Advances in Integrative Medicine xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Advances in Integrative Medicine

journal homepage: www.elsevier.com/locate/aimed

Comparison of the prevalence of non-communicable diseases and

traditional herbal medicine use in urban and rural communities in South
Africa
⁎
Gail Denise Hughes a, , Oluwaseyi Mayode Aboyade b, Christabel Osaretin Okonji c,
Bobby Clark d, Smart Z. Mabweazara e,f
a
Department of Medical Biosciences, University of the Western Cape, Bellville, Western Cape, South Africa
b
Nutrigo SA, 79 Stellanie Street, Willow Park Pretoria East, 0184, South Africa
c
School of Pharmacy, University of the Western Cape, Bellville, Western Cape, South Africa
d
Clark & Associates Statistical Consulting, Nolensville, Tennessee, United States
e
School of Public Health, University of the Western Cape, Bellville, Western Cape, South Africa
f
Department of Sport, Recreation and Exercise Science, University of the Western Cape, Bellville, Western Cape, South Africa

a r t i cl e i nfo a bstr ac t

Article history: Background: To quantify the use of traditional herbal medicines (THM), we documented the prevalence of
Received 27 February 2020 specific health conditions, the use of THM and the influences and reasons for using indigenous treatment
Received in revised form 24 November 2020 practices.
Accepted 30 November 2020
Methods: A cross-sectional descriptive study using a homogenous purposive sampling among 721 South
Available online xxxx
Africans living in rural and urban black South African communities. A structured questionnaire was used to
collect data between April–October 2014 on clinical/medical history, health-seeking behavior, and
Keywords:
Integrative medicine Traditional Herbal Medicine (THM) use. Descriptive, bivariate and multivariable analyses was done using R.
Complementary and alternative medicine Results: Majority of participants (77.5%) were from the urban area. More than (90%) had no health in-
Non-communicable diseases surance, and 80% had monthly income of < R2000 (equivalent to $ 126) in both urban and rural areas. Most
South Africa participants had NCD irrespective of location, but prevalence was higher amongst urban dwellers (61%).
Sub-Saharan Africa Hypertension was found to be the most dominant cardiovascular disease risk factor. Rural participants had
statistically significant higher rates of hypertension (67.1%) and diabetes (32.1%). Use of THM was sig-
nificantly associated with recommendations by family or colleagues. Participants who reported poorer
health status in rural areas used THM more than those in urban areas. Using multiple logistic regression,
rural participants have greater than 12-to-1 odds of being THM users than urban participants (odds ratio
[OR] = 12.62; 95% confidence interval [CI] = (4.09, 55.34)).
Conclusions: NCDs were more prevalent in urban communities with hypertension being the most prevalent.
There is widespread use of THM across South Africa. Rural residents and individuals of low social economic
status rely more on THM. These findings suggest a need for systematic and larger studies to understand the
magnitude and predictors of variation in access to and use of healthcare services, as these are critical to
developing effective culturally appropriate interventions for approaching hard-to-reach patients. Helping
patients navigate the complex healthcare system is the hallmark of a responsive system of care.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction

The use of traditional herbal medicines (THM) is becoming in-

⁎
Correspondence to: University of Western Cape, Faculty of Natural Sciences,
Medical Biosciences Department, New Life Science Building, Private Bag X17 (Robert
Sobukwe Rd), Bellville 7535, South Africa.
E-mail addresses: ghughes@uwc.ac.za (G.D. Hughes),
seyij.aboyade@gmail.com (O.M. Aboyade), okonjichristabel@gmail.com (C.O. Okonji),
bobby.l.clark@sbcglobal.net (B. Clark),
smabweazara@googlemail.com (S.Z. Mabweazara).
creasingly important in the primary health care of individuals and
communities in many developing countries [1–6]. THM use is more
prevalent in developing countries [7] and has also been widely
embraced in the developed world, including Europe, North America
and Australia [8]. Evidence of the significance of THM is shown in the
use of natural products from the herbal remedy, medicinal plants,

https://doi.org/10.1016/j.aimed.2020.11.002
2212-9588/© 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: G.D. Hughes, O.M. Aboyade, C.O. Okonji et al., Comparison of the prevalence of non-communicable diseases and
traditional herbal medicine use in urban and rural communities in South Africa, Advances in Integrative Medicine, https://doi.org/10.1016/
j.aimed.2020.11.002i
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al.
and functional foods and their constituents in the treatment of
various diseases [9].
In sub-Saharan Africa, herbal medicine is the predominant form
of traditional and complementary medicine use [10,11]. The adop-
tion of THM may be attributed to its low cost, accessibility, cultural
suitability, choice, perceived efficacy and safety, and dissatisfaction
with conventional medicine [3,12–16]. A prevalence of 86.1% and
38.6% for THM use was reported in Ghana [6] and Tanzania, [5] re-
spectively. Gyasi et al. [6] reported various reasons, such as attitudes
and beliefs, which were attributable to participants’ increased use of
THM, whereas sociodemographic factors had little effect. Other
factors responsible for the growing demand of THM is the anxiety of
adverse effects of biomedical drugs, improved access to health in-
formation, changing values and reduced tolerance of paternalism
[17]. THM is thought to be desirable and necessary for treating dif-
ferent health problems which could not be treated adequately with
CM [18].
Rural and urban populations may differ demographically, in so-
cioeconomic and cultural composition, and proximity to formal and
informal sources of health care [4]. The consequence of these so-
ciodemographic and cultural differences is that rural residents, who
are more likely to be impoverished and less educated are more
likely, then, to be THM-users compared to their urban counterparts
[7]. Sociodemographic differences even impact at country level. It
has been found that inadequate access to modern medicines and
drugs to treat diseases, especially in Africa, may have contributed to
the widespread use of THM, especially in poor households [5]. Ac-
cording to the World Health Organization (WHO) [16], the ratio of
traditional healers to the African population is 1:500 compared to
1:40 000 medically qualified doctors. Thus, indicating that most of
these doctors are concentrated in urban areas at the expense of rural
areas. Hence, for millions of people in rural areas, native healers and
THM remain their predominant sources of health care [19]. Tradi-
tional health practitioners (THP) are culturally embedded within
each community, and they are well-respected citizens. They are
readily accessible and usually less expensive than healthcare provi-
ders [20]. THPs are known to charge clients based on their ability to
pay. They will accept various means of payment, for instance, in-
kind or installments instead of a flat rate payable in advance, which
physicians or CM providers usually require [6]. THM provides
an avenue through which cultural heritage is preserved and
respected [21].
In South Africa, about 27 million South Africans, most especially,
the black population use THM to treat a variety of ailments [18,22].
In a survey among 135 hypertensive South African participants of the
Prospective Urban and Rural Epidemiological (PURE) study, there
was a significant difference in the age, marital and employment
status as factors predicting the frequency of THM use [4]. In another
report by the same author, among 456 PURE participants, 49% of
those with non-communicable diseases (NCD) used THM because of
a family history and 33% because of sociocultural beliefs [3].
Participants, in various South African studies, reported using
THM for a range of conditions such as diabetes, high blood pressure,
dental problems, severe tiredness, heart palpitation, sexually trans-
mitted diseases, asthma, pain, HIV/AIDS, gynecological and obstetric
complaints [1,3,4,23–28].
Non-communicable diseases (NCD) have in recent years become
a rapid increasing public health concern, especially for individuals in
low- and middle-income countries. South Africa is experiencing in-
creasing burden of chronic NCD. Currently, diabetes, hypertension
and other forms of heart disease are the most prevalent NCD asso-
ciated with rapid increase in mortality in South Africa [29]. While
South Africa has focused on controlling and treating communicable
diseases such as HIV, NCD have increased substantially, and now
pose a similar threat [30]. Risk factors such as ageing, decreased
physical activity, increased consumption of unhealthy food, and
2
Advances in Integrative Medicine xxx (xxxx) xxx–xxx
tobacco use has led to the increased burden of chronic NCDs in LMIC
[30]. Due to socioeconomic disparities, majority of those suffering
from uncontrolled chronic NCD are the urban poor, who are unable
to afford primary health care [30].
There is a dearth of knowledge about the factors that influence
the choice and use of THM in rural and urban settings of South
Africa. Healthcare-seeking behavior is a complex outcome of many
factors operating at individual, family and community level.
Comparing the healthcare-seeking behavior in urban and rural South
African populations is recommended to assist with the design of
healthcare policies and programs to ascribe appropriate medical care
by healthcare professionals (HCP). Thus, in the current study, we
seek to document the prevalence of specific health conditions, the
use of THM and the influences and reasons for using indigenous
treatment practices among urban and rural participants. Particularly,
the results are discussed under the following sub-themes:
(a) THM use between urban vs rural participants by socioeconomic
status.
(b) Prevalence of NCDs.
(c) Source of THM use between urban vs rural participants.
(d) General health status and THM use.
(e) Reasons and disclosure of THM use.
2. Methods
2.1. Study design
A cross-sectional descriptive study was conducted utilizing a
sample drawn from a population-based cohort study which involved
adult males and females in South Africa. These participants were
recruited as part of the South African arm (n = 2000) of a major
prospective study, the PURE study [31]. In this study, a global cohort
has been developed to investigate the impact of social and en-
vironmental transition on health involving over 150,000 adults in-
itially aged 35–75 years from communities in 17 low-, middle- and
high-income countries. A detailed description of the selection of this
study population has been published elsewhere [31].
2.2. Study setting
The current investigation was conducted in two black commu-
nities, i.e. Langa, a township located in Cape Town in the Western
Cape Province (urban), and Mount Frere, a small town located in the
Eastern Cape Province (rural).
2.3. Sampling for PURE South Africa
The cohort was drawn to be representative of the adult popula-
tion resident in both communities (Langa and Mount Frere) but also
with mindfulness to the possibility of follow-up of participants. The
communities were purposively selected based on having a relatively
stable (less migratory) black population, thus allowing for the fea-
sibility of follow-up in a prospective cohort study. For the urban
community (Langa), households were grouped into three develop-
ment areas recognized administratively by the City of Cape Town
and which mirror the socioeconomic status of the residents. A street
map obtained from the City of Cape Town was used to select streets
randomly in each of the three areas. Once a street was chosen, a
systematic sample of every second house was approached for pos-
sible inclusion in the study.
Household’s eligibility was based on the criteria that at least one
member was between ages 35 and 70 years and that this person
intended to continue living in the current home for the next four
years. All households with eligible individuals were approached by
trained field workers for recruitment. All individuals who were
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al.
“usual residents” were considered “household members” and eli-
gible to be selected into the study. A “usual resident” was defined as
one “who eats and sleeps in the household on most days of the week
and in [sic] most weeks of the year and one [who] considered the
household his/her primary place of habitation.”
For the rural community (Mount Frere), the absence of deli-
neated streets precluded the possibility to follow the same sampling
approach used for the urban township. A cluster sample of houses in
the community was, therefore, undertaken according to the division
of areas by the clan heads. All households within the clusters were
included if there was a household member aged 30–70 years old.
The initial recruitment took place between April and August 2009
with close to 1 000 participants recruited in both locations, while
second phase recruitment occurred between April and August 2010.
The response rate was 85%. All the individuals who agreed to par-
ticipate provided written informed consent.
2.4. Sampling for the current study
The sampling frame for the current study was the 2000 partici-
pants who took part in the original South African PURE study.
Calculation of the sample size using EPI-Info version 2007, showed
that about 721 participants were required for the current study.
The sampling frame for this study utilized the spreadsheet of the
1030 participants who were recruited from Langa in the urban South
Africa cohort of the PURE parent study. From this spreadsheet, the
participants who indicated having at least one NCD were recruited.
From this subset, 559 people completed the questionnaire. The same
procedure was utilized in a rural site, Mount Frere, where of the
about 1000 participants, only 162 people were located during the
fieldwork to complete the questionnaire. These participants were
then interviewed to determine the prevalence of NCDs and THM use.
2.5. Data collection
Data on the epidemiology of traditional medicine use for hy-
pertension and other chronic conditions were collected from
households and individuals in the study sample. Face-to-face inter-
views using structured questionnaires were conducted in these
households between October 2012 and November 2015. Eight (n = 8)
trained data collectors conducted the interviews in the preferred
language of the respondent (English or Xhosa). Data were collected
about the respondents’ demographic characteristics’ (age, sex, edu-
cation, marital and employment status), clinical/medical history and
traditional medicine usage (duration of use, condition for use, do-
sage, and form). The quality of data collected was maintained using
standardized protocols and centralized training. Excerpts from the
questionnaire that asked about THM use included:
1. Are you using any herbal medicine?
2. Who prescribed the traditional medicine to you?
3. What condition are you treating with traditional medicine?
4. How often are you taking traditional medicine?
5. When did you start using traditional medicine?
Ethical approval was obtained from the Senate Ethics Committee,
University of Western Cape, Bellville, South Africa.
2.6. Statistical methods
To examine differences between urban and rural participants, we
calculated frequencies and percentages. We used Fisher's exact test
and crosstabulation procedures to check for statistically significant
differences. Multi-variable logistic regression methods were used to
examine the relationship between sociodemographic characteristics,
urban-rural residence, and traditional herbal medicines. We present
3
Advances in Integrative Medicine xxx (xxxx) xxx–xxx
odds ratios and 95% confidence intervals. All bi-variate and multi-
variable analyses used list-wise deletion to address missing data.
Statistical analyses were conducted using the statistical computing
and graphics language ‘R′.
3. Results
This study involved analyzing responses from 721 study partici-
pants, with 77.5% from the urban area, and 22.5% from rural area
(Table 1). The female-to-male ratio was approximately four-to-one
for urban and rural residents, yet a greater concentration of younger
adults, ages 30–49 years, resided in the urban area compared to rural
area (30.7% versus 16.0%). The rural participants were more likely to
be married or cohabitating than urban participants (49.7% versus
28.9%). Rural participants were also more likely to have only primary
or no formal education than urban participants (52.0% versus 29.4%).
Urban participants were more likely to be current smokers (26.5%
versus 10.7%) and current drinkers (27.3% versus 9.6%) than their
rural counterparts. Sixty-five percent of urban participants reported
their health status, as being good or excellent, versus 49.3% of those
in the rural area. While 25.9% of rural participants mentioned, their
health had become worse or much worse compared to the previous
year, only 13.8% of urbanites mentioned this. There were no sig-
nificant differences between employment status (about 19.9% versus
18.9% employed) and monthly income (approximately 80% with in-
comes below R2000 per month) between urban and rural partici-
pants.
Sixty-one percent of urban participants had NCDs compared to
47.6% of rural participants (Table 2). Rural participants had statisti-
cally significant higher rates of hypertension (67.1% versus 48.7%),
diabetes (32.1% versus 16.9%), cancer (5.6% versus 0.9%), and cardi-
ovascular disease (CVD; 5.8% versus 1.3%) than urban participants.
Hypertension was the most prevalent risk factor for developing NCD
in both areas.
Among the 559 urban participants, 29.3% (N = 164) reported ever
using THM, as against 13.6% (N = 22) rural participants (Table 3). Of
these urban participants, 53.2% reported being influenced to use
THM by family/relatives, followed by 18.6% who reported being in-
fluenced by friends/colleagues. However, 40.0% of rural participants
reported being influenced by family/relatives, followed by 20% who
reported being influenced by partners to use THM.
Family history was the most prevalent reason given for using
THM for urban and rural participants (51.8% and 64.7%, respectively).
Trailing this was cultural beliefs (31.1%) and treating health condi-
tions (30.0%) for urban participants. Among rural participants, after a
family history, cultural beliefs (57.1%), accessibility (38.5%), and
treating health conditions (35.7%) were reasons. A higher percentage
of urban THM users reported using these in combination with CM
compared to rural participants (37.7% versus 18.2%). Rural THM users
were more likely to visit THPs (50.0% versus 24.4%), more likely to
disclose CM use to their THP (28.6% versus 20.4%), and THM use to
their HCP (41.2% versus 11.9%), and more likely to have HCP who
inquire about their THM use (29.4% versus 7.5%).
In Table 4, the sociodemographic and health characteristics of
urban and rural users of THM are described. Rural THM users had
slightly fewer female participants (63.6% versus 75.6%), a lower
percentage of younger adults, ages 30–49, (18.2% versus 27.4%), and
much fewer never-married (18.2% versus 39.2%) than urban THM
users. Rural THM users compared to their urban counterparts were
also more likely to be unemployed (60.0% versus 44.7%), more likely
to have only primary or no formal education (68.2% versus 36.2%),
and more likely to have monthly incomes less than R2000 (95.5%
versus 73.8%).
Regarding health characteristics of rural and urban THM users,
rural participants were substantially more likely to have never drunk
alcohol (71.4% versus 57.3%), to report having poor health (40.9%
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al. Advances in Integrative Medicine xxx (xxxx) xxx–xxx

Table 1
Social, demographic and health characteristics of urban and rural participants.

Urban (n = 559) Rural (n = 162) Fisher’s exact test (p-value)

Gender Male 128 (22.9%) 31 (20.1%) 0.513

Female 431 (77.1%) 123 (79.9%)
Age group (years) 30–49 171 (30.7%) 26 (16.0%) <0.001**
50–69 326 (58.5%) 113 (69.8%)
70–89 60 (10.8%) 23 (14.2%)
Marital status Never married 269 (48.9%) 28 (18.5%) <0.001**
Married/cohabitating 159 (28.9%) 75 (49.7%)
Widowed/divorce/separated 122 (22.2%) 48 (31.8%)
Education level None or primary 162 (29.4%) 79 (52.0%) <0.001**
Secondary 343 (62.3%) 64 (42.1%)
Tertiary or vocational 46 (8.3%) 9 (5.9%)
Employment status Employed 107 (19.9%) 28 (18.9%) 0.248
Unemployed 270 (50.2%) 85 (57.4%)
Retired 161 (29.9%) 35 (23.6%)
Religion Christian 532 (95.4%) 148 (98.0%) 0.540
Other 20 (3.6%) 3 (2.0%)
Monthly household income <R2000 440 (79.3%) 125 (81.2%) 0.939
R2000-R5000 99 (17.8%) 25 (16.2%)
>R5000 16 (2.9%) 4 (2.6%)
Health insurance Yes 24 (4.4%) 2 (1.4%) 0.091
No 518 (95.6%) 145 (98.6%)
Smoking history Current smoker 142 (26.5%) 16 (10.7%) <0.001**
Never smoked 324 (60.6%) 125 (83.9%)
Past smoker 49 (9.2%) 4 (2.7%)
Casual smoker 20 (3.7%) 4 (2.7%)
Alcohol history Current drinker 147 (27.3%) 14 (9.6%) <0.001**
Never drank 269 (49.9%) 122 (83.6%)
Past drinker 54 (10.0%) 8 (5.5%)
Casual drinker 69 (12.8%) 2 (1.4%)
General health Excellent 46 (8.6%) 11 (7.3%) <0.001**
Very good 82 (15.3%) 13 (8.7%)
Good 219 (40.9%) 50 (33.3%)
Fair 120 (22.4%) 36 (24.0%)
Poor 69 (12.9%) 40 (26.7%)
Health compared to previous year Much better 229 (42.1%) 34 (22.5%) <0.001**
Somewhat better 94 (17.3%) 21 (13.9%)
About the same 146 (26.8%) 57 (37.7%)
Worse 50 (9.2%) 33 (21.9%)
Much worse 25 (4.6%) 6 (4.0%)

(*) Statistically significant at the 95% confidence level; (**) statistically significant at the 99% confidence level.

Table 2
Non-communicable diseases among urban and rural participants. Table 3
Traditional herbal medicine (THM) use by urban and rural participants.
Urban Rural Fisher’s exact
(n = 559) (n = 162) test (p-value) Urban Rural
**
Non-communicable Yes 339 (61.0%) 70 (47.6%) 0.004 THM historical use n = 164 (29.3%) n = 22 (13.6%)
diseases No 217 (39.0%) 77 (52.4%) THM use influences Friends/colleagues 29 (18.6%) 3 (15.0%)
**
Hypertension Yes 264 (48.7%) 51 (67.1%) 0.003 Partner 17 (10.9%) 4 (20.0%)
No 278 (51.3%) 25 (32.9%) Family/relatives 83 (53.2%) 8 (40.0%)
Diabetes mellitus Yes 88 (16.9%) 17 (32.1%) 0.013* Self 11 (7.1%) 3 (15.0%)
No 434 (83.1%) 36 (67.9%) Traditional practitioner 10 (6.4%) 1 (5.0%)
Rheumatoid arthritis Yes 64 (11.9%) 6 (11.3%) 1.000 Advertisement/Books/ 4 (2.6%) 1 (5.0%)
No 475 (88.1%) 47 (88.7%) Internet
Cancer Yes 5 (0.9%) 3 (5.7%) 0.027* Healthcare providers 2 (1.3%) 0 (0.0%)
No 534 (91.1%) 50 (94.3%) Reason for THM use: Family history 85 (51.8%) 11 (64.7%)
Cardiovascular disease Yes 7 (1.3%) 3 (5.8%) 0.049* Reason for THM use: Cultural beliefs 51 (31.1%) 8 (57.1%)
No 531 (98.7%) 49 (94.2%) Reason for THM use: Low cost 29 (17.8%) 3 (25.0%)
Heart disease Yes 9 (1.7%) 3 (5.7%) 0.083 Reason for THM use: Accessibility 22 (13.6%) 5 (38.5%)
No 529 (98.3%) 50 (94.3%) Reason for THM use: Positive recommendation 38 (23.3%) 1 (8.3%)
Stroke Yes 8 (1.5%) 0 (0.0%) 1.000 Reason for THM use: Failure of CM 2 (1.3%) 1 (8.3%)
No 530 (98.5%) 51 (100.0%) Reason for THM use: Curing disease 16 (9.9%) 2 (18.2%)
Depression Yes 19 (3.5%) 0 (0.0%) 0.395 Reason for THM use: Treating side effects 5 (3.1%) 1 (9.1%)
No 519 (96.5%) 51 (100.0%) Reason for THM use: Delay in medical care 2 (1.2%) 0 (0.0%)
Psychotic disease Yes 4 (0.7%) 0 (0.0%) 1.000 Reason for THM use: Recommendation by HCP 11 (7.0%) 1 (8.3%)
No 534 (99.3%) 51 (100.0%) Reason for THM use: Treat condition 48 (30.0%) 5 (35.7%)
Hypercholesterolemia Yes 12 (2.2%) 0 (0.0%) 0.612 Reason for THM use: Manage condition 23 (15.0%) 1 (8.3%)
No 526 (97.8%) 51 (100.0%) THM in combination with CM 61 (37.7%) 4 (18.2%)
Asthma Yes 17 (3.2%) 1 (2.0%) 1.000 Use of TP 39 (24.4%) 8 (50.0%)
No 521 (96.8%) 50 (98.0%) Disclosure of CM use to TP 19 (20.4%) 2 (28.6%)
Bronchitis Yes 2 (0.4%) 1 (2.0%) 0.234 Disclosure of THM use to HCP 19 (11.9%) 7 (41.2%)
No 535 (99.6%) 49 (98.0%) HCP inquire about their THM use 12 (7.5%) 5 (29.4%)
*
Statistically significant at the 95% confidence level. CM = conventional medicine; HCP = healthcare providers; TP = traditional practi-
**
Statistically significant at the 99% confidence level. tioners.

4
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al. Advances in Integrative Medicine xxx (xxxx) xxx–xxx

Table 4 Table 5
Traditional herbal medicine use by social, demographic and health characteristics for Multivariable logistic regression results: sociodemographic, health characteristics and
urban and rural participants. region regressed on traditional herbal medicine.

Urban Rural Odds ratio (95% CI)

Region Urban
THM n = 186 n = 164 n = 22
Rural 12.62 (4.09, 55.34)
Gender Male 40 (24.4%) 8 (36.4%)
Gender Male
Female 124 (75.6%) 14 (63.6%)
Female 1.04 (0.64, 1.71)
Age group (years) 30–49 45 (27.4%) 4 (18.2%)
Age group (years) 30–49
50–69 95 (57.9%) 13 (59.1%)
50–89 1.14 (0.72, 1.81)
70–89 24 (14.6%) 5 (22.7%)
Marital status Married/cohabitating
Marital status Never married 62 (39.2%) 4 (18.2%)
Never
Married/ 52 (32.9%) 9 (40.9%)
Married/divorced/ 0.87 (0.55, 1.38)
cohabitating
widowed/separated
Widowed/divorce/ 44 (27.8%) 9 (40.9%)
Education level None or primary
separated
Secondary/tertiary/ 0.48 (0.30, 0.75)
Education level None or primary 59 (36.2%) 15 (68.2%)
vocational
Secondary 92 (56.4%) 7 (31.8%)
Employment status Employed
Tertiary or 12 (7.4%) 0 (0.0%)
Unemployed/retired 0.74 (0.43, 1.29)
vocational
Monthly household Greater than or equal
Employment status Employed 33 (20.8%) 1 (5.0%)
income to R2000
Unemployed 71 (44.7%) 12 (60.0%)
Less than R2000 0.50 (0.30, 0.84)
Retired 55 (34.6%) 7 (35.0%)
Health status Good/excellent
Religion Christian 155 (94.5%) 19 (100.0%)
Fair/poor 0.86 (0.55, 1.31)
Other 9 (5.5%) 0 (0.0%)
Monthly household <R2000 121 (73.8%) 21 (95.5%)
income
R2000-R5000 37 (22.6%) 1 (4.5%)
>R5000 6 (3.7%) 0 (0.0%)
indigenous populations to THM. To quantify the use of THM, we
Health insurance Yes 10 (6.3%) 0 (0.0%) undertook to document the prevalence of specific health conditions,
No 149 (93.7%) 20 (100.0%) the use of THM, and the influences and reasons for the use of in-
Smoking history Current smoker 30 (19.4%) 5 (23.8%) digenous treatment practices.
Never smoked 104 (67.1%) 15 (71.4%)
In this study, there was an overwhelming THM use by rural re-
Past smoker 17 (11.0%) 0 (0.0%)
Casual smoker 4 (2.6%) 1 (4.8%) sidents with primary education or less, and among the unemployed
Alcohol history Current drinker 26 (16.6%) 4 (19.0%) irrespective of urban or rural residence. In general, among rural re-
Never drank 90 (57.3%) 15 (71.4%) sidents, there was greater reliance on THM, suggesting engagement
Past drinker 17 (10.8%) 2 (9.5%) in medical dualism. Monthly income was also pronounced among
Casual drinker 24 (15.3%) 0 (0.0%)
General health Excellent 15 (9.7%) 1 (4.5%)
rural residents, with most of them who earned more than R2000
Very good 18 (11.6%) 0 (0.0%) reporting the use of THM. While we report greater reliance on THM
Good 71 (45.8%) 6 (27.3%) among rural residents, in recent study conducted in Malaysia, gen-
Fair 30 (19.4%) 6 (27.3%) eral CAM usage, probably including THM, was found to be higher
Poor 21 (13.5%) 9 (40.9%)
among urban residents [32].
Health compared to Much better 65 (40.6%) 3 (14.3%)
previous year However, for the post-diagnosis of chronic disease usage, the
Somewhat better 33 (20.6%) 2 (9.5%) odds were higher among those with less education and living in
About the same 38 (23.7%) 9 (42.9%) rural areas. Medicinal plants are likely to be abundant in rural areas
Worse 19 (11.9%) 7 (33.3%) where the effect of urbanization has not yet had a profound negative
Much worse 5 (3.1%) 0 (0.0%)
effect because of deforestation. The availability and affordability of
THM in rural areas make it a preferred healthcare alternative [33]. As
in the current findings, report has shown that persons of low social
versus 13.5%), and that their health was worse or much worse than economic (SES) based on a low level of education, unemployment,
the previous year (33.3% versus 15.0%). and low monthly income, are likely to rely on THM [33]. These
To determine the potential impact of region on the use of THM, findings mirror those from a recent systematic review of studies
we present a multivariable logistic regression model regressing re- conducted in sub-Saharan Africa on THM use, in which the authors
gion on THM use and adjust for gender, age, marital status, educa- reported low SES based on persons who are unemployed, and those
tion, employment status, and income and health status (Table 5). with low education more likely to use THM [14].
Rural participants were shown to have greater than 12-to-1 odds of Possible reasons for these findings are that individuals with
being THM users controlling for gender, age, marital status, educa- lower education have low exposure to formal education, and are
tion, employment status, and income and health status (odds ratio, mostly exposed to cultural, traditional, and cheaper alternatives to
12.6; 95% confidence interval (4.1, 55.3)). Educational level and health care such as THM. On the other hand, individuals with higher
monthly household income were also shown to be significant pre- levels of education will prefer conventional medicine, possibly be-
dictors of THM use. The more educated and the poorest were less cause of ease of consumption, storability and carriage [33]. Un-
likely to use THM adjusted for the other factors in the model. employed individuals and those who have a low monthly income
will also most likely prefer THM because of their affordability and
4. Discussion availability compared to orthodox drugs [33].
In the current study, more than half of the participants had a NCD
The epidemiological transition and effect of globalization, along irrespective of location. Far more participants living in Langa, the
with the impact of the three-decade-old HIV/AIDS, have had the urban area, were found to have a NCD compared to those in the rural
most significant influence on Africa’s population. The implication of area. This finding could be linked to the different lifestyles between
this transition is a decline in the capacity of health systems to urban and rural dwelling South Africans. For example, in an earlier
shoulder the burden of large numbers of people with chronic dis- study, 51% of non-urban dwelling residents were found to walk more
eases. Consequently, there has been a greater shift and return among than a kilometer to fetch firewood [34]. Consequently, individuals

5
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al.
residing in rural South-Africa, are likely to engage more in physical
activity and thus be at low risk for developing NCDs.
The proportions of CVD and heart disease in urban and rural
residents, respectively, appear lower in this study than had been
reported elsewhere among South Africans [35]. The high prevalence
of hypertension observed in both study sites is not surprising, as
already has been mentioned, in South-Africa, it is the most dominant
CVD risk factor and prime contributor to CVD morbidity and mor-
tality [36]. Interestingly, diabetes was more prevalent in the rural
site compared to the urban one. The increase in the prevalence of
diabetes in rural areas might be attributed to the proportion of
adults who drink sugar-sweetened beverages in rural South-
Africa [37].
Although we saw variations among urban and rural residents
with partner influence appearing to have a larger effect on THM use
than among urban dwellers. Using THM also appeared to be sig-
nificantly associated with recommendations by family or colleagues.
Similarly, in a systematic review on the use of CAM in sub-Saharan
Africa, the common sources of information on THM use were from
respected and trusted peers such as family and friends [14]. Advice
from family and friends has shown to be more trusted compared to
other sources [38,39]. Family and friends can also be the closest and
most trusted sources of health-related social support. African THM is
also entrenched within cultures, and the information is handed
down from close family members [20,39]. As such, THM-related
information is most likely to be passed on from one family member
to another.
Ironically, the proportion of rural residents who identified THPs
as the source of influence was lower than in urban areas. This is
uncommon since it is expected that THPs tend to be more easily
accessible, known, and trusted in rural areas than in urban settings.
They are likely to have grown up in the same area as the people who
need their specialized THM products and thus influence their THM
use. However, it can be postulated that traditional healing knowl-
edge, especially among older family members, might be the reason
why family/friends influence THM use more than THP among our
rural participants.
A few urban residents identified their healthcare provider as
having a major influence on their use of THM. However, there was no
such influence in rural areas, which may suggest that there are no
HCP in rural areas, or they may lack an appreciation of THM in the
lives of the local rural population. These findings are interesting
since when asked if HCP inquired about their use of THM, less than
30% of rural residents responded in the affirmative, while a mere
7.5% of urban participants did so. This finding is consistent with that
of our previous report [3]. We concluded that when physicians
consult with patients with predictors of THM use, they need to assist
them in making informed decisions by educating them about THM
use and pointing them to materials that can be of help.
Participants who reported fair-to-poor health status in rural
areas used THM more than those in urban areas. Furthermore, those
who perceived that there was no change in their health compared to
the previous year, in either group, had higher rates of THM use. As
previously mentioned, persons of low SES and rural participants are
likely to use THM [7], which is because of the affordability of THM
compared to CM. Therefore, this finding is expected since most rural
dwellers in S.A are likely to be of low SES. Furthermore, health
conditions such as depression and hypertension have been asso-
ciated with increased THM use [7]. Similar findings have also been
reported in other studies [40,41]. Recently, high usage of THM
among adults diagnosed with hypertension was also reported [42].
As such, the use of THM may be quite common among adults with
bad health, especially those living in rural areas, who are bound to
depend on THM because of its affordability.
When asked about, who influenced their use of THM, nearly two-
thirds of rural residents identified family members as the main
6
Advances in Integrative Medicine xxx (xxxx) xxx–xxx
influence. The high rate of family history as a major driver for both
urban and rural residents suggests that there are deeply rooted fa-
mily and cultural connections to traditional medical practices [43].
Delay in medical care was not cited as a reason for THM use in
rural residents, yet more than a third reported using THM to treat
their condition. Given the inadequacies of healthcare facilities, the
lower educational attainment of rural residents, and the cultural
definitions of disease, could be reasons why the participants did not
understand the context of the question. Within the study sample,
there is a significant level of medical dualism where more of the
urban participants reported using THM in combination with CMs.
For South Africans who have a long history with traditional herbal
medicine before the introduction of western medicine, this suggests
there are greater acceptance and exploitation of the synergetic
benefits of both worlds of medicine. For these individuals, the
question or possibility of drug interactions is not a consideration.
However, depending on the conditions, medical dualism could cause
physiologic damage, especially if the potential interactions between
the active components of the THM and CMs are unknown [44].
Furthermore, it is important to carefully analyze the extent of THM
use either as sole treatment regimens or in combination with CM.
The prevention of NCD and health promotion programs in com-
munities where THM is known to be prevalent must include mod-
ules on the dangers of potential drug interactions between the
traditional products and pharmacological agents used in their
management. Although there are legislation and policies in place to
accelerate the institutionalization of THM, there is slow progress in
the applications of these policies [45]. Thus, the local communities
do not have the negotiating power required to benefit from the use
of THM and are often unaware of their rights, which lead to ma-
nipulation and misappropriation of their knowledge [46]. This si-
tuation has a huge impact on individuals who utilize THM. There is
need to provide guidelines and regulation for collaboration at pri-
mary health care [45]. HCP should include questions about the use of
THM on their admission forms to create complete patient records.
These providers should also openly discuss the role of THM with
their patients for them to feel comfortable in discussing their THM
use with them, which will build a trust-based patient-provider re-
lationship. In turn, this will aid the providers to better engage pa-
tients in discussions about the potential dangers of drug
interactions. Even among rural residents, it is encouraging that more
than a third of the participants reported disclosing their THM use to
their HCP.
5. Conclusions
Our findings show us that there is evidence of the widespread
reliance on THM in South-Africa among urban and rural residents.
Rural participants and individuals of low SES specifically were
shown to rely more on THM. Another significant finding was that
most participants had NCDs irrespective of location but more so
among urban dwellers. Hypertension was found to be the most
dominant CVD risk factor among study participants. The significant
association with NCDs prevalence between rural and urban residents
confirms findings from our previous study. These findings suggest a
need for systematic and larger studies to understand the magnitude
and predictors of variation in access to, and use of healthcare ser-
vices, as these are critical to developing effective culturally appro-
priate interventions for approaching hard-to-reach patients. Helping
patients navigate the complex healthcare system is the hallmark of a
responsive system of care. In low- to middle-income countries, with
limited resources, formal and traditional herbal medicinal processes
can assist public health and community health workers in devel-
oping integrated systems and interventions that address the unique
challenges facing rural populations. While the current study has
demonstrated significant differences between rural and urban
G.D. Hughes, O.M. Aboyade, C.O. Okonji et al.
residents in their use of THM, future studies should examine the
conditions for use and determine if there are differences in their use
by a specific disease.
5.1. Study limitation
One major limitation of this study is that it is not generalizable
across the black population of South Africa because the study par-
ticipants are not a true reflection of all the black ethnic groups in the
country. Furthermore, self-report bias could not be avoided because
the participants had to provide information about their health and
health-seeking behaviors.
Ethics statement
Ethical approval was obtained from the Senate Ethics Committee,
University of Western Cape, Bellville, South Africa.
Authors statement
All authors approve of the submission of the revised manuscript.
CRediT authorship contribution statement
GH and OMA conceptualized and designed the study; GH, OMA
and OOC captured and cleaned the data; BC conducted the statistical
analysis; GH, OMA, OOC, BC and SCZ contributed to writing the
manuscript.
Conflict of interest
The authors declare that there is no conflict of interest.
Acknowledgements
This study was funded by National Research Foundation of South
Africa and University of Western Cape Office of Research. In addition,
sincere appreciation goes to the PURE study team at the School of
Public Health, University of the Western Cape and the PURE study
participants. The authors would like to acknowledge Jean Fourie for
her editorial contributions.
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