Evidence of past and current collaborations between traditional health practitioners and biomedical health practitioners: a scoping review protocol.

INTRODUCTION: Healthcare seekers around the globe use more than one healthcare system, with most using the traditional and the Western approaches concurrently. To date, little collaboration between the two systems has taken place within the mental health space compared with other areas of medicine. In order to inform integrating plans for traditional health practitioners and biomedical health practitioners in the South African mental health system, it is important to know which models of collaboration are used in other medical settings and contexts. This study aims to document global evidence on collaboration practices between traditional health practitioners and biomedical professionals when working with various health conditions. METHODS AND ANALYSIS: This scoping review will be guided by an improved Arksey and O'Malley framework, the 2010 Levac et al methodological framework and the 2017 Joanna Briggs Institute guidelines. A systematic literature search will be carried out using seven different databases, EMBASE, PubMed, LILACS MEDLINE, APA PsycArticles, CINAHL Plus, Academic Search Complete and Scopus, in addition to the WHO repository, bibliographical search engines, and Open Access Theses and Dissertations. Moreover, the references of relevant publications between January 1978 and March 2020 will be scanned. Two reviewers will independently screen articles for eligibility based on the predetermined inclusion and exclusion criteria. Thematic analysis and descriptive numerical analysis will be performed using ATLAS.ti V.8 and Excel software, respectively. The results for this review will be presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review. ETHICS AND DISSEMINATION: This study will not require ethics approval because publicly available material will be used. Study findings will be published in an open-access journal and be presented to other key health system stakeholders and academic research gatherings. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This will be the first scoping review that maps evidence of past and current practitioner-level collaborations between traditional health practitioners and biomedical health practitioners.

The search strategy will be conducted on seven databases, and a literature search will be inclusive of grey literature from government and institutional libraries.

The Rayyan software that will be used for screening data in the study allows for ‘blind’ screening, which will ensure minimisation of bias. This will further increase the credibility of the screening process.

Although inclusive of global evidence, this review will only review articles written in English due to the lack of resources for data translation.

The reviewers will not conduct a formal appraisal of the included studies and, therefore, there is a possibility of including studies with methodological limitations. However, to limit the inclusion of studies with poor quality, only peer-reviewed and published primary studies will be included.

Introduction

Traditional health practitioners (THPs) and biomedical health practitioners (BHPs) have practised concurrently in the healthcare system for a long time, with the Western-trained healers being recognised as the official health providers in most health policies around the world.1–3 A WHO expert meeting on mental health in 1978 reported that collaboration between THPs and Western-trained healers is needed since THPs are in an ideal position to influence the attitudes of healthcare seekers.4 Besides the inevitable need to increase human resources for poorly resourced and developing countries, the call was made by WHO for THPs and BHPs to work together in offering comprehensive and holistic healthcare to the pluralistic populations that use both healthcare models.5–7

Multisectoral collaboration is viewed as essential for elevating the burden on the health system, and it is also regarded as a necessary step towards achieving an integrated health system.8 Since the 1978 Declaration of Alma Ata by WHO, the recognition given to THPs in all government laws and regulations is widespread across most countries,2 9 with the African and Southeast Asian countries leading in terms of having programmes for the integration of THPs into official health services.9 Despite the progress made, the implementation of these policies and the advancement of programmes has been slow. In 1982, Lee,10 followed by Pinkoane et al11 in the early 2000s and Busia and Kasilo12 in 2010, summarised the different ways in which countries have attempted to integrate traditional medicine and THPs into the health sector, and their findings illustrate that there are few countries with an integrated health system.

The lack of official frameworks for collaboration between THPs and biomedical professionals together with other governmental and interpersonal hindering factors has been cited as the cause of this.11 13–16 Interestingly, with the changing landscape of the health system due to the recent pandemics that have added stress to the primary health system and advanced policy and research in regard to traditional medicine, several collaboration projects have emerged. This has mainly occurred in the management of HIV and AIDS in Africa.5 17 18 Current evidence in South Africa suggests that more THPs and BHPs are willing to forge collaborations at the service delivery level.19 20 However, there is a paucity of research on effective models of collaboration and the settings and context in which they can be applied.

In order to accelerate the rate of collaboration, it is vital to learn from previous attempts at establishing collaborations between THPs and BHPs. This review attempts to map existing evidence on practitioner-level collaborations for all health conditions. To date, there is a scarcity of studies aimed at consolidating evidence on these projects. As a result, there is little understanding of how to implement and sustain collaboration projects better. The review forms part of the first phase of a doctoral study on collaboration between THPs and mental health practitioners in South Africa. As such, results from the current study will be used to inform upcoming research on collaboration models between THPs and mental health practitioners within the South African context.

Objective

The main objective of this scoping review is to systematically map global evidence on collaborations between THPs and biomedical professionals’ practices when working on any health conditions and to identify possible knowledge gaps.

Methods and analysis

Protocol design

According to Davis et al,21 a scoping review is instrumental in providing conceptual clarity about a certain field of evidence. A scoping review was considered suitable for investigating the type and depth of evidence that is available regarding collaborations between THPs and BHPs. This scoping review will be guided by Arksey and O’Malley,22 the methodological framework of Levac et al23 and the 2017 recommendations of the Joanna Briggs Institute (JBI).24 The methodological framework that guided this review involved five stages: (I) identifying the research question; (II) identifying relevant studies; (III) study selection; (IV) charting the data; (V) collating, summarising, and reporting the results.

Stage I: identification of the research question

The study will use the JBI24 PCC mnemonic (population, concept and context) to determine the eligibility of the research question, as presented in table 1. Due to the diverse nature of traditional practices, a clear definition with set parameters for this study is provided in the following section.

Table 1

PCC framework and eligibility criteria for inclusion and exclusion of studies

Criteria	Determinants	Inclusion criteria	Exclusion criteria
Population	THPs: THPs vary across countries and tribesBHPs: All relevant BHPsAll participants are older than 18 years	Articles reporting on collaboration with THPs who are classified as traditional healers, diviners and herbalists, alternative healers, native healers, aboriginal healers, indigenous healers, traditional Chinese healers, Traditional Indian healers, ShammasArticles reporting on different cadres of BHPs such as biomedical healers, general practitioner, psychologists, psychiatrists, medical doctors, nurses, medical doctors, physicians, healthcare workers, social workers	Articles presenting evidence on collaboration with faith healers, traditional surgeons, traditional birth attendants, midwives, doulas
Content	Collaboration practices such as task-shifting, consultation, cooperation and integration of servicesMedical conditions such as mental health, HIV and AIDS, TB, cancer, and mild or chronic illnesses	Evidence presenting one or more forms of collaboration at all levels of the continuum of careStudies focusing on all health conditions	Articles and studies that do not include collaboration between practitionersStudies focusing on animals
Context	Global	Articles published between January 1978* and March 2020 reporting global evidence	Evidence published in non-English languages
Sources of evidence†		Evidence from empirical literature and grey literature including government documents, NGO reports and academic dissertationsAll study designs are considered	Literature reviews, protocols, editorials, commentaries, news reports

*The year 1978 was chosen because it is the year WHO declared the importance of THPs and traditional medicine in the 1978 Declaration of Alma Ata.

†Not part of the JBI PCC framework. Added by the authors to highlight included and excluded evidence types.

BHP, biomedical health practitioner; THP, traditional health practitioner.

Research question

The key research question for this review study is as follows: What is the global evidence of past and current collaboration practices between THPs and biomedical professionals when working on any health conditions?

Population term definition

WHO9 defines THPs as practitioners who use indigenous or native approaches, knowledge, spiritual therapies and beliefs that incorporate plant, animal and/or mineral-based medicines separately or in combination to maintain well-being. In this study, the practice of incorporating spirituality during healing is key in distinguishing THPs.

WHO9 defines BHPs as Western-trained health professionals who use the principles of biology or biochemistry.9

Stage II: identification of relevant literature

A systematic search will be conducted on the following databases: EMBASE, PubMed and EBSCOhost interface, and will include MEDLINE, APA PsycArticles, Cumulative Index of Nursing and Allied Health (CINAHL) Plus, Academic Search Complete and Scopus. To capture Latin American and Caribbean health sciences literature, the reviewers will also search the LILACS database. In addition, a literature search will be conducted using free-text words on bibliographical search engines such as Google Scholar and Academia.edu. National health departments, the WHO repository, and the Open Access Theses and Dissertations library will be searched for grey literature such as reports, dissertations and theses. The search will include studies conducted between January 1978 and March 2020 that were published in English.

The search process will be iterative and will be documented in the methods section of the scoping review report. During the search period, the ‘MeSH term’, the title/abstract tab, the text word tab and the keyword tabs will be chosen. The search terms will be combined using the Boolean (AND, OR) method. A preliminary search was conducted on Google and Google Scholar to explore terms that are used to refer to Western and traditionally trained healers in the global and local literature. This assisted in the choice of the terms that will be used in the review. The search strategy is presented in the second column of table 2. With the assistance of an experienced librarian, a pilot search of the search terms was conducted in PubMed, and this is presented in the electronic search record table below. The inclusion and exclusion criteria defined in table 1 were applied during the pilot search and will be applied in the literature search.

Table 2

Electronic search record and results of the pilot search

Date	Keyword searched	Search engine used	Number of publications retrieved
15/10/2020	(((((((((((((((((((((((((((((Traditional health practitioners(Text Word)) OR (Traditional healers(Text Word))) OR (“aboriginal healers”(Text Word))) OR (alternative healers [Text word))) OR (“indigenous healers”(Text Word))) OR (diviners(Text Word))) OR (herbalists(Text Word))) OR (traditional Chinese healers(Text Word))) OR (Traditional indian healers(Text Word))) OR (shammas(Text Word))) AND (biomedical health practitioners(Text Word))) OR (biomedical healers(Text Word))) OR (psychologists(MeSH Terms))) OR (psychiatrists(MeSH Terms))) OR (“medical doctors”(Text Word))) OR (nurse(Text Word))) OR (“social workers”(Text Word))) OR (“healthcare workers”(Text Word))) OR (doctor(Text Word))) OR (physician(Text Word))) OR (“medical staff”(Text Word))) OR (“general practitioner”(Text Word))) AND (collaboration(Text Word))) OR (“task shifting”(Text Word))) OR (integration(Text Word))) OR (cooperation(Text Word))) NOT (birth attendants, traditional(MeSH Terms))) NOT (midwives(MeSH Terms))) NOT (doulas(MeSH Terms))) NOT (“traditional surgeons”(Text Word))Filters applied: Journal Article, English, Complementary Medicine, from 1978/1/1 to 2020/3/30.	PubMed	6872

Pilot search

The electronic search record and results of the pilot search are presented in table 2.

An updated record of searches will be kept to monitor when the same search terms are applied in other databases (table 2). The literature results will be exported to EndNote X7 software. At this stage, all duplicated articles will be excluded.

Stage III: study selection

The study selection process is shown in the PRISMA flow diagram (figure 1).

Figure 1

PRISMA flow diagram.

Screening for this study will be conducted at two levels. The first level will involve double and independent screening of the title and the abstract based on whether they potentially meet the inclusion criteria described in table 1. The second level will involve full-text screening, which will be conducted independently by two screeners. Should the full texts not be available online, the authors will be contacted to request the full texts. In cases where such attempts fail, the abstracts will be excluded from the study. Screening at both levels will be performed on Rayyan QCRI Systematic Reviews Web Application.25 This process will be blinded to minimise bias. The screening manual, which comprises instructions and eligibility form to guide screeners, is presented in online supplemental appendices A and B. This guide will be trialled on the abstract screening of 10 articles and full-text screening of 4 articles. The two reviewers will meet to resolve any conflicts recorded on the Rayyan application, and study supervisors will be consulted to reach a consensus regarding unresolved conflicts.

Stage IV: charting

Data will be charted independently by two researchers. For this study, a data collection Excel worksheet will be used. This will be adapted from the JBI24 data charting document (see online supplemental appendix C) to chart the bibliographic details of the study, the study design, the aim of the study, the characteristics of the THPs and BHPs, the intervention processes, the conclusions for the primary and the secondary outcomes of the interventions, and other aspects. The charting tool will be piloted on a random selection of two to five articles to determine if the reviewers have a full grasp of the data collection instructions and whether the tool is comprehensive enough to capture relevant information. After the pilot study, the team will update the charting sheet to accommodate emerging items.

Stage V: collating, summarising and reporting results

For this scoping review, the models of collaboration between the THPs and the BHPs that are identified and extracted will be coded and analysed using a thematic analysis technique. Data will be coded by two researchers independently, employing a qualitative computer-based software, ATLAS.ti V.8, and Excel software. The new Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review guide will be used to report outcomes of the review.26

The analysis will highlight the nature and the distribution of the studies that are included in the review. Tables and chart maps that illustrate the distribution of the reviewed studies geographically and the nature of the collaborations between the THPs and the BHPs will be produced. In addition, a narrative account of the generated themes surrounding the type of collaborations and their outcomes will be presented. To minimise bias and ensure a consistent approach in reporting the results, the research team will meet to discuss the emerging themes. Furthermore, the study team will scrutinise the meanings of the findings as they relate to the overall aim of the study and discuss the implications for future research, practice and policy.

Patient and public involvement

This study will use publicly available data; therefore, patients or the public will not be involved in the design, or conduct, or reporting, or dissemination plans of this review.

Ethics and dissemination

This study will constitute the first step in a multiphase research doctoral study aimed at investigating emerging small-scale collaboration models between THPs and BPHs who are treating mental illnesses in South Africa. The results from this scoping review will help inform the subsequent phases of the study and contribute to the growing literature on suitable and effective models for collaborations between the traditional and Western health systems. This study will use publicly available materials and will not include human or animal participants; therefore, the study does not require ethical approval. The scoping report will be presented to other key health system stakeholders and will be introduced at conferences and other academic research gatherings. Findings will also be published in an open-access journal.