RESEARCH

 

Cultural Beliefs and Oral Health Practices in Rural KwaZulu-Natal: Bridging Tradition with Modernity through Perspectives of Traditional Health Practitioners

 

 

S Dlamini^I; I Moodle^II; M Reddy^III

^INGAP Lecturer, PhD student. University of KwaZulu-Natal. College of Health Sciences. Discipline of Dentistry Tel: 031 260 7639. Cell: 082 758 1503. Email: DlaminiS27@ukzn.ac.za ORCID: http://orcid.org/0000-0002-9827-4290
^IISenior Lecturer, Academic Leader, Co-supervisor. University of KwaZulu-Natal.College of Health Sciences. Discipline of Dentistry. Tel: 031 260 6215. Cell: 084 920 1088 ORCID: http://orcid.org/0000-0001-5834-887
^IIISenior Lecturer, Supervisor. University of KwaZulu-Natal College of Health Sciences Discipline of Dentistry. Tel: 031 260 8270. Cell: 084 584 4288 ORCID: http://orcid.org/0000-0001-9830-451

Correspondence

 

 

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ABSTRACT

KwaZulu-Natal (KZN), the second largest province in South Africa, is home to the Zulu nation, whose culture is deeply rooted in ancestral traditions, including health practices. Oral health, although essential to overall health, is often influenced by cultural beliefs and practices in rural communities. While modern oral care such as brushing with fluoride toothpaste and visiting a dental professional regularly is widely promoted in urban areas, rural areas in KZN still rely on indigenous methods for maintaining oral hygiene and treating dental problems. These traditional practices reflect both practical solutions and spiritual beliefs. This qualitative study explored how rural KwaZulu-Natal's oral health practices are shaped by cultural traditions, the role of traditional health practitioners (THPs), and modern dentistry and the challenges of integrating the two.
METHODS: Purposive sampling included 42 participants from 5 KZN district municipalities who were selected by the Traditional Healers' Research Officer of the province. Selecting participants was based on the criteria of being a registered THP under a recognised organisation, namely Traditional Healers' Organisation (THO), Vukuzenzele and Nupatsa
RESULTS: The vast majority of traditional health practitioners revealed that oral diseases can be caused by spiritual and physical forces. This means that a disturbance of spiritual ease can manifest physically through disease. Furthermore
they advocated that in order to strengthen the care of oral diseases, it could be managed by both dental professionals and traditional healers concurrently although different interventions were necessary.
CONCLUSION: By valuing and integrating traditional practices, rural communities in KZN can achieve oral health outcomes while preserving their rich cultural heritage, demonstrating the confluence of tradition and modernity which can lead to innovative and culturally competent oral health solutions. This collaboration will not only enhance accessibility and acceptability of oral health programs but also foster mutual respect and understanding between diverse oral health paradigms

Keywords: Traditional health practitioners, cultural belief, oral diseases, oral health.

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INTRODUCTION

The healthcare system in South Africa (SA) faces significant challenges in meeting the needs of its population, particularly in KwaZulu-Natal (KZN), which is burdened by a quadruple disease load of Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome (HIV/AIDS), Tuberculosis (TB), chronic illnesses, and injuries.¹ The shortage of healthcare workers, unevenly distributed between the public and private sectors, exacerbates these challenges.² In the public sector, urban areas have more healthcare workers compared to rural regions.³ With a population exceeding 10 million, only 15% of KZN residents have medical insurance, granting them access to private healthcare services, while the remaining 85% rely on public health services.^4,5 This disparity creates additional vulnerabilities for those in rural and disadvantaged communities, where access to healthcare, including oral health services, is limited. While rural communities in KZN have access to dental care, these are often infrequent and insufficient to meet the population's needs. Many rural residents face barriers such as long travel distances, lack of transportation, and financial constraints, which prevent them from accessing regular dental checkups.⁶ Consequently, individuals often seek oral healthcare only when experiencing severe pain, leading to late presentations of oral diseases.

This situation is further complicated by cultural beliefs. The majority of the population in KZN is the Zulu nation, whose societal perceptions, culture and practices are highly influential in shaping local health behaviors, representing a known but underexplored barrier to accessing healthcare services in rural areas.⁷

Rural communities tend to have more traditional beliefs, where culture dictates not only social and economic organisation but also health and well-being. Health is viewed holistically, with physical, spiritual, and ancestral well-being interconnected. Communities often place trust in natural, herbal remedies and the guidance of Traditional Health Practitioners (THPs) (Faith healers- abathandazi, diviners-izangoma and herbalists- izinyanga).⁸ According to the Zulu culture, there are two views of the causes of disease. Good health is usually associated with principled ancestral recognition; it is believed that good health is a blessing for good behaviour, upholding norms and values of the traditions of society.⁹ Therefore, when the ancestors are distressed, people manifest with disease. Oral health is not seen in isolation, but as part of one's overall health, influenced by factors including diet, hygiene practices, and spiritual balance. Hence, if someone experiences dental problems such as toothaches or abscesses, it might be interpreted not just as a medical issue but as a sign of spiritual imbalance or a disconnection from their ancestors ^10,11. The second view is that disease is caused by evil or bad spirits from spell casting or witchcraft, particularly disease that defies scientific treatment.¹²

In SA, 80% of black South Africans seek assistance from THPs for health-related conditions.¹² There are currently over 200 000 THPs compared to 25 000 physicians.¹² Although they have no formal medical training, THPs are highly regarded as being capable for treating health-related issues in their communities, as they are easily accessible and affordable,¹² making them the first point of access for health-related issues.^13,14 Many South Africans consult THPs before or alongside conventional healthcare providers.⁹

The use of THPs in management of general health and oral health care is well established in other African countries.^{14, 17} The World Health Organization (WHO) reports that 80% of Africans rely on Traditional Medicine (TM) for their healthcare needs.^18,19,20 THPs in Nigeria are known to treat most oral health related conditions with plants and herbs.²¹ They further play a pivotal role in addressing early diagnosis of the oral manifestations of HIV/AIDS.²²

While there is extensive evidence on the role of THPs in managing oral diseases in African countries, there is limited knowledge about their role in SA. Given the high prevalence of oral diseases, such as dental caries and periodontitis, in rural KZN, effective and efficient oral health programs are essential to strengthen oral healthcare.²³ This study aimed to explore how rural KwaZulu-Natal's oral health practices are shaped by cultural traditions, the role of traditional health practitioners and modern healthcare, and the challenges of integrating the two.

 

METHODOLOGY

Study design

This study was an exploratory, cross sectional study, conducted among THPs to explore cultural beliefs on oral health related conditions among rural communities. Furthermore, it investigated the role THPs could play in strengthening oral health care and improving the quality of life in rural KZN through focus group discussions.

Setting

The study was conducted in Ave of the eleven district municipalities of KZN; eThekwini, Harry Gwala, ILembe, Umgungundlovu and Ugu districts. The study was approved by the Human and Social Sciences Research Ethics Committee of the University of KwaZulu Natal (HSSREC/00000951/2020). The researcher adhered to the ethical principles as per the University guidelines. Gatekeeper permission to conduct research with THPs was obtained from the KZN THP facilitator at the KZN Department of Health office.

Sampling and selection criteria

A purposive sampling technique in the form of expert sampling was used in this study, where participants were selected by the Traditional Health Practitioners' Research Officer in KZN. As part of the inclusion criteria, THPs had to be registered under a recognised organisation, such as Traditional Healers' Organisation (THO), Vukuzenzele and Nupatsa. Initially the study was to be conducted in the 11 district municipalities of KZN, however, due to the lockdown restrictions imposed by the COVID-19 pandemic, only participants from 5 district municipalities volunteered to participate in the study. The researcher explained the purpose of the study to the Chairperson of the THP organisation in each district and asked him/her to invite THPs to a focus group discussion. The final sample size was made up of 42 THPs.

Data collection

Data was collected from participants using focus group discussions. Informed consent and permission to record the entire session was obtained from all participants. Five focus group discussions were conducted in the community halls of each of the districts using an interview schedule with semi-structured questions which afforded THPs the discussion on their viewpoints on oral health care in rural communities. The average number of participants in each group were eight. The questions were asked in IsiZulu, as all participants were Zulu speaking and the participants' responses were also in IsiZulu. Each participant was given an opportunity to express his/her views, with participant anonymity being maintained by using code names. The code names were dependent on the sequence of data collection per district, as well as the number of participants per group. The focus group discussions were conducted with strict adherence to the COVID 19 protocol.

Data analysis

All the focus group discussions were transcribed verbatim and translated into English. The data from this study was analysed using the qualitative method. This method is described as the analysis narrative through converting raw data into partially processed data where it is then observed, coded and interpreted. ²⁴

The content of the data from the focus group discussions were recorded, documented, Altered and summarized to report the main aspects of the respondents' accounts. The data obtained from various respondents was compared with each other and classified into 'themes' that emerged in the data set. Data codes were then created based on the identified themes.

The data was then reviewed and a final coding framework was decided upon. This process was applied to each individual transcript until the analysis was complete. The data was analysed by the researcher and the contributing authors separately and then together, the notes were compared for common themes that emerged until consensus was reached.

 

RESULTS

Out of the 42 participants, 27 were females (64%) and 15 were males (36%), with an average age of 48. A notable (29%; n=12) of participants had completed up to grade 8 as their highest level of education, while 24% (n=10) were graduates of higher education institutions. Among these graduates, one held a Master's degree and another a PhD. All participants were religiously affiliated, with 86% (n=36) identifying as Africanists and 14% (n=6) as Christians. Regarding employment, all participants practiced as THPs on a full-time basis: 62% (n=26) were izangoma (diviners), 12% (n=5) were izinyanga (herbalists), and 26% (n=11) were abathandazi (faith healers).

In many rural communities, THPs play a crucial role in diagnosing and managing oral diseases. In this study, nearly all participants (95%; n=40) reported being consulted for oral health-related conditions. The THPs indicated that the most common conditions they were consulted for included toothache, tooth decay, gum diseases, oral cancer, mouth ulcers, tooth abscesses, and tonsillitis.

Three key themes emerged from the data analysis: These included the cultural beliefs and oral health, perceived challenges confronted by THPs, possible collaboration of THPs with dental professionals.

Theme 1: Cultural Beliefs and Oral Health

This theme highlights the underlying cultural beliefs that influence oral health practices in rural communities. All participants believed that there is a connection between tooth pain and its potential spiritual implications. They believe that toothache is a means of communication of the ancestors to the living as affirmed by some of the participants:

"Toothache could mean that the ancestors are communicating through that pain." (F2) and "Very often it is a communication stream from the ancestors." (G3) The following are the sub-themes that illustrate this belief:

1.1 Failure to seek permission from the Ancestors for a tooth extraction

Most of the participants believed that individuals must seek permission from the ancestors before having a tooth extraction, and failure to do so results in a difficult extraction or post-extraction complications:

"The pain after an extraction can be due to a traumatic dental extraction experience, which often happens when an individual doesn't report to their ancestors before having the dental extraction done." (H1)

"Even a painful socket after the extraction can be caused by spiritual forces because a person had an extraction done when it was not meant to be done before finding out what the ancestors want. Not practicing whatever the ancestors require of you causes disease." (B3)

1.2 Toothache, a reprimand for moral misdeeds

The THPs believed that when one suffers from toothache, one is being reprimanded by the ancestors for moral wrongdoing. The pain may be seen as divine warning or a result of not respecting one's elders or ancestors as noted by the following:

"Often our clients cannot locate the pain. The ancestors communicate via mouth pain but at times the pain can be due to a person's ill behaviour and the ancestors are trying to discipline them." (A4)

"Mouth diseases could be punishment for not doing right with your ancestors, of warning in order to alert you that something is lacking or of conflict in your spiritual well-being." (F1)

"The mouth sores persisted and I ended up mixing my own concoctions and begging the ancestors to show me a sign. Eventually I received a sign that she was using the wrong surname (her father's surname) yet her parents are not married. This angered the ancestors." (J1)

1.5 Teeth and Rites of Passage

Some THPs associated toothache with a rite of passage or an indicator of maturity. In some rural communities, there are certain prayers or rituals that have to be performed in the transition from childhood to adulthood and when they are not undertaken, the person experiences toothache:

"Teeth represent growth, therefore mouth related conditions could be a sign of positive developments that require a certain prayer or practice that will ensure success in the upcoming stages of life." (G1)

"Teeth are part of our spiritual identity, each eruption date signifies a developmental stage spiritually, that require practices of growth and special prayers need to be carried out for each stage of growth." (F1). "If these processes and prayers are not carried out then troubles start". (A1)

"Toothache can mean that a certain ancestor used to suffer from the same diseases of the mouth and requires some sort of prayer from the suffering individual." (G3)

Physical and spiritual forces responsible for toothache

All participants reported that toothache cannot be caused only by spiritual forces but also physical forces too.

"A traditional healer can spiritually investigate holistically as to what caused the physical force to transpire and manifest as a disease." (D2) "Once the reason has been found then the traditional healer and the patient deal with the root cause spiritually." (B1)

"It can't always be spiritual, for example bad breath can be caused by a problem in your gastrointestinal tract or some form of oropharyngeal disease." (B2)

Treatment of dental diseases

All the study participants agreed that dental conditions cannot be treated only by THPs.

"As much as we play a healing role in the elimination of pain, we still believe that dental professionals also have a role to play. For example, we don't remove teeth or do fillings, or cleanings. However, we do have our own plants that we use for cleaning." (E1)

"Sometimes a person can go to the clinic and the extraction can be difficult, and some may even refuse to extract after the tooth has broken. We are able to give them concoctions that can loosen the tooth and manage pain until they go to someone else for an extraction if need be." (F3)

"There is no guaranteed healing/ cure from one practice both THPs and dental professionals are capable in their own ways." (D4)

"I also think both practices are good in their own rights. At the end of the day we are not in competition with each other, the purpose is to serve the people and save lives." (G4)

Theme 2: Perceived Challenges confronted by THPs

This theme highlights some of the perceived challenges experienced by THPs.

2.1 The need for THPs in the Modern Age

As the world advances technologically, participants had a contradictory perception to the need for THPs in the future. Almost all participants (95%) believed that they will survive in the future:

"Technology is ever developing and it is possible to develop healing through technology. Traditional healing taps into all aspects of human existence; physical, psychological, spiritual and otherwise. Therefore, the demand for THPs will definitely increase in the near future." (B1)

"There will definitely be an increase in the future. New diseases are being discovered, substance abuse is rife and the quality of the food we eat is now becoming poorer, this means more illnesses that need Traditional Healing." (F3)

"The demand will increase because traditional healing is a natural and a special gift regardless of physical advancements and changing times." (A4)

"THPs are born every year, they are spiritually chosen. That will never change, so the demand for THPs in the near future will rise." (E3)

However, a few participants (5%) believed that the demand for THPs will decrease in the future for the following reasons:

"There will be a decrease in demand of THPs in future, because our government does not include THPs in the national health system. Also, we never have workshops where we are taught to advance ourselves educationally and technologically." (D2)

"We are neglected and out casted, that's why you will find that most rural THPs are still very backward in terms of technology." (A2)

2.2 Bogus Traditional Health Practitioners

The participants believed that they are threatened by fake traditional healers:

Social media is a threat because it allows bogus healers to thrive." (F1)

"Some bogus healers can simply Google different types of traditional medicines and start calling themselves healers, jeopardizing the entire body of authentic THPs." (D1)

"There are far too many chance takers who offer magical healing through dark spirits. Unfortunately, these so-called healers attract scores of patients as most people are looking for instant success." (A5)

2.3 Lack of internet access

Participants believed that the lack of internet access in rural areas can be challenging for them:

"Access to online consultations may also cause a decline in demand as we have THPs who are highly gifted but are unable to use the internet due to a lack of education and poor signal in most rural areas." (H2)

Theme 3: Possible collaboration of THPs with dental professionals

This theme highlights that the possibility of THPs and dental professionals working together with dental professionals in managing their clients' dental problems:

3.1 Acknowledging the role of dental professionals

As much as THPs consult and treat clients with dental problems, they acknowledge the need for dental professionals to treat dental conditions:

"Some illnesses are beyond my understanding and may need a dental professional even after I have tried several attempts to relieve the person from pain. As THPs, we ought to know our boundaries as much as dental professionals should know theirs. No one is better than the other, we just need to accept each other and help ill people." (H1)

"Some of our clients start by seeing dental professionals, others start by seeing a THP and then we ask them to have the tooth removed by dental professional after certain procedures have been carried out by us. It's not a problem because the patient has that right." (C3)

"Dental professionals know the detailed structure of the tooth more than I do. So, it's ok if my clients see them before or after me. I don't have a problem with that." (D3)

"There are procedures which we cannot do and do not conduct, such as cleaning, fillings, dental extractions etc. We only stick to what we know and prefer the professionals to deal with the rest." (A5)

3.2 Willingness to collaborate with dental professionals:

The results show that participants were willing to collaborate with dental professionals in the holistic management of their clients:

"I actually informally refer my patients to the dental clinics after working out the root cause and fixing it." (G4)

"Whenever I treat an illness, I prefer sending my patients back to the doctor even if they feel ok, just to have tests done that will ensure that they are fully healed physically." (D4)

3.3 Perceived barriers to collaborate with dental professionals:

As much as THPs are willing to collaborate with dental professional in the management of oral diseases, they also perceived barriers in doing so, such as not being recognized by the government or being looked down upon by dental professionals or not having their clients being referred back to them:

"The non-recognition by the government of THPs." (F1) "Traditional healing plays a vital role in healing holistically, even though we are often looked down upon by western health care workers." (C5)

"What we have realized is that we refer to the conventional health system and we hardly get referrals back." (D1)

 

THE WAY FORWARD

The participants were asked about their perceptions regarding collaboration with dental professionals in order to improve oral health in rural KZN. The following are some of their suggestions:

"Dental professionals should be more accepting to the patients' belief systems, be more open minded and not just rely on textbook information." (A2)

"THPs can be invited to dental workshops, and dental professionals can be invited to THP workshops. This can help in exchanging knowledge and benefit the patient." (C2)

"Dental professionals shouldn't look down on us, they shouldn't isolate us from helping people because we tend to treat the same patients anyway. They shouldn't judge us by the level of our education. What they don't know is that tooth extractions can be deadly if caused by spiritual forces, we see this in our communities. This can have a bad effect on the dental professional's spiritual being in the long run." (A3)

"Cross referrals are important. Post treatment evaluation is rare by the dental professionals, because some of their clients come to us afterwards. Just because these clients do not go back to them doesn't mean that the patient was completely healed or that dental professionals are the only capable body of treating oral diseases." (B3)

"We do understand that some of the herbs and traditional medicines do not respond to toothache hence the importance of dental professionals. Pain medication doesn't work too at times when you have toothache and we are accepting to that. We seek that acceptance and acknowledgement from dental professionals." (G3)

"I would like dental professionals to respond by accepting the existence of THPs and have a round table discussion with us which will ensure that in the end, the patient is healed and equipped with knowledge." (B4)

"Dental professionals should also consider referring their patients to THPs as much as we also refer to them." (G4)

"Oral health awareness programs should also be done in deep rural areas. We would also like seminars and workshops where we are also given the platform to present what we know about the disease of the mouth and oral health."(D4)

"We would also like our traditional medicines to be tested and accepted, not stolen and repackaged." (E4)

"We can think we are doing a good job but if we're not getting positive feedback from health professionals and other organisations, it worries us." (D4)

"We would like the dental professionals to respond by firstly acknowledging that their patients have different belief systems, secondly by acknowledging that THPs exist and do treat some oral health related conditions. Lastly, and most importantly would be by creating a platform where both the dental professionals and the THPs can have knowledge-sharing discussions for the benefit of the patient whose total health comes first, that's if we put business aside and practice the National Department of Health's 'Batho Pele' principle." (A5)

 

DISCUSSION

There is a huge disparity in oral health between rural and urban areas in KZN. Rural communities face considerable challenges in accessing dental care, compounded by cultural beliefs and mistrust in healthcare systems. This study found that Traditional Health Practitioners (THPs) are often consulted for dental problems, indicating that people in rural areas may turn to THPs for a spiritual diagnosis and seek answers from their ancestors for their pain. This finding is similar to a study conducted by Wright in 2008 who noted that cultural beliefs are often interwoven with spirituality, where health is not merely a physical state but a reflection of a person's relationship with their ancestors and the natural world.¹¹ This is further supported by Sithole & Odhav in 2011, who found that some rural people believe that toothaches could be caused by ancestral spirits or witchcraft, requiring spiritual interventions and herbal remedies.¹⁰

African traditional health practice is a holistic healthcare system, viewing illness as having both natural and spiritual causes. Treatment aims to restore physical, mental, and spiritual well-being. This study found that THPs treat their patients spiritually and offer TM when necessary, similar to findings by other researchers, who noted that TM aims to restore the patient's overall well-being through alternative health practices.¹³

Participants in this study highlighted ongoing challenges faced by THPs, particularly the lack of legal recognition and explicit legislation governing their profession.¹³ In this study, THPS felt threatened by bogus healers using internet (Google) to get information to treat people. Traditional healers are practitioners who use indigenous knowledge, spiritual practices, and natural remedies. They are often revered within their communities for their deep knowledge of medicinal plants, spiritual healing techniques, and holistic approaches to health.²⁶ They typically undergo years of training, often inheriting healing knowledge passed down through generations.²⁷ The authenticity of a traditional healer is generally determined by their training, community reputation, and experience. In contrast, bogus healers are individuals who claim to possess healing abilities but lack the necessary training and genuine expertise. They are often motivated by financial gain, and their practices can be unproven, misleading, or harmful as observed by other researchers.^{28, 29}

The increasing reliance on modern medicine and technological innovations in healthcare has led some to question the necessity of THPs in the future. In this study, while most believed that there will still be a demand for THPs in the future, some were pondering the need for them. A study by Andaleeb and Yousaf suggests that technological advancements may threaten the role of traditional healers, particularly in urban and technologically advanced regions where access to modern healthcare is easily available.²⁷ On the other hand, many argue that the need for THPs will not disappear in the future, but rather, they will continue to play an important role, particularly in rural areas and within communities that maintain a strong cultural connection to traditional practices. Traditional healers often offer more holistic, culturally relevant, and personalised care, addressing not only physical but also mental, emotional, and spiritual aspects of health. ²⁸

This study found that THPs were willing to collaborate with dental professionals in combating the high prevalence of oral diseases. WHO emphasizes the importance of integrating traditional medicine with conventional healthcare systems, especially in rural or underserved regions where traditional healers are often the primary source of medical care.²⁹ Many governments have initiated policies to encourage collaboration between traditional healers and formal health sectors, acknowledging that these practices can coexist and even enhance each other's impact on public health. The South African government has acknowledged the contributions of traditional healers and supports collaborative work between the two health practices.³⁰ One such collaboration includes the work done by THPs who visited the patients to fast track and monitor distribution of HIV and TB treatment in rural communities.³¹

This study showed that THPs regularly refer their clients to dental professionals recognising their limitations in managing dental diseases. This finding is supported by previous study which found that THPs referred their patients to local oral health clinics if the treatment offered was non- effective.³² While some studies found that competing and contradictory treatments can coexist without conflict, ³³ others noted that conventional health practices were not ready to work with THPs due to differences in scientific concepts, sources of knowledge, and lack of policy. ³⁴

Respecting the cultural context of KZN, there is a growing need for dental professionals to collaborate with THPs to improve oral health outcomes in rural communities. Supporting collaborative work between these two health practices reflects an understanding that modern and traditional medicine can complement each other in promoting public health.

 

CLINICAL IMPLICATIONS

Dental professionals can collaborate with THPs to spread messages about the benefits of regular dental visits while respecting the use of traditional remedies. Such collaboration can help bridge the gap between modern and traditional practices, making health interventions more effective and widely accepted.

It is crucial to design oral health education programs that recognise and respect cultural values. For example, instead of discouraging traditional practices outright, health educators can work with communities to promote safe and effective oral care methods that blend traditional and modern practices.

 

CONCLUSION

Oral health in rural KZN is shaped by a blend of traditional practices and modern healthcare strategies. While cultural beliefs remain strong, there is a growing need for integrating the two practices. By respecting and understanding cultural perspectives, dental professionals and THPs can collaborate to promote better oral health outcomes for rural communities in KZN.

 

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Correspondence:
Name: Sibusisiwe Dlamini
Tel: 031 260 7639 Cell: 082 758 1503
Email: DlaminiS27@ukzn.ac.za