Healthcare in Lesotho is in the hands of the government, the private sector (churches and private surgeries), and civil society (traditional health practitioners), with the government support directed towards the Ministry of Health, excluding the private sector and civil society organizations [1]. The country continues to face an alarming double burden of disease, because of increases in the burden of infectious diseases (IDs), as well as, non-communicable diseases (NCDs) [2]. Lesotho has been using Traditional, Complementary and Alternative Medicine (TCAM) products from time immemorial [3]. The World Health Organization (WHO) defines TCAM as any diagnosis, treatment and prevention that are used in conjunction (complementary) or place (alternative) of standard medical treatment [4]. Studies in Lesotho have reported more on the use of medicinal plants or herbal medicine to treat conditions, such as HIV [5], wound care [6] and reproductive problems [7]. However, the impact of uncoordinated harvesting of medicinal plants is a serious concern to the environmentalists and the communities as a whole in the country [3]. Documented side effects due to concomitant use of TCAM products include gastrointestinal disturbances (nausea, vomiting, diarrhoea and abdominal pain), dizziness, headache and malaise [8-10].

In Africa, TCAM use is estimated at an average of 58.2%, ranging from 4.6% to 94% [11-13], and has long been widespread in developing countries with a considerable number of its population relying on TCAM to maintain their health or prevent and treat IDs and NCDs [14-16]. The push factors of TCAM use are mainly centered on the dissatisfaction with conventional healthcare [17]. This includes issues, such as long-distance to health facilities, unavailability of drugs, difficulty and inequity in accessing care, negative attitude of healthcare providers, long waiting time, lengthy procedures and fear of being diagnosed with a serious disease [18-21]. TCAM use is further motivated by the inability of conventional medicine to treat their diseases, control of symptoms, and management of drug side effects believed to be due to lack of knowledge on the potential dangers for concurrent use of TCAM with conventional medicines [22, 23]. Additionally, healthcare costs are perceived to be too much, even for state-run hospitals and clinics, where consultation and treatment are assumed subsidized [24]. To solve the problem of a drug shortage or high cost in part, many health-oriented ministries are now encouraging the use of local medicinal plants for disease treatment [24]. The lack of health care systems in rural areas forces local people to treat themselves, either by using medicinal plants or by buying high-cost medicine in the rural markets or still further, going for cheap roadside medication, predisposing themselves to health dangers caused by the unknown source of these poor medications [25].

In Africa, including Lesotho, South Africa, Uganda, and Northern Morocco, Traditional Herbal Medicine (THM) is the most common TCAM healing system used for treating chronic diseases, mainly HIV, some medical conditions that occur during pregnancy [5, 26-28] and later, against COVID-19 [29]. Individuals adopt TCAM to prevent or treat common diseases, such as flu and common cold, headaches, indigestion and stomach problems [30]. Furthermore, TCAM products are used by patients to treat NCDs, hypertension and diabetes [31, 32], as well as asthma [33] and paediatric conditions [34]. Literature further reports a high use of TCAM among patients with cancer in Sub-Saharan Africa (SSA) [35, 36]. Then, follow faith-based healing methods (prayer/spirituality), and mind-body therapies (massage, traditional bone setting relaxation, mediation and yoga) [37]. Homoeopathy as a TCAM modality has been reported in various African countries among university staff (South Africa) [17], prayer/spirituality mode among patients with HIV/AIDS (Nigeria and South Africa) [38, 39] and massage among cancer patients (Ghana) [36].

Several sociodemographic factors, including age, gender, marital status, and level of education, health status, income status religion and ethnicity, have been associated with TCAM use [37]. Studies conducted in urban or semi-urban areas have reported TCAM use among younger individuals [40, 41], while in the rural areas, TCAM users are older [42]. Other studies have reported TCAM use to be common among individuals with little or no formal education [40, 43], and those who are married [9] than those who are not married [40]. Another study reported that TCAM users were likely to be Christians compared to other religions [41]. On the other hand, no significant correlations between the sociodemographic characteristics of the respondents and TCAM use have been reported [44]. Other researchers have indicated contrasting results for other factors such as gender and religion [9, 45]. Both male and females have been reported to use TCAM alike [9], while no difference have been observed on TCAM use by religion [45].

The use of TCAM is a concern to clinicians, especially, on safety and potential health risks [22, 36]. Concerns that simultaneous use of conventional medicines and TCAM exposes people to pharmacokinetic and pharmacodynamics interactions have been reported, which could lead to decreased effectiveness, toxicity and non-adherence to conventional medicines [22, 36]. It is well documented that pharmacokinetic or pharmacodynamics are herb-drug interactions and may alter the concentration of a therapeutic drug in the blood, which results in the potentiated or decreased action of drugs [46, 47].

Despite these concerns, it seems as if there is a limited commitment to advise patients to ensure maximum treatment outcomes and limit complications associated with TCAM usage, such as alterations in therapeutic efficacy and/or potential toxicities. Additionally, there is a paucity of data on TCAM usage and related factors among patients receiving healthcare in a health facility in Lesotho, except for the few studies that have been conducted on medicinal plants [5-7]. Because of this, the study aimed to determine the prevalence of TCAM usage and associated factors among patients receiving healthcare in a health facility in Lesotho. Considering the high utilisation of TCAM across SSA [37], it becomes pertinent to find out how common the usage is in this clinic in Lesotho, to judge whether a suitable response needs to be formulated.

This study determined the prevalence of TCAM usage and related factors among patients receiving healthcare in a health facility in Maseru District, Lesotho. Poor sociodemographic status in terms of education and employment status was observed. About 57% of the people are living below the national poverty line in Lesotho [53], with an unemployment rate estimated at 25,3%, roughly the same as South Africa's unemployment rate (25.2%) reported in the first quarter of 2013 [54], but now has increased to 32.5%, according to Statistics South Africa [55]. Despite gains made in the past two decades in improving education access rates, Lesotho continues to suffer from high dropout rates at the primary level and poor access rates at the secondary level, particularly in the rural areas [56], in addition, to gender discrimination reported in the country, concerning education access [57]. Therefore, depressed socioeconomic status is still evident in Lesotho.

Most participants in this study were taking treatment for STIs, NCDs, comorbidities, and were on prescribed medication. Lesotho is highly affected by the HIV pandemic [58] and the country has an estimated adult HIV prevalence rate of about 23% and a high burden of NCDs [59]. Studies in Lesotho have reported a 42% of the patients living with HIV had at least one NCD [60], as well as hypertension, estimated at 35%, and diabetes at 2.5% [61]. Research on the management of STIs and NCDs has reported that 90% of the patients have received a combination of antihypertensive therapy [62] and 32% of patients having NCDs were on antiretroviral therapy [60]. Coexistence and management of STIs and NCDs have been confirmed in Lesotho [60], similar to South Africa [63, 64]. As well, tobacco and alcohol use have been reported in Lesotho [65, 66] and South Africa [67], lifestyle factors reported in the current study. Similar to other sub-Saharan countries, Lesotho is also experiencing its share on the convergence of IDs and NCDs, in addition to unhealthy lifestyle factors.

Our study showed a low prevalence of TCAM usage among patients receiving healthcare in Maseru, Lesotho. Almost a similar lower than 10% prevalence of TCAM use has been reported in several African countries, such as South Africa [40], and Ethiopia [11]. On the other hand, a high prevalence of TCAM use has been reported in South Africa, among patients attending primary health care facilities in KwaZulu Natal [49], while Peltzer et al. [39] reported 51.3% of TCAM use in the same province (KwaZulu Natal) and 29.6% reported to use herbal therapies. Variabilities in study designs, recall periods and seasonal variations in disease frequency and the associated choice of treatment options may have influenced the prevalence of TCAM use in various countries, settings and population [37]. In addition, the method of data collection, and the type of sample chosen affect the prevalence estimates [68]. Under-reporting of TCAM use based on several reasons like the community's belief that traditional practice is an unlawful act or high prevalence of illnesses is believed to be treatable by modern care [11], which might be the case in the current study. Therefore, it could be that the participants in the current study did not want to tell the researchers that they were using TCAM because they were aware that the facility disapproves concurrent use of TCAM with western treatment.

The current study also observed a very low disclosure rate of TCAM use to HCWs. This might impact negatively on the prevalence estimate in this population, considering that medicinal plants are used extensively in Lesotho, especially for the treatment of STIs [48]. In SSA, the non-disclosure rate of TCAM use to healthcare providers ranged from 55.8% to 100%, with an average of 83.0% [37]. Reasons for non-disclosure of TCAM usage by patients in this study were because they were told not to use TCAM, fear of HCWs, and poor communication. Fear of receiving improper care has been reported as the main reason for not disclosing their TCAM use status to their healthcare provider [69]. Another reason for the non-disclosure of TCAM use was the conventional medicine provider’s negative attitude with perceived lack of support and understanding that lead to mistrust and stigma from conventional providers in Nigeria [70] and South Africa [71]. Patients in other countries, such as in Ethiopia was that their conventional healthcare providers lack knowledge about TCAM was another reason for not divulging their TCAM use status [35]. Healthcare providers’ lack of enquiry about TCAM use was also cited among patients in Nigeria [8]. Given the potential for adverse reactions and drug interactions related to TCAM use, health care providers' awareness of TCAM use is crucial to optimize patient care [72]. Hence, health care providers should be informed about this to include inquiring about herbal and TCAM use for both HIV-related illnesses and other comorbid conditions as part of their history taking and clinical assessments, as Langlois-Klassen et al. [27] have suggested.

The vast majority of patients in our study reported a high degree of satisfaction with the medical treatment they were receiving, similar to the findings in a study of Petzer et al. [39] in South Africa. However, treatment challenges due to long queues, shortage of medication and travel costs to the hospital were reported in this study, similar to other studies in Ghana [20], Uganda [19, 21] and Nigeria [18]. In the rural areas, one sometimes travels for several days before finding the nearest dispensary and pharmacy or health clinic for consultation. In addition to losing working days, transport fares the high cost of medicine must also be taken into consideration [24].

THM was a widely used healing type of TCAM system in this study, which might be centered on the dissatisfaction with conventional healthcare [17]. The current study further showed that the most used THM were Dicoma Anomala, Eriocephalus Punctulatus, Aloe Ferox mill, Allium Sativum and Artemesia Afra. In Lesotho, a considerable proportion (69.9%) of HIV-positive people use medicinal herbs, and Allium sativum and Dicoma Anomala, have been reported to be the most commonly used medicinal herbs in this population [5]. Allium sativum is known to pharmacokinetically reduce the serum concentration of protease inhibitors (PIs), such as saquinavir and indinavir [27, 73]. Dicoma Anomala has been reported as an inhibitor of cytochrome-P enzymes and may interact with drugs that use these cytochrome-P enzymatic pathways [5, 74]. In addition, the use of Aloiampelos Striatula and Bulbine narcissifolia reported in the current study have been previously reported in Lesotho for the treatment of several ailments [6]. Similar to South African studies, traditional medicines such as Aloe ferox mill, Hypoxis hemerocallide (i.e. African potato) and Aloe vera have been reported to be used to meet primary health care needs [75, 76]. These results suggest the possibility of the interaction between TCAM usage, especially with THM, and conventional medicine, considering the high use of THM, while half of the participants did not know whether there is an interaction of TCAM use with conventional medication. This poses a serious concern in this facility because the use of THM is implicated to decreased effectiveness, toxicity and non-adherence to conventional medicines, although the use of TCAM was low in this study.

The sources of these medicinal plants reported in this study were mostly traditional healers, followed by friends/relatives, pharmacists and open market. Traditional healers remain popular because they are accessible, affordable, adaptable and culturally familiar, and thus acceptable and respected in the wider community [3]. Herbalists and traditional healers in Lesotho continue to dispense a wide range of topical herbal medicinal preparations for various treatments [5, 7, 48, 60], while the role of the pharmacist is to provide medical information on these compounds to promote the safe use of herbal products in combination with conventional medicine [6]. These medicinal plants were used to treat ailments, such as IDs and non-IDs, includings STIs, hypertension, body discomfort, bile, and flu in our study. Adoption of TCAM by individuals to prevent or treat common diseases, such as flu and common cold, headaches, indigestion and stomach problems, has been reported in Africa [30]. TCAM products have been utilized to treat NCDs, such as hypertension and diabetes in South Africa [31], and Guinea [32], as well as, cancer [8, 36], asthma [33], and HIV/AIDS [5, 39, 71]. The fact that medicinal plants are still viewed as the most cost-effective and accessible therapy by many rural dwellers in Lesotho cannot be denied, as mentioned before [6]. Our findings suggested low costs for TCAM, which was indicated to be lower than purchasing prescribed medication.

Chi-square and univariate analyses showed that age, education level, employment status, smoking and alcohol use were associated with TCAM and THM usage. These results might reflect access issues among the older persons, as well as the cultural significance of some TCAM modalities. Although contrary results exist on education as a predictor of TCAM, in this study, the more educated participants seem to be using TCAM. This could be because participants were more likely to be able to afford TCAM, as well as their prescribed medications. On the other hand, in the adjusted model, both TCAM and THM usage was associated with employment and alcohol use. Self-employed participants were 6.3 times more likely, while students were 3.6 times more likely to use TCAM than the unemployed were. This might be because these participants, especially those who were self-employed, had income, which allowed them to buy the product than the unemployed.

Similarly, with THM usage, employed participants were 2.4 times more likely, while self-employed participants were 5.1 times more likely, to use THM than the unemployed. This also indicates the possibility of income enabling them to purchase THM, same as the above suggestion. In addition, the participants might have had access to herbal medicines freely from the bush. Literature documents that generally, Basotho are knowledgeable on the usage of numerous medicinal plants in the treatment of various disorders [77, 78].

Age, gender, marital status, and level of education, health status, income status, religion and ethnicity have been associated with TCAM use [37], including a lower socioeconomic status [40, 78] and those who are unemployed and unskilled [40, 41] when compared with non-users. Both males and females have been reported to use TCAM alike [9]. In rural areas, TCAM use is associated with older age [42]. Literature documents that TCAM users reported in many studies to be more common in individuals with a lower socioeconomic status [9, 40]. Other studies have reported TCAM users to have little or no formal education [40, 42]. Alcohol users were 2.8 times more likely to use TCAM than non-users, while alcohol users were 2.9 times more likely to use THM than non-users. Data on TCAM usage and lifestyle factors, such as tobacco and alcohol use is limited.

TCAM usage appears relatively low in the study population. However, the THM system was widespread and this emphasizes the substantial role as a source of basic healthcare in the study populations in Lesotho. This study reported several medicinal plants used by patients for treatment. Stakeholders involved in healthcare should be mindful of the critical role of TCAM usage in healthcare service delivery in Lesotho. Prospective cohort studies on TCAM usage are urgently required to provide information regarding proper practice, safety, efficiency and harmonized healthcare in the country. Furthermore, it is worrying that most participants in this study reported have been counselled on the use of TCAM, yet a significant number did not know or consider TCAM to interact with medication.

In addition, patients’ disclosure rate of TCAM usage to HCWs was low and this warrants concern over communication between patients who are using TCAM, and their healthcare providers. Barriers to the disclosure of TCAM usage should be established, as well, HCWs need to improve communication with patients as a routine. The facility should be less harsh on TCAM use and encourage patients to disclose exactly what they are using so that they can be advised over whether there is a conflict between the prescribed and herbal medications they are taking. The study further showed associations of TCAM usage among participants who were employed and using alcohol, in addition to other factors, such as older age and high school education level. It is clear that although Western medicine is generally accepted throughout Africa, it has not replaced, but rather augmented indigenous health approaches, concurring with Mushapa et al. [3].