 Limitations and Requirement for Future Research

One of the limitations of this research is the small number of participants

involved in the study (n=35). Hence, one should exercise caution in the interpretation

of the data. We should acknowledge the difficulty in generalising any of the findings

and conclusions. Also, the study collected data from only two hospitals in the region

which dealt with only gynaecology and prostate cancer cases. Hence, the accounts of

participants were not a complete reflection or representation of all types of people

living with cancer or patients in the region. Equally, the lack of records in the herbal

clinics hindered the ability to confirm the diagnosis of participants recruited in these

clinics. I relied on the staff in these clinics and their descriptions of patients’ condition

as a diagnosis of cancer. Also, the participants themselves in both the hospitals and

the herbal clinics did not discuss their cancer diagnosis explicitly. Hence, the study

cannot claim that all participants were people living with cancer. The findings do not

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claim to be a representation of the experiences of people living with cancer in the entire

region.

As acknowledged in most social researches, the study represents an instant of what

takes place. Hence, the assumption is that a different reconstruction of the reality is possible

at contrasting times and various sites. The findings of the study cannot be generalised to the

whole community or another context. However, the study still has relevance and applicability

in a similar context.

Moreover, most participants of the study had low socioeconomic status. So, it was not

possible to compare the study participants behaviour or accounts with the rest of the

population who may have higher education or better access to Conventional medicine. It was

not possible to compare the study participants behaviour or accounts with the rest of the

population who may have higher education or better access to Conventional medicine.

In other words, the study did not uncover the extent of the influence of socio-

economic status in participants’ behaviour and whether wealthy participants would have had

a different level of trust in doctors’ or Traditional Healers. It is possible that patients who

have formal or western-style education, live in the city and have money may have had their

views changed regarding the socio-cultural values and unlikely to trust or use Traditional

Healers. It would be interested in exploring in future the views of patients who have moved

from the village to the city to understand how their views have transitory.

The study did not interview doctors or Traditional Healers, and hence, it was not

possible to clarify some of the assertions or impression that the study participants have

created about them. It would be interesting to know in future the findings of studies that

would consider the Traditional Healers and doctors as their participants.

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6.4 Recommendations for practice policy and education

The study did not offer criticism to any existing policies or lack of it but aimed

to conceptualise the motivations and experiences of people living with cancer who use

Traditional Healers. However, the findings of the study are significant to augment the

effective functioning of health delivery systems among the indigenous populations of

Ghana and similar settings. This section discusses the recommendations regarding the

relevance of the study to practice or the practical implications of the study on

improving practice and local delivery of healthcare. Also, the section discusses the

significance of the study to the development of health policies and regulatory

frameworks that acknowledge and reflect the active use of Traditional Healers in

some communities of Ghana. Such policies would position Traditional Medicine

alongside Conventional Medicine with the appropriate recognition of safety standards

and oversight. Additionally, the section discusses the importance of the study to how

Conventional Medical Education is designed and delivered in Ghana. Furthermore,

The section discusses the relevance of the study to research development to maximise

safety and innovation in Traditional Medicine.

6.4.1 Recommendations for Practice

Many patients in the study had concerns that Conventional Medical

Practitioners were unfriendly, paid them no attention or respected their cultures

during the therapeutic encounter. Friendly and cordial relationships, cultural greetings

and use of the local dialect were vital to enhancing patients experience of the

therapeutic encounters and building trust. Hence, Conventional Medical Practitioners

should have the necessary skill to interact with their patients at a human level. Such a

manner of interaction should occur at both the community level and in the hospitals.

Conventional Medical Practitioners should try to learn these cultural skills through

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engagements and interactions with the local communities, social groups and activities.

Equally, the hospital authorities should create engagement opportunities between

health professionals and the communities. This approach will help health professionals to

understand the populations' cultural priorities and expectations during the therapeutic

encounter. Such a culturally appropriate approach of interactions and engagements will

enable patients to identify with the health care system and the hospital environment. Also,

such practices would encourage patients to feel comfortable to discuss their concerns with

health professionals and inform them of any herbal treatments they may be using. Such

conversations would allow doctors the opportunity to give the right advice to patients on

safety and potential drug interactions in using Traditional Healers.

Furthermore, the study revealed many participants and Traditional Healers lack of

trust and suspicion for doctors and the Conventional Medical System. The lack of trust, as

reported, was deepened by the dichotomy and lack of dialogue between Conventional

Medical Practitioners and Traditional Healers. Accordingly, both Conventional Medical

Practitioners and Traditional Healers should be willing to set aside their ideological and

practical differences and work together for the best interest of their local communities. Such

collaboration would be difficult but possible with the appropriate policy backing and

stakeholders involvement. Also, the local community leaders can take the initiative to create

forums of communication to facilitate engagement between Conventional Medical

Practitioners and the Traditional Healers. These practical engagements and interactions

would encourage open discussions and help to build the necessary trust for collaboration

between Conventional Medical Practitioners and Traditional Healers. The collaboration

between Conventional Medical Practitioners and Traditional Healers would ensure continuity

of care and safety for patients who use the Traditional Healers.

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6.4.2 Recommendation for Policy

The findings of the study showed that the Traditional Healers and

Conventional Medical Practitioners function independently without a system of

collaboration. The lack of collaboration does not allow oversight and development of

safety systems for Traditional Healers (Boateng et al. 2016, Owoahene-Acheampong,

Vasconi 2010). The government should develop policies and strategies of integration

between Traditional Healers and Conventional Medical Practitioners wherever

possible. The policies of integration can help to improve the safety, efficacy and raise

the standard profile of Traditional Healers (Griffiths 2009, Robinson 2006).

Conventional Medical facilities can use their expertise to support the Traditional

Healers and to make it safer for patients who would like to continue to use them.

Equally, Conventional Medicine Practitioners can point patients who prefer

Traditional Medicine to the appropriate Traditional Healers who have the requisite

skills and accreditation to practice.

The government of Ghana and Conventional Health Care Systems currently

legally tolerate Traditional Healers or Traditional Medicine. However, there is no

formal accreditation or regulation of the entire Traditional healing system. The lack of

regulation and standards for Traditional Healers is a concern to patients' safety.

Consequently, there is no system of holding Traditional Healers accountable for

medical negligence or harms to patients unless in cases of a criminal offence. The

broader policy initiatives around the recognition of Traditional Healers, training, and

standardisation should be set out by the Central government and serve as the basis for

local guidelines. The government of Ghana made some previous attempts to introduce

and enforce the registration of Traditional Healers. Unfortunately, the complexity of

Traditional healing, the difficulty of bringing Traditional Healers together and the

lack of government's motivation to enforce such policies and regulations have led to

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their abandonment. The government should have the political will to introduce policies that

would ensure appropriate oversight of Traditional Healers as has been done in China, Hong

Kong and India (Griffiths 2009, Robinson 2006). In these countries, Traditional Healers are

trained, recognised, regulated, and to some varying extends integrated into the Primary

Health care system (Griffiths 2009, Robinson 2006).

Similarly, the policies in Ghana should ensure that the Traditional Healers have the

training, knowledge and skills before accrediting them to practice. The appropriate standard

and process of accreditation will protect patients' safety and the quality of care that they

receive from Traditional Healers. It would also be simpler and more feasible to hold

Traditional Healers professionally and legally accountable.

Furthermore, although Traditional Healers were found to play a significant

role in supporting the healthcare of indigenous communities, there is the danger of delaying

patients from seeking appropriate and advanced health support. Hence, the government

should have a clear policy and guidelines on what minor ailments Traditional Healers can

treat. (Griffiths 2009, Robinson 2006). Equally, the government should develop guidelines

for referral to the appropriate health facilities for cases beyond the Traditional Healers’

expertise.

Traditional Healers have trust and respect in indigenous communities and can

play a vital role in expanding Primary Health Care in these communities where Conventional

Health Practitioners are lacking. The government should develop strong Primary Health Care

policies that would involve Traditional Healers and existing indigenous facilities in health

delivery. These policies should offer standardised training in first aid, infection prevention,

health promotion practices, hygiene, treatment of minor ailments and guidance on patient

referral to hospitals. For example, the Global Network for Women's and Children Health

Research in Argentina, Guatemala, India, Kenya, Pakistan and Zambia found a reduction in

266 | P a g e

maternal-child death and postpartum haemorrhage using community interventions

(Pasha et al. 2010). Other studies have highlighted the use of Traditional birth

attendance, and community trained health workers and Traditional healers to improve

Primary Health (Pasha et al. 2010, Bahl et al. 2010, Sibley, Sipe 2006). Such an

inclusive approach would maximise the expertise and existing facilities of Traditional

Healers through Primary Health Care and minimise the risk of delay or unsafe

treatments.

6.4.3 Recommendation for Education

The study has shown that the Traditional Healers were educated in their

communities and involved in community or neighbourhood life. In contrast,

Conventional Medical Practitioners are trained in western style institution and have

no practical involvement in their local communities. The current western-style

education system or institutions provide the training of doctors and nurses without any

community input or considerations. The current policy on Patients Charter in Ghana

talks about the importance of patient-professional partnership and user involvement

(Ghana Health Service 2017). However, some authors argue that the policy is a latent

document for health professional while patients and the public are not aware of it

(Yarney et al. 2016).

The current medical training or education are confined to western-style

institutions and lack cultural trust, sensitivity and community relevance.

Conventional Medical Practitioners must-have cultural sensitivity, humility and

understanding of the needs and the dynamics of the communities in which they work.

Hence, universities and medical institutions should design their curriculum and

training programs to reflect the Ghanaian cultural traditions such as Traditional

Medicine and the dynamics of local communities. Practically, these curricula should

267 | P a g e

allow Conventional Medical Practitioners to spend time in the communities and with

Traditional Healers as part of their training to gain more community understanding of

illnesses and to win the trust of the populations.

Moreover, the curriculum and training should incorporate lessons on history,

tradition, culture and their relevance on health decisions and behaviours. Such an approach is

imperative for doctors to acquire the necessary skills to negotiate and function effectively

within the communities that they serve after their training.

It is equally essential that Traditional Healers are also supported to gain some level of

education and training to improve the safety and quality of their practice. Ghana has no

formal education or training and accreditation for Traditional Healers. Hence, there is no way

of measuring or standardising a minimum level of skills and knowledge required for them to

practice safely. The current lack of consistency in the criteria of how people become

Traditional Healers and minimum knowledge and skillset for Traditional Healers encourage

the proliferation of treatments which may have serious safety implication for users (Adusei

et al. 2019)

Also, the current open system may allow imposters who may defraud patients and

make their conditions worse. Traditional Healers who have the right treatments, skills and

knowledge may still lack knowledge in hygienic preparation of their products and accurate

dosing. To protect patients and to make Traditional Medicine safer for them, there should be

some minimum qualification, formal training and registration of Traditional Healers. Primary

Health Care (PHC) and public health professionals can organise informal workshops,

engagement programs, and seminars to support Traditional Healers to acquire these essential

skills and knowledge. The government and other stakeholders should support the creation

incentives such as given special recognition to Traditional Healers who participate in these

workshops.

268 | P a g e

6.4.4 Recommendation for Research

The evidence of the efficacy and safety of most Traditional Medicines in Ghana has not

appropriately been investigated or verified. The only source of the claim of their safety,

efficacy and potency to treat specific ailments usually come from the individual patient

account and the Traditional Healers themselves. The government should ensure the

involvement of educational and medical institution in researching to establish the efficacies,

safety and appropriate dosages of these medicines. Researching into Traditional Medicine can

also help to eradicate the potentially dangerous and harmful elements of Traditional Medicine

to patients. Equally, efficacious and safe Traditional Medicine can be a source of revenue for

the government and reduce the cost of specific treatments in Ghana.

6.5 Conclusion

The study has shown the complexities of health-seeking behaviours of people living with

cancer in the Brong-Ahafo region of Ghana. The findings of the study have been theoretically

positioned and compared to the relevant literature, focusing on health-seeking behaviours in a

socio-cultural context. Previous studies have found socioeconomic statuses of people and

their inability to access Conventional Medicine as the motivations for using Traditional

Healers.

However, this study has found deeper and shared trusting community socio-cultural

traditions, beliefs and identities as the motivations for using Traditional Healers by people

living with cancer. These trusting identities include the language traditions, neighbourhood

and community goodwill and accountability, ancestral connections, and community

reputational characteristics. The trusting identities enabled a positive experience for people

living with cancer in their therapeutic encounters with Traditional Healers.

In contrast, participants experienced Conventional Medicine based on western and

modern scientific philosophy and education. The operations and practices of Conventional

269 | P a g e

systems of health and its professionals did not conform to the socio-cultural trusting identities

in the communities. Most Conventional Health professionals did not speak the local dialect,

engage in neighbourhood interactions, nor had the standard of reputation that the community

and culture expected of them. Hence, people living with cancer did not feel they had the basis

for trusting Conventional Health professionals.

The theory of the” Community of Us” shows the foundation of the trusting

relationship between Traditional Healers and people living with cancer and how that trust

affects their motivation to use the Traditional Healers for therapeutic reasons. The theory was

developed from the trusting community identities and shared cultural traditions and beliefs

between people living with cancer and Traditional Healers.

These reciprocal and shared trusting relationships unified the Traditional Healers and

people living with cancer together as " Community of Us "and created a sense of oneness

with each other. The sense of trust and collectiveness was a motivation for people living with

cancer to use Traditional Healers as they behaved with cultural sensitivity and a shared

rightness. However, the "Community of Us" had boundaries and exclusions, and mostly

excluded Conventional doctors who did not share the same cultural identities and therefore,

not the same level of trust. Doctors were perceived with having a “whiteness" or an

exemplification of a colonial past. These include cultural detachment and power, which was

associated with post-colonial histories and socioeconomic inequalities.

The theory has implications on designing health programmes and systems in Ghana

and highlights the importance and necessity of trust in health professionals and the health

system. Also, the study has shown how health-seeking behaviours among people living with

cancer are influenced by their trust in health professional. However, the components of trust

are culturally dynamic and vary in context. Hence, the study has shown the need for health

policies, strategies, planning and education to broadly reflect their socio-cultural context. In

270 | P a g e

practice, such an approach would make the health system relevant and identifiable to the

target populations.

Furthermore, the study has identified the importance of health professionals having

cultural competence and sensitivity to the local communities in which they work. Moreover,

many people in the Ghanaian indigenous communities’ trust in Traditional Healers for

therapeutic purposes. Hence, any bespoke health delivery approach in Ghana must integrate

Traditional Healers to ensure patients who access Traditional Healers are doing so safely and

under the right regulations and standards.

6.6 Dissemination of Findings

Part of the findings of the study has already been presented at the British

Medical Sociology Conference (2016 and 2019) and the Qualitative Health Research

Network Conference (2019). I am currently writing drafting a paper for publication.

The regional health director of the Brong-Ahafo region of Ghana has shown interest

in the study and would like to know the findings. A summary of the findings and

recommendation will be sent to him. Also, the recruitment hospitals are interested to

know the findings. I am keeping all the necessary contacts and hoping to do these

presentations in Ghana by next year.

271 | P a g e

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APPENDIXES

Appendix 1 CASP Appraisal Tool

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Appendix 2: Participants Information sheet

s

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Appendix 3: Consent form

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Appendix 4 Interview Schedule

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Appendix 5: Risk assessment

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Appendix 6: Ethics Approval Certificate, University of Surrey

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Appendix 7 Ethics Approval Certificate, Ghana

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Appendix 8: Scientific Research Approval certificate, Ghana