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Traditional Healers' Views of the Required Processes for a “Good Death” Among Xhosa Patients Pre- and Post-Death

Open AccessPublished:November 12, 2012DOI:https://doi.org/10.1016/j.jpainsymman.2012.08.005

      Abstract

      Context

      South Africa faces enormous HIV-related mortality and increasing cancer incidence. Traditional healers are the preferred source of advice and care in Africa, and this is true for the large Xhosa ethnic group.

      Objectives

      To provide more appropriate multidimensional, culturally suitable care at the end of life; this study aimed to identify the care needs and cultural practices of Xhosa patients and families at the end of life, from the perspective of traditional healers.

      Methods

      The study design was qualitative and cross-sectional. The research took place in a 300 km radius around East London, Eastern Cape, South Africa. Interviewees were Xhosa individuals who were recognized by their communities as traditional healers. Data from two focus groups and eight individual interviews were analyzed, using an inductive thematic approach.

      Results

      Data were elicited around the facilitation of a good death in terms of care needs before death and important rituals after death. Care needs before death focused on relief of psychosocial suffering; the importance of the spoken word at the deathbed; and the importance of a relationship and spiritual connection at the end of life. There were broad similarities across the rituals described after death, but these rituals were recognized to differ according to family customs or the dying person's wishes.

      Conclusion

      Awareness of potential needs at the end of life can assist clinicians to understand the choices of their patients and develop effective end-of-life care plans that improve the outcomes for patients and families.

      Key Words

      Introduction

      During 2008, there were 1251 daily deaths from progressive illness in South Africa,
      • Statistics South Africa
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      • Wilson D.
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      • Cotton M.
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      Handbook of HIV medicine.

      Bradshaw D, Pillay-Van Wyk V, Laubscher R, et al. Cause of death statistics for South Africa: challenges and possibilities for improvement. Burden of Disease Research Unit, Medical Research Council, South Africa. November 2010. Available from http://www.mrc.ac.za/bod/cause_death_statsSA.pdf. Accessed October 13, 2012.

      placing a great strain on clinicians who require the skills to manage highly prevalent multidimensional problems.
      • Sepulveda C.
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      • Yoshida T.
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      Palliative care: the World Health Organization's global perspective.
      • Harding R.
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      The prevalence and burden of symptoms amongst cancer patients attending palliative care in two African countries.
      • Harding R.
      • Selman L.
      • Agupio G.
      • et al.
      Prevalence, burden and correlates of physical and psychological symptoms among HIV palliative care patients in sub-Saharan Africa: an international multicenter study.
      The vast majority of evidence regarding end-of-life care has been generated in non-African populations,
      • Harding R.
      • Higginson I.J.
      Palliative care in sub-Saharan Africa.
      although recent advances in the development of outcome measurement tools have meant that it is possible to measure and improve the outcomes that matter to African patients.
      • Harding R.
      • Selman L.
      • Agupio G.
      • et al.
      Validation of a core outcome measure for palliative care in Africa: the APCA African Palliative Outcome Scale.
      • Selman L.
      • Siegert R.J.
      • Higginson I.J.
      • et al.
      The “Spirit 8” successfully captured spiritual well-being in African palliative care: factor and Rasch analysis.
      • Selman L.
      • Siegert R.J.
      • Higginson I.J.
      • et al.
      The MVQOLI successfully captured quality of life in African palliative care: a factor analysis.
      Locally generated data are essential because each person experiences death through their own context, and patient needs may differ from those of their health practitioner.
      • Cassidy J.
      • Davies D.
      Cultural and spiritual issues in palliative care.
      Therefore, clinicians have a responsibility to understand the health philosophies and systems that their patients find helpful
      • Doyle D.
      Introduction.
      to provide patient-centered care that meets the proposed standards and recommendations for culturally appropriate spiritual palliative care provision in Africa.

      African Palliative Care Association. APCA standards for providing quality palliative care across Africa. Available from http://www.hospicecare.com/standards/APCA_Standards_AW.pdf: 2012. Accessed July 2012.

      Selman L, Harding R, Agupio G, et al. Spiritual care recommendations for people receiving palliative care in sub-Saharan Africa. 2010. Available from http://www.csi.kcl.ac.uk/spiritualcare.html?searched=spiritual+care+recommendations&advsearch=exactphrase&highlight=ajaxSearch_highlight+ajaxSearch_highlight1. Accessed July 2012.

      The World Health Organization estimates that 80% of African patients make use of both Western biomedicine and traditional healing practitioners.

      World Health Organization. Traditional medicine strategy. 2002. Available from http://www.who.int/medicinedocs/en/d/Js2297e/#Js2297e. Ac-cessed July 2012.

      The use of traditional healing practices is closely linked to traditional African beliefs and customs.

      Pew Forum on Religion and Public Life. Tolerance and tension: Islam and Christianity in sub-Saharan Africa. 2010. Available from http://www.pewforum.org/executive-summary-islam-and-christianity-in-sub-saharan-africa.aspx. Accessed August 2012.

      Traditional healers also are described as the “guardians of cultural norms and social order, and bastions of cultural practice.”
      • Felhaber T.
      • Mayeng I.
      South African primary health care handbook—combining Western and traditional practices.
      Consequently, traditional healers can provide insights into death processes and meanings to inform relevant clinical practice. There is a national
      • Meissner O.
      The traditional healer as part of the primary health care team?.
      • Gqaleni N.
      • Mbatha N.
      • Mkhize T.
      • et al.
      Education and development of traditional health practitioners in isiZulu to promote their collaboration with public health care workers.
      • Abdool Kariem S.
      • Ziqubu-Page T.
      • Arendse R.
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      • Baleta A.
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      • Mngqundaniso N.
      • Petros G.
      A controlled study of an HIV/AIDS/STI/TB intervention with traditional healers in KwaZulu-Natal, South Africa.
      and international

      World Health Organization. Traditional medicine strategy. 2002. Available from http://www.who.int/medicinedocs/en/d/Js2297e/#Js2297e. Ac-cessed July 2012.

      World Health Organization. WHO policy perspectives on medicine: Traditional medicine—growing needs and potential. 2002. Available from http://whqlibdoc.who.int/hq/2002/WHO_EDM_2002.4.pdf. Accessed August 2012.

      trend toward collaboration with traditional health systems.
      The amaXhosa are an ethnic group constituting 18% of the national population, comprising many large family clans and lineages. The amaXhosa are concentrated in South Africa's Eastern Cape, with 7.9 million speaking isiXhosa as their home language.

      Statistics South Africa. Census 2001 key results. 2001. Available from http://www.statssa.gov.za/census01/html/Key%20results_files/Key%20results.pdf. Accessed August 2012.

      It is necessary to generate evidence on the traditional perspectives of health behaviors and beliefs at the end of life that can inform palliative care practitioners who, therefore, may provide more appropriate patient-centered care. This study identifies the care needs and cultural practices of Xhosa patients and their families at the end of life to achieve a good death both pre- and post-death, from the perspective of traditional healers.

      Methods

      Study Design and Setting

      This was a qualitative cross-sectional study across the urban, peri-urban, and rural Eastern Cape of South Africa, and was approved by the Research Ethics Committee of the University of Cape Town (Ref:079/2008). The study comprised individual interviews and focus groups. Given the exploratory nature of the research and the “outsider” status of the lead researcher, a qualitative-interpretive research orientation was used, aiming to understand the actions of individuals and the meaning they attribute to those actions.
      • Bryman A.
      Social research methods.
      The recognition that social phenomena are continuously being constructed and revised through social interactions positions this research within a constructionist paradigm, that is, the findings of the research cannot be considered definitive but are put forward as a specific view supported with data. Therefore, this study aimed to elicit sensitizing rather than definitive data.

      Sampling and Recruitment

      Using snowball sampling through personal and professional contacts, eight key informants (including a security guard, a housekeeper from a local hospital, a home-based carer, and a technician from a local nongovernmental organization) acted in their capacity as community members to introduce the researcher to the healers across a 300 km distance from the main provincial town. Traditional healers were invited to participate if they practiced within their community from a Xhosa cultural background. Both inyangas/iixwele (herbalists) and sangomas/iiqirha (diviners) were included, as well as those who also may incorporate Western-style health care. Traditional birth attendants and traditional surgeons were excluded.

      Data Collection

      Interviews were requested with nominated traditional healers, and signed consent obtained. Approximately 25% of those approached declined, with reasons volunteered as concern that the study wanted to know the secrets of their practice; that they did not feel equipped or able to answer on behalf of traditional healers; and time pressures. The topic guide was iteratively reviewed and refined in light of the emerging data. Two focus group interviews and eight individual interviews were conducted. One focus group contained rural participants and the other contained urban participants. The iterative process of individual and group interviews continuously developed the semi-structured interview guide. An initial series of individual interviews informed the subsequent focus group discussions, and findings from these expanded discussion groups were then pursued in greater detail in the final individual interviews. The lead author conducted the interviews with the translator present. All interviews were audio-recorded and additional field notes documenting observations and impressions were collected.

      Translation

      It was anticipated that the interviews would be translated fully between isiXhosa and English. However, it was apparent that the translator wielded power in the interview setting, and the interviewees often preferred to make themselves understood in English. Most interviews were conducted in a mixture of English and isiXhosa and participants made variable use of the translator present, sometimes extensively, sometimes only to check English meanings of isiXhosa words. Full interview recordings were transcribed, including isiXhosa and English translations, and these transcripts were verified by another independent first-language isiXhosa speaker.

      Analysis

      The lead researcher's position as a young, white, female, Western-trained doctor had to be considered in contacts with interviewees, and in analysis of the interview data.
      • Gantley M.
      • Tissier J.
      An introduction to qualitative methods for health professionals.
      These reflections were recorded and were used to inform the analysis of the results.
      • Mays N.
      • Pope C.
      Qualitative research in health care. Assessing quality in qualitative research.
      The applied nature of the research made an inductive approach within a functional framework most appropriate.
      • Hewson M.G.
      Traditional healers in southern Africa.
      After familiarization with the transcripts, alongside the context of the reflexive journal, the data were initially coded, and subsequently the general categories were transformed and fragmented to better fit the data. These more detailed codes were clustered into nodes and reviewed by a colleague, and out of these nodes the themes for analysis emerged inductively.

      Results

      The two focus groups contained seven and six members, respectively, and eight individual interviews were conducted.

      Sample Characteristics

      The age of the 13 focus group attendees ranged from 38 to 64 years, eight were female, one group was conducted with rural respondents and one with peri-urban respondents. Their years in practice of traditional healing ranged from six months to 40 years.
      The age of the eight individual interviewees ranged from 30 to 80 years, and five were female. Two interviewees practiced in an urban area, four in a peri-urban area, and two in a rural area. Additional occupations included subsistence farming, businessperson, management in an HIV nongovernmental organization, a nursing sister, and other health care setting roles such as volunteer and laboratory assistant.

      Main Findings

      Before describing the main coding frame, the following central finding gives context to the data.

      The Interaction Between Traditional Healing and Death

      Across the sample, there was a described reluctance in managing death directly in their professional capacity as traditional healers. There were complex reasons given for this reluctance, including the fear of blame by the family and the negative impact of death on their practice, described as “that dark cloud,” and the difficulty posed by rituals necessary for a traditional healer to “wash away” the contagious nature of death. Although they were able to describe the cultural practice and processes at the end of life, and were present, managing the “good death” was not perceived as their role. The coding framework is shown in Fig. 1.
      The four data codes under the main heading of “before death” are described first. The “good death” was defined mostly in terms of relief of psychosocial suffering. Although physical symptoms were mentioned, there was a more significant focus on the psychosocial and spiritual aspects of suffering, and the importance of addressing these to die well.Somebody should also be given a chance to talk about things. They may say, “I wish to be discharged so that I can go and talk with my ancestors.” There are various places where the ancestors are, and a person may want to go there. He should be allowed to do that.—Participant 8 (55-year-old woman, urban setting, formally trained with 13 years' experience)If he has been believing in something, you should call that, you should give it because he is facing death. If he says, “I want to have the medication that I believe in from my father,” or whatever, somebody should be able to have that, because he would feel comfortable at death now that that thing has been done.—Participant 8 (55-year-old woman, urban setting, formally trained with 13 years' experience)
      There were descriptions of meeting specific needs of the individuals as death approached, which ranged from being given a favorite food to being discharged to make a spiritual pilgrimage. These needs vary across individuals, and the person should be asked what will satisfy them and allow them a good death.…as a person comes to die, for each person it is different. You have to listen to him…—Participant 8 (55-year-old woman, urban setting, formally trained with 13 years' experience)
      Death was described as a collective affair, with the presence of the family at the deathbed a significant factor in the quality of the death.But if the family is not around, you will see them really struggling. They can be very ill, they can be critical, and you can think they will die that day, but tomorrow they are still struggling, waiting for their family to come. After having seen the family, then they are at peace with themselves and with the family.—Participant 7 (47-year-old woman, urban setting, formally trained with six months' experience)
      Their family gathering at the deathbed is not only for the comfort of the dying person but also for the chance to restore relationships, express wishes for the family, and give a verbal will—“umnyolelo.”
      There was much emphasis placed on the spoken word at the time of death in our sample.But for us, we can't do anything, only talk, only the talk that is going to take her away.—Participant 1 (66-year-old woman, semi-rural setting, formally trained with 26 years' experience)So you can see that the person is going to die? I think you have to talk to that person so that they can die peacefully.—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with five years' experience)
      The verbal will, umnyolelo, and the taboos placed on what should and should not be said were prominent, and highlighted the importance of speech at this time.We are a culture of verbalization.—Participant 1 of Focus Group 1 (female healers, peri-urban setting, formally trained)
      There were different views about whether talk at the deathbed should include truth-telling about the imminent death or not. Some healers expressed that honesty about the impending death was a release.Like maybe, the whole day you have watched this person and seen that they are going to go—but they can't go. Then you must just come and talk to her and say, you can go now. You can say, this is the end of your life, so you must go straightaway! And everyone must be saying the same thing. You can't have this one over here saying, “Oh, I'm so hurt, I don't want her to go.” That is wrong. You must only talk honestly. And then you will see that person will go.—Participant 1 (66-year-old woman, semi-rural setting, formally trained with 26 years' experience)
      Other healers thought that truth-telling was unkind and would rob an individual of a chance for a peaceful death.You would never talk like that. You always give hope. You always give hope. Because you want them to die peacefully, and that might escalate the condition, which you don't want. To die peacefully, you must always give them hope.—Participant 2 of Focus Group 1 (female healers, peri-urban setting, formally trained)I don't like to tell somebody that they are going to die because it's not nice.—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with five years' experience)
      There was a recognition that the dying person's words carry much weight for continuity after death. The contract with the dying has gravity, and is binding because the person will soon become an ancestor and will act in the lives of those left behind.If somebody dies and says they want something, you must do that thing, otherwise you will have bad luck. Because it is her wish. And if you don't do that wish, she will be cross with you. And her spirit is now an ancestor.—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with five years' experience)
      The five codes explaining the processes after death are now described.And after the person has died, you should close the mouth, close the eyes, and stretch out the arms and legs. You can also put a bit of salt in the mouth to make the mouth soft to close it if they died with their mouth open.—Participant 2 (woman older than 80 years—birth date unknown, semi-rural setting, formally trained with more than 40 years' experience)
      Rituals after death were recognized to differ in structure according to different family cultures.I would say that the culture in different families can be very different. Because if you belong to this clan, you might slaughter something. But if I belong to another clan, then that can be very wrong for that clan. They do differ. The way they do their own things. What is right for the one clan can be poison for another.—Participant 8 (55-year-old woman, urban setting, formally trained with 13 years' experience)
      As mentioned previously, the specific requests of the individual also influence the structure of the rituals.If you were there and the person said, “Now I can see that I am going to die. Don't slaughter anything, just give the people maize only.” And you must do it the way he said. And you must tell the others that I was there with him, and he said to me that he knew he was going to die. He said that we must not slaughter anything, we must do this and this and this…—Participant 2 of Focus Group 2 (mixed male and female healers, rural setting, method of training unknown)
      Part of the purpose of the rituals after death is to ease the passage of the spirit into the afterlife and to join the other ancestors. Cleansing was described as an important aspect of postdeath ritual. A form of cleansing needs to take place to wash away the contagiousness of death.Yes, the day after the funeral, there are some things that are supposed to be done. But it depends on that family exactly what happens. But something should be done to wash away all that darkness, or else it becomes part of the family. Especially in our culture.—Participant 8 (55-year-old woman, urban setting, formally trained with 13 years' experience)If a person dies in a home, we use uqomboti, the African beer, to cleanse the home. There was darkness in this house. Because the coffin came in here, there was a death of a person, there was darkness in the house so we have to do something. Other people are cleansing the spade because in our culture, we have to dig for the grave. So we do this cleansing ceremony by making this African beer. And we are cleansing the house because there is that darkness.—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with 5 years' experience)
      Between the time of death of the person and the time that the necessary rituals have been performed, there is a period of hibernation for the family.When you have lost someone, then there is a funeral, and everyone must be there. Say this is on Saturday. Then on Sunday, you take all the clothes and you must wash them. Then we are going to wait for 5 days—we are here, all of us, and we are going to wait for 5 days. Then we are going to have that ceremony on Saturday. That ceremony means that now everyone can go back to their places, back to school, back to work, back to their houses. That is the culture—except with those people who don't believe. But everyone here agrees.—Participant 1 of Focus Group 2, (mixed male and female healers, rural setting, method of training unknown)And also we don't go and visit other people's ceremonies or works until we have done this thing, so we are respecting that person who left us. So we don't even go next door and ask them for salt, or something to eat.—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with 5 years' experience)
      The timing of this ceremony of ritual accompaniment to the ancestors varied, but most healers described a ritual to release the spirit to be with the other ancestors.And then maybe a year or so after, if it is the father of the family, then there must be a cow that is slaughtered as a sort of send off ritual for the person.—Participant 7 (47-year-old woman, urban setting, formally trained with six months' experience)Like my grandfather, his cow which was slaughtered—it was an ox which was slaughtered on the funeral day. We call it siyamkhapha utatumkhulu. In English it means “we are accompanying him to his ancestors.”—Participant 3 (42-year-old woman, peri-urban setting, trained only by ancestors, with 5 years' experience)
      Following the release ceremony, also at a variable time, another ritual is performed to welcome the spirit home, to protect the household and guard the family.So one will find that you slaughter another cow as a welcoming of the spirit of that person, so that spirit must be able to come in and guard over evil spirits or bad luck. I don't know how to explain it, “uvuyisa.” But it isn't the person coming home physically, it's the spirit coming home.—Participant 7 (47-year-old woman, urban setting, formally trained with six months' experience)
      In summary, the traditional healers described practices necessary before and after death that were necessary for a good death. Before death, they placed focus on the relief of psychosocial suffering, importance of the spoken word at the deathbed, and the value placed on relationship and community with the living, which continues in a spiritual way after death. After death, the healers described the importance of the post-death ritual. Although the specifics of the rituals differed from clan to clan, and across families, there were common elements of cleansing the home, sequestration of the family, rituals to release the spirit, and then to call the spirit back home. Not adhering to the clan rituals, or the wishes of the deceased, were described to have considerable consequences for those who remain alive.

      Discussion

      This study is the first to identify cultural practices and beliefs before and after death for African Xhosa patients. The finding that traditional healers are reluctant to deal with death in their professional capacity corroborated the findings of a previous smaller study of six sub-Saharan traditional healers.
      • Hewson M.G.
      Traditional healers in southern Africa.
      The family or biomedical establishments were identified as the units of care at the end of life, although patients did consult the traditional healers.
      “The struggle,” or suffering, was recognized as an obstacle to a good death—largely described in terms of emotional or spiritual suffering. Often the issues were unresolved relationships, a sense of loneliness, and a need for spiritual connectedness. The clinical implication of this is to recognize the importance of unspoken psycho-socio-spiritual needs of dying patients. This supports data from African patients at the end of life who, when determining quality of life, placed greater importance on their spiritual well-being than on other domains.
      • Selman L.E.
      • Higginson I.J.
      • Agupio G.
      • et al.
      Quality of life among patients receiving palliative care in South Africa and Uganda: a multi-centred study.
      The African philosophy of ubuntu is explained through the translation of umuntu ngumuntu ngabantu—a person is only a person through his interaction with other people.
      • Elion B.
      • Strieman M.
      Clued up on culture. A practical guide for all South Africans.
      Consequently, if health care workers are able to facilitate the gathering of family at the deathbed, they may provide a meaningful opportunity for restoration of relationships, expression of wishes, and peaceful acceptance of death.
      The concept that a dying person will become an ancestral spirit has an impact on death transactions, with weight placed on the need for continuity as the spirit continues to act in the world beyond death. Family members respect those demands about what should happen after death, from respect for the person and because not following through may have consequences. Here there is a common theme of the dying person wanting their family members to honor both specific rituals and their decisions for the family after death.
      The traditional belief that the dead continue to live, unseen by the living, affects the choice of language used to describe death.
      • Elion B.
      • Strieman M.
      Clued up on culture. A practical guide for all South Africans.
      The general isiXhosa and isiZulu words for death are avoided in relation to people and are only used for other forms of life. This reflects the concept that people do not die but transition from living to ancestor. Euphemism, therefore, may not only represent a form of kind speech but may reflect the deeper underlying philosophy of the afterlife. For a clinician caring for patients at the end of life, it is essential to have some understanding of the depth and complexity that words about death can hold.
      A sense of spiritual connectedness underlies the importance of being home in a spiritual sense. Connecting with one's roots, the place of the family and of the ancestors, and the place where your spirit will come out were all cited as strong motivators not to die in an institutional setting but in a setting rich with relationship. This is similar to the good death described by people of Kwahu-Tafo, Ghana.
      • van der Geest S.
      Dying peacefully: considering good death and bad death in Kwahu-Tafo, Ghana.
      There was much emphasis placed on the spoken word. The verbal will (umnyolelo) and taboos on what should and should not be said, highlighted the importance of speech, and contrast with the British “nonexpressive stereotype” of watchfulness, silence and silent weeping described by Woodhouse.
      • Woodhouse J.
      A personal reflection on sitting at the bedside of a dying loved one: the final hours of life.
      Group 1 described this emphasis on the spoken word by describing themselves as a culture of verbalization.
      Sub-Saharan Africa has adapted palliative care into its systems and cultures. Our data offer new knowledge to truly deliver multidimensional care that addresses the physical, psychological, social, and spiritual needs of patients and families.
      There are a number of limitations to our study. Given the snowball recruitment method, there maybe sampling bias and only interested healers were interviewed; however, the majority of those contacted had no previous connection to the researcher that may have biased them toward an interest in palliative or end-of-life care. Because of access issues, it is difficult to sample this population in other ways. We recognize that focus groups may introduce a social desirability bias; therefore, the use of individual interviews to expand the themes and responses was included. The interviewees' use of the translator was not consistent across the interviews, and this resulted in differences for the translation process from isiXhosa to English. It also is recognized that the culture is dynamic and changing, and that although the views of traditional healers may represent the views of many people within Xhosa culture, not all Xhosa individuals would subscribe to the views held by traditional healers.
      In light of the original findings, we propose a number of recommendations. We propose first that clinicians ask the important questions around the needs and wishes of the person at the end of life: specific requests; the degree of information they wish to have about their impending death; and the needs of the family as the unit of care. Second, it should be accepted that the choices of the individual may differ from those of the health care practitioner. Third, end-of-life care planning should include psychosocial needs and expectations of both the family and community. Although health care providers are often under-resourced and under pressure to provide care to a large numbers of patients, fundamental care in line with belief and practice at the end of life should be provided.
      Further research needs to be directed at comparing the findings with other cultural settings and geographical areas. The needs of Xhosa patients should be assessed by studying Xhosa patients directly, and further study may help define the role of the traditional healer at the end of life as part of the patient's care and support team. Training programs need to be developed that up-skill traditional healers in end-of-life care; that educate palliative care practitioners about traditional health approaches; and that facilitate increased collaboration between the two sectors.

      Disclosures and Acknowledgments

      The authors have no conflict of interest to declare, and no funding was received for this study.
      The authors would like to thank the community members who assisted in recruitment, the traditional healers who took part, and Kate Sherry and Nicholas Graham for their insightful input during the analysis and write-up phases.

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