Whilst scholars have proposed different definitions of ‘rurality’, there is no consensus on a standardised description accepted universally (Bosworth & Somerville 2014; Gaede & Versteeg 2011). Although each nation has its definition of rural and urban, population size and distance from urban centres are the most critical metrics, according to Bosworth and Somerville (2014). Gaede and Versteeg (2011) further highlighted that some shared characteristics can assist in identifying rural areas, such as the availability of public services (rural health provision) and public amenities. This article defines rural health as the health and health care delivery in rural areas lacking urban characteristics such as amenities and infrastructure.

Rural health in Africa has become a critical matter, and one of the reasons is the lack of health care service providers (Guo et al. 2017; Ogunkola et al. 2020). Ogunkola et al. (2020) agreed with Amzat and Razum (2018) that more than 60% of the population on the African continent lives in rural areas, whilst most professional health care services are located in urban areas. These authors also emphasised that modern health care services and facilities do not exist in many rural regions of Africa. Similar findings have been reported by Harris et al. (2011), who surveyed 4668 participants in South Africa (SA). They agreed that there is a significant shortage of appropriate health care services in most regions. Harris et al. (2011) state that the accessibility of available health care services is still an enormous challenge in rural settings. Against this backdrop, the authors believe that the lack of medical services has significantly affected the health of rural areas. It is therefore necessary to introduce available, uncomplicated and effective medical approaches amongst rural communities.

Amzat and Razum (2018) highlighted that TM is widely applied to primary health in African counties, especially in rural areas. They explained that the reason is that TM is cost-effective, affordable and easily accessible. Traditional medicine is considered an alternative healthcare system in many African countries. Therefore, they argued that it would reduce the burden on healthcare in Africa if implemented widely (Amzat & Razum 2018). It must be borne in mind that TM has many distinct features, including culture, spirituality and experience base (Amzat & Razum 2018). However, it is argued that the involvement of the spiritual aspects in TM practice has limited its implementation in different contexts because it may be perceived as voodooism, ancient healing or pantheism.

Amzat and Razum (2018) revealed that, for years, the health burden of primary diseases in rural areas in Africa has contributed to almost 70% of the morbidities and mortalities. They further highlighted that one of the primary challenges is the high cost of health care, especially in rural areas where poverty is more prevalent. Lower costs on medical services are an important reason for the public to choose alternative medicine forms, significantly so when medical costs are escalating along with chronic diseases (Mellor 2014; Tlou 2018; WHO 2013). The researchers support that alternative medicine will reduce the government’s financial burden, especially amongst the rural population during times of dire crisis, for example, the COVID-19 pandemic.

Maroyi (2013) argued that in Zimbabwe, alternative medicine remains the most affordable and acceptable medicine to the public. In Ethiopia, Wassie et al. (2015) revealed that the residents are highly accepting of alternative medicine, which can be confirmed in that 70.9% of participants have used herbal medicine at least once. Similarly, in South Africa, many people in rural areas often consult with traditional or herbal doctors. They have robust belief systems deeply entrenched in their cultural philosophy that traditional healers will heal their illnesses. This can be confirmed by Semenya and Potgieter (2014), who highlighted that TM plays a vital role in the primary health of the rural population in Limpopo, South Africa. Harris et al. (2011) pointed out that one of the challenges in South Africa is the lack of health care service providers, whilst there is an increased need for quality health care services. We note that a similar situation can be seen in other African countries on the continent.

As discussed previously, health care services are not available in many rural areas in African countries because of poor accessibility and affordability. Wardle et al. (2011) argued that alternative medicine plays a vital role in health in rural settings without the availability of conventional health care services. The shortage of conventional health care professionals increases alternative or TM use, as reported by Guo et al. (2017) and Ogunkola et al. (2020). Wardle et al. (2011) asserted that alternative medicine is more likely to be accepted when there is no access to conventional medical assistance. We argue that TCM may be one such solution to improve rural health.

Traditional Chinese medicine is one of the primary forms of alternative medicine worldwide that has a long history of constant clinical practice (Zhang et al. 2019). It is an ancient medical system that treats diseases with different interventions, including Chinese herbal medicine, acupuncture, moxibustion, Chinese therapeutic massage, cupping, food therapy and exercise (Li, Chen & Zhao 2019). Chinese herbal medicine is one of the most common therapeutic modalities in TCM, mainly focusing on using plants to treat various diseases (Zhang et al. 2019). Acupuncture is performed by inserting thin needles on specific points (namely acupoints) in the body to treat various diseases (Li et al. 2019). Moxibustion is another therapeutic technique that burns moxa cones or sticks (Artemisia argyi) over acupoints (Cheng 2019). Cupping therapy is achieved by creating negative pressure on the skin, and it is commonly used in TCM practices (Cheng 2019; Li et al. 2019). According to TCM theories, food therapy takes the effects of food on the properties, tastes and therapeutic functions (Li et al. 2019).

Traditional Chinese medicine focuses not only on the treatment of diseases but also on the prevention of diseases. Evidence supporting this view can be found from Kim et al. (2018), who argued that TCM is a recommended treatment for many medical conditions. Traditional Chinese medicine is recommended to be used as an alternative medicine to improve health conditions, according to Lam, Lyu and Bian (2019) and WHO (2013). Traditional Chinese medicine has played a memorable role in the treatment of pandemics in recent years, from severe acute respiratory syndrome (SARS) in 2003 to the COVID-19 outbreak in 2020, as specified by Yang et al. (2020). This opinion is further asserted by Ren, Zhang and Wang (2020), who claimed that remarkable clinical effects have been shown in treatment with TCM. They reported that TCM may increase the clinical cure rate of COVID-19, reduce the percentage of cases that develop into severe conditions and shorten the average length of stay in hospitals.

Many TMs involve the practice of spirit, as revealed by Amzat and Razum (2018). Although the words ‘spirit or spiritual’ are adopted in TCM theories, the original term in TCM is shen. This term does not relate to religious discourse or spiritual aspects in TCM, as it refers to the interpretation of the highest level of heaven and earth in theory (Wielander 2017). The researchers of this study agree that this term refers to the mind or psychological perspective. Therefore, according to the WHO, TCM has no spiritual concern, even though TCM is defined and categorised as TM (or alternative medicine). In light of this, there should be no confusion in implementing TCM in rural communities from a spiritual concern (Amzat & Razum 2018).

Traditional Chinese medicine aims to treat individuals with a holistic approach (Li et al. 2019), including interventions from multiple aspects. These approaches include food therapy (diet), lifestyle, herbal medicine, acupuncture, moxibustion, cupping and Chinese therapeutic massage. Most of these interventions are accessible and affordable, which meet the unique needs of rural health in Africa. Studies have revealed that TCM is practical and cost-effective in treating many different diseases with fewer adverse effects and side effects (Lam et al. 2019; Li et al. 2019). According to a survey conducted by Venzke, Calvert Jr and Gilbertson (2010), in a rural area in the United States, it was reported that acupuncture can successfully assist postmenopausal women, including reducing hot flashes, depression and anxiety. This concurs with Schlabach et al. (2012), who conducted a study in Nepal and revealed that the low cost and effectiveness of TCM use may assist primary health in developing countries, especially in rural areas. Despite the advantages of TCM, Fung and Linn (2015) argued that there is a need for TCM to be explained and proven in an evidence-based approach.

Ethics clearance was obtained from a Research Ethics Committee at a public university in Gauteng province (reference number: REC-1233-2021). To ensure the anonymity of the 10 participants, the numerical codes P1–P10 were used.

Rural health is crucial globally, and the population in rural areas is more open to alternative medicine (Tlou 2018; Wardle et al. 2011). This study revealed that the attitude towards alternative medicine amongst rural residents plays a vital role in its application and use as a choice. All participants in this study were open to TCM and were willing to utilise TCM as a form of treatment for their health. A participant stated that:

Another response to TCM was:

Similar sentiments were reported by many authors who have paid particular attention to the rural population’s attitude to alternative medicine. For example, both Shumer et al. (2016) and Wardle et al. (2011) asserted that rural populations are more open to alternative medicine in Japan and Australia. Another study conducted in rural China obtained similar findings that the rural residents prefer to use TCM for chronic diseases (Liu et al. 2008). P4 (Male, 38 years old), P5 (Male, 40 years old) and P7 (Male, 25 years old) agreed that:

Studies have shown that millions of people in Africa are open to alternative medicine, as reported by Amzat and Razum (2018), Maroyi (2013) and Wassie et al. (2015). Therefore, there is a high probability that Africa’s rural residents’ attitudes will be favourable towards TCM.

In response to the question on their perception of the use of TCM, P9 (Female, 48 years old) and P10 (Male, 30 years old) stated that:

The knowledge of TCM is of paramount importance for the choices of patients when they are selecting medical assistance (Wardle et al. 2011). Li et al. (2015) argued that patients with high education levels are more likely to use TCM. This claim is in agreement with the study conducted by Shumer et al. (2016) in Japan. We believe that residents with better education may have a better understanding of TCM. Therefore, the introduction of TCM knowledge to rural residents becomes necessary. According to the HBM, people will improve their health only if they understand that they can be affected (perceived susceptibility) and the severity of the disease (perceived severity). They will also need to realise that their health may benefit from taking actions to prevent or treat conditions (perceived benefits). The researchers of this study are of the view that these aspects will be strengthened by introducing TCM knowledge to rural residents.

Traditional Chinese medicine is widely used as a treatment for various diseases worldwide, according to Kim et al. (2018) and Lam et al. (2019). The findings of this study were supported by other researchers that TCM can treat a wide range of diseases with confirmed effectiveness and low cost in different counties. To this, a participant stated:

Another participant added:

Similar findings were reported by Schlabach et al. (2012) and Venzke et al. (2010) as mentioned in the literature.

Wang et al. (2015) claimed that the TCM can effectively improve patients’ conditions with metabolic syndrome from a study with 598 participants in China. Ren et al. (2014) carried out a randomised, double-blinded controlled trial with moxibustion on patients with chronic knee osteoarthritis. Patients in the treatment group experienced pain reduction, function improvement and stiffness decrease compared with the controlled group. Arslan et al. (2015) argued that cupping may be considered for all musculoskeletal pain conditions. This suggestion aligns with Coyle (2010), who agreed that pain is the most common reason people seek alternative medicine. As stated above, TCM has been widely used in different contexts worldwide for various diseases at affordable costs. The implementation of TCM in rural communities will improve the quality of their health.

According to Eaton et al. (2018), the rural population is less likely to use self-management interventions than the urban population. Similar sentiments were identified in our study. All participants reported that they would seek medical assistance only when they experienced ailments they could not tolerate. When answering their views on health, a participant said:

Another participant stated that:

As specified by Harris et al. (2011), one of the common reasons for delays in seeking medical assistance is a lack of awareness of the severity of diseases. Tarkang and Zotor (2015) supported that the HBM can be used for health promotion. Coyle (2010) conducted a study in a rural area in south-eastern Victoria, Australia; the findings revealed that 31% of residents were referred through word of mouth. In response to how participants knew of TCM, P1 (Male, 45 years old) indicated, ‘I heard of traditional Chinese medicine from a friend of mine who went for acupuncture treatment to a Chinese doctor in Johannesburg.’ According to P3 (Female, 35 years old) and P6 (Male, 69 years old), they heard of Chinese medicine from their families and friends’ children who were studying homoeopathy at the university. These findings correlate with the literature by Coyle (2010), where it appears that word of mouth is significant advocacy for the use of TCM.

In South Africa, TCM has been gaining recognition because it was formally introduced as part of a degree programme (Traditional & Natural Health Alliance 2018); the researcher believes that teaching TCM to rural residents is essential and affordable to help people engage in self-care and maintain their health. According to HBM, to promote healthy behaviours and decisions, individuals must believe that there are risks of being sick (perceived susceptibility) and understand the severity of the diseases (perceived severity) – therefore, the use of appropriate alternative treatment is crucial. These two aspects, without a doubt, can be achieved by introducing general health knowledge of TCM. After understanding basic TCM knowledge, the belief in efficacy (perceived benefits) will be achieved by understanding diseases and health knowledge.

As revealed by Shen et al. (2010), applying correct Chinese food therapy in diet may reduce blood pressure in patients with hypertension. According to P2 (Female, 51 years old) and P8 (Female, 53 years old), they both indicated that they watched their diet and ate recommended foods. This has helped them to bring down their blood pressure. This claim is in agreement with Wang et al. (2017), after the implementation of ‘simple therapeutic techniques of TCM’ in the rural areas in China, the number of patients’ consultations was reduced by 34% after a two-year follow-up (p < 0.05). The content of the ‘simple therapeutic techniques of TCM’ focuses on the TCM health education and convenient treatment techniques that can be performed by residents themselves without comprehensive training, such as food therapy, moxibustion, cupping and Chinese therapeutic massage. It is a unique approach from a holistic perspective of TCM that applies interventions from multiple aspects to maintain health (Li et al. 2019). Findings from this study agreed with these authors as participants asserted that some simple techniques would benefit their health. For example, a participant stated:

Both Mellor (2014) and Tlou (2018) argued that the accessibility and affordability of alternative medicine, such as acupuncture, cupping and massage, are important reasons for patients’ choices. We believe that the rural residents in Africa will benefit significantly from this kind of holistic approach in both treating and preventing diseases, especially at no or low extra cost.

In a similar vein, Wassie et al. (2015) argued that the knowledge of TM can potentially assist in selecting plant materials and discovering their therapeutic effects. Wassie et al. (2015), in a study conducted in Ethiopia, further highlighted that 90.3% of the participants would like to acquire knowledge of herbal medicine. We believe that employing TCM theories to analyse African medicinal plants will broaden their actions and indications. After gaining basic knowledge of TCM, the rural residents in Africa will identify different functions of herbs to treat diseases or maintain health by themselves.

With a deep understanding of the advantages of TCM, rural residents may be encouraged to accept multiple health behaviours, including diet changes, the use of herbal medicine, moxibustion, cupping and massage. According to the HBM, rural communities also like to enjoy good health. They are eager to try alternative medicine, even visiting herbalists. Self-efficacy, according to the HBM, which refers to the ability to conduct action, will also be encouraged. Furthermore, the number of qualified TCM service providers is essential for long-term implementation; as argued by Liu et al. (2008), most residents in rural areas prefer to have TCM treatment performed by qualified TCM practitioners. We argue that training for different levels of TCM service providers is encouraged for the specific need of rural health in Africa. This can be supported by the successful experience of ‘barefoot doctors’ who were specifically trained for the market of rural health in China in the mid-twentieth century (Xu & Hu 2017).