Study design and setting

This study examined the perspectives of traditional medicine practitioners (TMPs) and faith healers on breast cancer, focusing on its causes, main signs and symptoms, and methods of diagnosis. An exploratory, descriptive, qualitative design was employed, utilizing in-depth, semi-structured interviews to gather participants’ experiences [8]. The study was carried out in Kumasi, Ghana, with participants recruited from communities within the Kumasi Metropolitan Assembly (KMA).

Study population and eligibility

We targeted TMPs involved in breast health and BC care in Kumasi, Ghana. In this context, traditional medicine includes the use of medicinal plants and faith-based or spiritual healing [9,10]. This study defines TMPs as non-formally trained herbalists or faith healers recognized within their community for providing care based on traditional knowledge, practices, and beliefs. We included men and women aged 18 years or older who were involved in women’s breast health practices within the Kumasi Metropolitan Assembly (KMA), had at least 1 year of experience in breast health or cancer care, could speak either Twi or English, and were willing to participate. Formally trained TMPs were excluded from the study.

Sampling and sample size

We used purposive sampling to recruit participants who were willing to participate and able to share their experiences [8]. Fourteen TMPs were interviewed, with the sample size (n = 14) determined by data saturation. During concurrent data collection and analysis, later interviews did not add substantively new insights relevant to the research questions. By the 12th participant, responses were repetitive, and two additional interviews were conducted to confirm saturation [11–13].

Recruitment and the interview process

Before commencing the study, formal permission was obtained from the study site via an introductory letter and an ethics approval letter. Participants were recruited from communities within the Kumasi Metropolis via the Traditional Medicine Practice Council (TMPC). Two TMPC staff members served as “recruitment links”, providing potential participants with study information, eligibility criteria, and information leaflets. Interested TMPs were then referred to the first author (P.A.), who confirmed eligibility, discussed study details, and scheduled interview appointments. Data collection took place from 10^th February to 30th April 2023 through in-depth, face-to-face interviews guided by a semi-structured interview guide [14]. The guide (S1 File), developed based on the study objectives and existing literature, was reviewed by two TMPs with expertise in breast health and then translated into Twi using a back-to-back translation process. It was piloted with two herbal/faith healers to refine the questions; these pilot interviews were excluded from the primary analysis. Interviews were conducted by the first author (P.A.), a nurse trained in qualitative research, in Twi at participants’ chosen locations, usually their own centers, for privacy and comfort. Sessions lasted 35–60 minutes (averaging 45) and were audio-recorded with participants’ consent. Field notes capturing nonverbal cues and the researcher’s reflections were also taken. Written consent was obtained before participation. Demographic information from participants was also collected. Participants’ anonymity was maintained by assigning unique study codes (e.g., TMP001–TMP014), and they were reminded of their right to withdraw at any time.

Data analysis

Data collection and analysis were conducted concurrently. Interviews were transcribed from Twi into English by a professional transcriber proficient in both languages. A bilingual author (A.B.B.M.) cross-checked a random sample of the recordings and transcripts to support accuracy in interviewing, transcription, and translation. Transcripts were imported into NVivo 12.0 Plus [15] for data management and analysis. We used an inductive thematic analysis approach, developing codes and candidate themes through iterative engagement with the transcripts rather than applying a pre-existing theoretical framework [16,17]. Two analysts (A.B.B.M. and P.A.) independently read the transcripts, generated initial codes, and discussed analytic interpretations to refine broader categories and themes. Differences in interpretation were discussed with a senior author (B.V.) to deepen the analysis and enhance transparency. Themes were refined through constant comparison across transcripts, team debriefings, and repeated cross-checking with the data to strengthen credibility and confirmability [18,19]. By the 12th interview, additional interviews were not adding substantively new insights relevant to the research questions; two additional interviews were conducted to assess the dataset’s adequacy and depth [12]. Final themes were integrated and supported with illustrative participant quotes to preserve authenticity and transferability [20,21].

Trustworthiness

Credibility was supported through analyst triangulation and member checking. Analyst triangulation involved two authors (A.B.B.M. and P.A.) independently coding transcripts and comparing interpretations to refine the analytic account [22]. To enhance confirmability, the interviewer summarized each session for participants immediately after the interviews, and three randomly selected participants later reviewed their transcripts, all confirming accuracy without corrections [23]. Field notes documenting nonverbal cues, participants’ concerns, and the researcher’s reflections further strengthened dependability. Although the interviewer (P.A.) is a graduate nurse with clinical knowledge of breast cancer, she had no professional ties to the study setting or participants, which helped reduce potential bias.

Ethical approval and consent to participate

This study was approved by the Ghana Health Service Ethical Review Board with approval number [GHS-ERC: 007/09/22]. The participants provided written consent. All study methods were carried out in accordance with the ethical principles outlined in the 2013 World Medical Association Declaration of Helsinki [24]. All participants were informed about the study’s purpose, assured of confidentiality, and provided written consent before participating. Participation was voluntary, and participants could withdraw at any time without consequence. Participants were assured of anonymity using study numbers (codes) throughout the study and during the verbatim quotations of participants’ expressions. We de-identified transcripts before analysis to ensure anonymity. Audio recordings and transcripts (without any identifying information) were stored on a password-protected computer. We followed the Standards for Reporting Qualitative Research [25].

Participant’s profile

Fourteen herbal/faith-based healers participated in the study. Six were solely herbalists, while eight practiced both as herbalists and as spiritual (faith-based) healers. Table 1 presents detailed demographic characteristics, providing important context for understanding the diversity of backgrounds, experiences, and therapeutic approaches that shape their perspectives on breast cancer care within the Ghanaian traditional healing setting.

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Table 1. Participants’ Background Data.

https://doi.org/10.1371/journal.pone.0355289.t001

Thematic findings

Thematic analysis of the interviews identified four main themes: (i) sources of knowledge, (ii) multi-dimensional explanations of breast cancer causation, (iii) cardinal signs defining breast cancer recognition, and (iv) experiential and practice-based approaches to diagnosis. These themes and their sub-themes as shown in Table 2, offer insights into how TMPs understand breast cancer and the practices they use when responding to women’s breast-related concerns.

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Table 2. Themes and Sub-themes.

https://doi.org/10.1371/journal.pone.0355289.t002

Inherited and ancestral knowledge

TMPs’ understanding of breast cancer is rooted in knowledge passed down through generations, often from grandparents, parents, or family elders who practiced herbalism, spiritual healing, or both. This lineage-based transmission gives legitimacy and authority to their practices, combining cultural, spiritual, and experiential learning rather than formal biomedical training:

“I received the medicine from my grandmother; it was a gift. She healed cancer.” (TMP004)

“I learned it from my grandfather, … My grandfather was a pastor, and my father was a Mallam and a fetish priest. So, they all have their own ways of preparing their medicine.” (TMP006)

I don’t have any spirit. I only followed in my grandfather’s footsteps, and he taught me about the medicinal value of various natural herbs. (TMP014)

Blending traditional knowledge with formal and professional training

Some TMPs enhance their inherited or community-based knowledge through training, workshops, professional associations, and collaborations with biomedical practitioners. This evolving model is combines traditional healing with elements of modern healthcare, reinforcing legitimacy and expanding their skills:

“..., we do go through training courses. Occasionally, we self-fund an event for a nurse to come and teach us something. In addition to that, I have four doctors that I consult...” (TMP012)

“Every year, we attend training sessions. We are part of an organization called the Ghana National Traditional Medicine Practice Association.” (TMP001)

“I started with a family member, then I went to school and began reading books and other things. ... Yes, I attended a workshop on herbal medicine.” (TMP003)

Spiritual and social disharmony

TMPs viewed BC as a problem caused by spiritual imbalance or disrupted social connections. They believed that dreams, curses, and unresolved conflicts often precede physical symptoms, suggesting that the illness is more than a medical condition—it is a moral or spiritual issue that needs reconciliation or ritual healing:

“Many people who come here say they dreamt that someone bit their breast… and before they wake, they start to notice a change in their breast. Most sickness begins spiritually before manifesting physically.” (TMP013)

“A woman came here with a breast problem. I told her it was not just a disease, breast cancer; she wronged someone, and she must apologize to be healed.” (TMP008)

Bodily vulnerability and lifestyle practices

Some TMPs attributed BC to physical vulnerabilities linked to reproductive health, infections, poor hygiene, or lifestyle choices. Menstrual irregularities, abortions, sexually transmitted diseases, smoking, dietary habits, and even clothing practices were seen as weakening the body and creating conditions for disease, reflecting a holistic but non-biomedical understanding of risk:

“When they have menstrual problems or undergo late abortions, it causes many issues in the breast... those with menstrual problems may experience some gas in the breast, which can lead to pain, then cancer.” (TMP001).

“Nine out of ten breast cancer patients who visit my clinic have infectious diseases like gonorrhea, hepatitis B, syphilis…” (TMP014).

“If someone is complaining about her breasts, we usually examine her cervix because they are linked… If there’s a sore on the cervix, it can affect the breast, so I make sure to treat any infections in the cervix first before addressing the breast.” (TMP005)

“…, things like smoking and nipple biting during sex cause cancer.” (TMP011)

“Someone will use one brassiere for a long time... the blood does not circulate well, and they get breast cancer.” (TMP004)

“Eating foods high in fats can harm your health and make you more likely to get sick often. Too much of anything is unhealthy. Taking in too much fat is unhealthy.” (TMP004)

Abnormal lumps and swelling as primary indicators

For many TMPs, the presence of an abnormal lump or swelling are perceived as conclusive markers of disease.

“The breast will resemble the oval mouth of a deodorant, or other things, like an orange... For those with a lump in their breast, it becomes swollen... clearly indicating that the person has breast cancer.” (TMP013)

“Any lump other than the natural one is abnormal” (TMP001).

“We know it is painless. There is no pain or lump in the breast. So, based on the presenting symptoms, we can conclude it is cancer” (TMP012).

Nipple and skin changes as confirming signs

Beyond lumps, TMPs identified visible changes in the nipple including nipple retraction, hardness, loss, abnormal discharge, skin discoloration, rashes, sores, and peeling textures as clear evidence that the breast was diseased.

“You will notice that the nipple is either missing, diverted, or feels very hard” (TMP007).

“Some also notice that the area around the nipple changes color. Some may not be breastfeeding, but there is discharge from the nipple; all these signs indicate breast cancer.” (TMP012).

“Sometimes, you will see rashes and soreness around the breast, and at times, the texture of the breast feels like it is peeling away.” (TMP014).

Hands-on experiential assessment

TMPs stressed that their ability to diagnose relies on accumulated experience and direct physical examination of the breast. Using the hands to feel for lumps or to observe visible changes was considered sufficient to suspect BC. This reliance on practical knowledge positioned “experience as the best teacher,” with credibility based on years of practice rather than formal education.

“We assess the breast and any lump; aside from the natural lumps are considered abnormal. If you have much experience in breast cancer, you will know. For me, I use my hand to check it.” (TMP001)

“I will check their body and physical appearance. You will see they [breasts] have become smaller than they should be, so if we notice that, we check with our hands to confirm if it is cancer” (TMP005).

“For me, I oppose using gloves to examine the breast, so I usually use my hand to check for lumps. It might even surprise you that the situation isn’t even cancer in the end.” (TMP006)

“...because I have a lot of experience with this, when they visit, I check their breast to determine it.” (TMP001)

“Experience is the best teacher, and I have been doing this business for a long time” (TMP014).

Reliance on external biomedical confirmation

Although many TMPs relied on experiential methods, some acknowledged the role of biomedical tests and hospital diagnoses in confirming breast cancer. In such cases, practitioners either deferred to hospital scans or relied on patients bringing medical reports, which they used to validate their own suspicions. This blending of experiential knowledge with biomedical confirmation illustrates pragmatic hybridity in diagnostic reasoning.

“We only suspect breast cancer when we see that, but the scan will confirm it.” (TMP004)

“I typically see patients who have been to the hospital and whose doctors have already confirmed she has breast cancer. Such a person will come with her cancer results in hand.” (TMP014)

Analytical paragraph: Management responses after recognition or suspicion

Although the study did not systematically trace patients’ full care pathways after TMP recognition or suspicion of breast cancer, some accounts suggested that practitioners’ beliefs about aetiology shaped their immediate management responses. Where breast symptoms were interpreted through spiritual or social explanations, management could involve advice directed at spiritual or relational repair. For example, one practitioner explained: “A woman came here with a breast problem. I told her it was not just a disease, breast cancer; she wronged someone, and she must apologize to be healed” (TMP008).

Similarly, where breast cancer was attributed to bodily vulnerability, reproductive problems, or infection, management could focus first on treating those perceived underlying causes. One TMP stated: “If there’s a sore on the cervix, it can affect the breast, so I make sure to treat any infections in the cervix first before addressing the breast” (TMP005). These accounts suggest that aetiological beliefs informed how some TMPs advised or managed women with breast symptoms. However, other TMPs described a more cautious approach, recognizing suspicious signs but relying on biomedical confirmation: “We only suspect breast cancer when we see that, but the scan will confirm it” (TMP004). Another practitioner explained that some women came after hospital confirmation: “I typically see patients who have been to the hospital and whose doctors have already confirmed they have breast cancer. Such a person will come with her cancer results in hand” (TMP014).

Together, these findings indicate that TMP responses after recognition ranged from traditional or spiritually informed management to selective reliance on biomedical confirmation.

Strengths and limitations

This study has important strengths. It is among the first to systematically explore the perceptions of non-formally trained traditional medicine practitioners (TMPs) in Ghana regarding breast cancer, offering novel insights into their explanatory models, diagnostic practices, and openness to biomedical collaboration. The exploratory descriptive qualitative design, combined with in-depth interviews, enabled the collection of rich, nuanced accounts that quantitative approaches would not have captured. Rigor was ensured through analyst triangulation, member checking, and detailed field notes, which enhanced the credibility and trustworthiness of the findings. Nonetheless, several limitations should be acknowledged. The study was conducted in Kumasi alone and included a relatively small sample of 14 TMPs, which may limit the transferability of the findings to other contexts in Ghana. The reliance on self-reported perceptions also introduces the possibility of social desirability bias, particularly in responses regarding collaboration with biomedical practitioners. At the same time, the translation of interviews from Twi into English may have resulted in a subtle loss of meaning. Further, the study did not include the perspectives of women with breast cancer or biomedical providers, limiting a full understanding of how TMPs’ beliefs influence health-seeking behavior and patient outcomes. In addition, although the study explored TMPs’ recognition, beliefs about causation, and diagnostic practices, it did not systematically examine what happened after TMPs suspected breast cancer. We therefore could not fully assess whether practitioners referred women to biomedical facilities, treated them within traditional systems, advised spiritual or social remedies, or whether these responses contributed to diagnostic delays. Future research should follow patient pathways after TMP consultation and include the perspectives of women, TMPs, and biomedical providers to better understand how aetiological beliefs influence management, referral, and time to diagnosis.