Work

Beyond non-adherence: qualitative insights into how patients strategically navigate pluralistic chronic care in West Africa

Year: 2026

Type: article

Abstract: Background Across West Africa, people living with chronic non-communicable diseases (NCDs) routinely seek care across biomedical, traditional and spiritual sectors. Patients often navigate these pluralistic health systems intentionally, responding to economic and social constraints, yet movement away from biomedical care is commonly interpreted as non-adherence. We examine how and why patients in West Africa negotiate their NCD care pathways across multiple sectors, and how they exercise agency within these constraints. Methods We used a multiple qualitative case design, drawing on data from 11 purposively selected municipalities and districts in Burkina Faso, Ghana and Niger. Semistructured interviews were conducted with 84 participants: people with hypertension, diabetes or common mental health conditions (n=29); biomedical providers (n=29); traditional and spiritual healers (n=13); caregivers (n=3) and policy makers (n=10). Interviews in English, French and five local languages were analysed thematically, guided by frameworks on healthcare pluralism, patient agency and care-seeking trajectories. Results Three patterns of therapeutic navigation emerged across all three countries, shaped by collective decision-making within extended family and peer networks, economic constraints and expectations of cure. First, when biomedical costs became untenable, patients shifted from biomedicine to traditional providers, carrying their diagnoses into the folk sector and often returning to biomedical care when resources allowed. Second, some patients concurrently maintained biomedical treatment while running self-managed traditional regimens, assigning distinct functions to each sector: biomedicine for diagnosis and monitoring, traditional medicine for the prospect of cure. Third, for mental health, families followed a spiritual-first trajectory from the outset, driven by explanatory models of spiritual causation rather than service availability or cost. Across all three patterns, patients frequently concealed their pluralistic practices from biomedical providers, fearing reprimand or finding no clinical space in which to disclose. Conclusion Pluralistic care-seeking is a form of deliberate, conditioned agency, not simple non-adherence. Improving chronic NCD care requires more sustainably affordable biomedical services, consultation environments that enable open disclosure of pluralistic practice without penalty and health indicators that capture therapeutic navigation rather than biomedical endpoints alone.

Source: BMJ Open

DOI: 10.1136/bmjopen-2026-123607