Exploring health seeking behaviours among males in traditional initiation schools in Leribe District, Lesotho

¹School of Medicine and Health Sciences, Mulungushi University Livingstone, Livingstone, Zambia, ²District Health Management Teams, Maseru, Lesotho, ³Kabwe Newborn and Children Hospital, Kabwe, Zambia, ⁴Queen Mamohato Memorial Hospital, Maseru, Lesotho, ⁵Department of Internal Medicine, Livingstone University Teaching Hospital, Livingstone, Zambia

^&Corresponding author
Lukundo Siame, Department of Internal Medicine, Livingstone University Teaching Hospital, Livingstone, Zambia

Introduction    

Men consistently experience poorer health outcomes and shorter life expectancy than women globally, a pattern partly attributed to delayed health-seeking behavior and restrictive norms of masculinity that discourage vulnerability and help-seeking [1]. In sub-Saharan Africa, these gendered norms are often reinforced through cultural institutions that socialize boys into adulthood, including traditional initiation schools [2]. In Lesotho, male initiation schools (lebollo la banna) play a central role in the cultural construction of manhood, emphasizing endurance, secrecy, discipline, and resilience [3,4]. While these schools are culturally valued, multiple reports have documented injuries, infectious diseases, dehydration, and deaths among initiates. Notably, many initiates present late to formal health facilities with advanced complications, suggesting systematic delays in care-seeking [5]. Existing studies on men’s health-seeking behavior largely focus on the general male population and fail to account for the unique social environment of initiation schools, which are intensely preserved in Lesotho, where cultural authority, traditional healing, masculinity norms, and limited health system engagement intersect [6,7]. Moreover, little is known about how decisions to seek care are negotiated among initiates, teachers, traditional healers, chiefs, and biomedical professionals. This study therefore aimed to explore the factors influencing health-seeking behaviors among males attending traditional initiation schools in Leribe District, Lesotho, where cultural norms, masculinity, and entrenched traditions uniquely shape health decisions.

Methods     

Research design: this study employed a qualitative phenomenological research design to explore lived experiences and perceptions related to health-seeking behavior among males attending traditional initiation schools in Leribe District, Lesotho. A phenomenological approach was considered appropriate as it enables in-depth exploration of participants’ subjective experiences, meanings, and interpretations within a culturally sensitive context where health decisions are socially negotiated.

Study setting: the study was conducted in Leribe District, one of the ten districts of Lesotho, with Hlotse as its administrative centre. Leribe District is predominantly rural and shares a border with the Free State Province of South Africa. The district is well known for the preservation of Basotho cultural practices, including traditional male initiation schools (lebollo la banna).

Study population: the study population comprised individuals directly or indirectly involved in traditional initiation schools, including: i) male initiates who had recently completed initiation; ii) traditional initiation schoolteachers; iii) traditional healers; iv) traditional leaders (chiefs); v) medical doctors working in facilities that manage complications related to initiation practices. Including multiple stakeholder groups allowed for data triangulation and a more comprehensive understanding of decision-making processes surrounding health-seeking.

Inclusion criteria: the study included male initiates aged 180-40 years who had completed initiation between 2023 and 2024, as well as traditional initiation schoolteachers and traditional healers with at least five years of experience. It also included medical doctors working in medical or surgical wards who had managed complications related to initiation schools, along with chiefs residing within the study area and overseeing initiation activities. All participants had provided informed consent.

Exclusion criteria: the study excluded initiates who had not completed the initiation process, individuals younger than 18 years or older than 40 years, traditional teachers or healers with less than five years of experience, and medical doctors from departments unrelated to initiation-related care. Individuals who declined participation were also excluded.

Sample size and saturation: a total of 52 participants were recruited: i) twenty five male initiates; ii) nineteen traditional initiation school teachers; ii) three medical doctors; iv) three traditional healers; v) two traditional leaders (head chief and village chief). Sample size was determined using the principle of thematic saturation, defined as the point at which no new themes or insights emerged across interviews and focus group discussions [8]. Saturation was assessed iteratively during data collection and confirmed during preliminary analysis.

Sampling strategy: a purposive sampling technique was used to recruit participants with direct experience and knowledge of traditional initiation school practices and health-seeking decisions. Convenience sampling was additionally applied where access was constrained by cultural gatekeeping and geographical isolation. Traditional leaders facilitated access to initiation schools, while initiated health professionals assisted in identifying eligible participants within health facilities.

Data collection methods: data were collected between August-September/2025 using three qualitative methods.

Focus group discussion (FGD): six FGDs were conducted: a) three with male initiates (n=25); b) three with traditional initiation schoolteachers (n=19). Each FGD consisted of 6-9 participants and lasted approximately 60 minutes. Focus group discussion were conducted in Sesotho, using a semi-structured guide exploring illness experiences, reporting practices, cultural expectations, and pathways to care.

In depth interview: in depth interview (IDIs) were conducted with; i) three traditional healers; ii) the head chief; iii) one village chief. These interviews explored governance of initiation schools, disease interpretation, and decision-making authority. Each interview lasted approximately 45 minutes.

Key informant interviews (KIIs): three KIIs were conducted with medical doctors (two male, one female) working in medical and surgical wards. Interviews focused on clinical presentations, delays in care, referral challenges, and interactions with traditional structures.

Data management and analysis: all interviews and focus group discussions were audio-recorded with participants' informed consent, transcribed verbatim, and translated from Sesotho into English. We imported transcripts into NVivo (version 15) for data management. We analyzed the data using reflexive thematic analysis, following six phases, which included first our familiarization, coding, then core theme development; afterwards, we conducted theme review, theme definition, and reporting [9]. Our analysis was primarily inductive but informed by the three-delay model of healthcare access, which guided our interpretation of delays in decision-making, reaching care, and receiving adequate care [10].

Ethical considerations: ethical approval was obtained from the National Health Research Ethics Committee of Lesotho (Ref. ID: 210-2025, 3 July 2025). Written informed consent was obtained from all participants prior to data collection, and community entry approval was obtained from the relevant traditional authority. Participant confidentiality was maintained through anonymization and the use of unique identification codes. All interviews and focus group discussions were conducted in private settings, and participants were informed of their right to withdraw from the study at any time without penalty.

Results     

Some of the themes that emerged included requirements for owning or operating a traditional initiation school; entry requirements for initiates; punishment if entry requirements were not followed, parents’ refusal to give consent, screening of health conditions, common health conditions affecting the initiates, and deaths reported; perceived causes of diseases in initiation schools; and barriers to seeking medical care.

Requirements for owning or operating the traditional initiation school: the head chief reported to have granted permission only if the following requirements were met. The adult given permission to own a traditional initiation school had no criminal record and had to have a son 18 years and above who would also join the school. The son was known as "Leisa" (traditionally the firstborn of all initiates). In the year the application was made, the one who applied had animals and enough food from the fields, such as maize, that was used to feed the initiates. Some respondents explained that: The family must have a son aged 18 years and above, and this son is known as LEISA, and in Sesotho all the initiates to join the school are said to be coming to that same son. The family must have appointed the man from the community with a good reputation, with no criminal record, and who is a farmer. The year in which the application of being allowed to own the traditional school is made, the owner must have enough food from the fields, such as enough maize, and he must have animals, as some of the animals will be slaughtered and eaten by the initiates (IDI 1 participant 1). The person applying should be well-off; he must be able to afford the needs of his family, have animals, and must be a farmer, and in the year the application is done, there should be sufficient maize. He should not have a criminal record. There should be a male child above 18 years in that family who will also join the initiation school (IDI 2 participant 2).

Entry requirements for initiates: teachers, traditional healers, the chiefs, and the students reported that only initiates aged 18 years and above, which was confirmed with a birth certificate, were admitted to the traditional school. However, the chief mentioned that sometimes initiates who were underage and were coming from remote villages used their brothers' birth certificates to be admitted to the school. Traditional healers reported that sometimes the medical records of the students were required, though they still faced challenges in getting them. This was exemplified by the quotes below: Even if we ask for Bukanas (medical record), some parents will come and say they will bring it later until we forget, then we will now see problems among students (IDI 3 participant 3). Some will say they will bring it or say it is lost while in fact they know the aim is to hide their diseases. However, sometimes if we really suspect a student, we tell the parents to go to the hospital and bring the record from the doctor showing that such a student is fit to join the school (IDI 4 participant 4). When I joined, they asked my age and requested my birth certificate to ensure I am above 18 years old. They also asked me if I have any chronic illnesses, and I have medications like those for HIV that I am taking, and I said no (FGD 3 participant 1).

Methods of punishment if entry requirements are not followed: the head chief and village chief both reported that the owner of the school and the parents who failed to abide by the admission criteria were punished. However, they stated that the punishment was based on the degree of the offense. Some of the participants had this to say: As a chief, I decide on the punishment to give; for example, the punishment depends on the degree of offence committed. But the owner of the school can be asked to pay with a cow, or a sheep, or a goat. This animal will be slaughtered and eaten by the community members. Sometimes, where initiates die because of negligence, the owner of the school may be banned permanently from continuing with the school or maybe be banned for a certain number of years (IDI 1 participant 1). We do have schools that don't adhere to the rules; for example, if the initiated child is below 18 years, both the parents and the owner of the school are punished by the head chief. He can say they should pay with a cow, sheep, or a goat. The animal will then be slaughtered and eaten by the community members. But with death due to negligence, such as the school is banned permanently or for a certain number of years (IDI 2 participant 2).

Reasons for parental refusal to give consent: teachers reported that sometimes the male child came to join the school, but when the parent was informed so that she/he could give consent, some parents refused, and their children were sent home. Reasons for refusal of consent by parents included lack of finances to cover costs associated with the school, if the male was reported to be medically unfit, or the male had not yet completed high school. The teachers also reported that some parents refused to give consent because they had a negative attitude and misconception towards the initiation schools. This was confirmed by the following respondents who said that: Parents usually refuse to give permission in cases where the child is not yet done with formal education or is sick or the parents do not have enough money to pay for the costs for the traditional school (FGD3 participant 5). Some parents just hate traditional initiation school because of the myths they hear about initiation school. For example, some parents say males from initiation schools don’t respect elders and display bad behavior after graduating from the initiation school. So, they do not want their children to have bad behaviors (FGD 1 participant 2).

Screening of diseases: teachers reported that screening of diseases was important and they inspected the medical record of students to identify if initiates had chronic illness. However, this was not effective as some students could not present their medical record booklet (bukana) as required. Some initiates and parents were reported to have intentionally avoided disclosing the health status of the children because they had the hope that the traditional healers would cure different diseases. Some students reported that they were screened for some diseases such as HIV, while others reported that they were never screened. Some participants said this in confirmation: Some will say they will bring the bukana (medical record booklet) or say it is lost, while in fact they know the aim is to hide their diseases. However, sometimes if we really suspect a student, we tell the parents to go to the hospital and bring the record from the doctor showing that such a student is fit to join the school (IDI 3 participant 3). Back then, parents were asked about the illnesses the child has so that the traditional healers could be informed, but now the teachers want us to produce our medical record (bukana) for them to confirm that we have or we don’t have a chronic illness (FGD 3 participant 4). Some students do not disclose that they are HIV positive, and they are on medication, thinking that they will get cured by joining traditional school. With time, the health condition of the student will change, and he will be sick; it is at this point that traditional medicines will be given to the student, who will not even get better. Such a student may end up dying or being taken to a clinic where it will be noticed that the student was on HIV medication (FGD 5 participant 7). We also must make sure that the initiates provide us with the medical record (bukana) because some of them hide their sicknesses, such as HIV status, epilepsy, asthma, and others, so the medical record will help us identify some diseases (IDI 2 participant 2).

Common health issues affecting initiates and deaths reported: all participants mentioned that there were some diseases that affected male initiates while at school. So, this meant that every cohort of initiates had at least sick initiates. Common diseases said by most participants included: diarrhea and vomiting associated with abdominal pain, chicken pox, pneumonia, and common cold. Asthma, pulmonary tuberculosis, injuries, and septic wounds were also reported. Below, the common conditions are explained in detail: There are many diseases affecting the students, such as abdominal pains, vomiting and diarrhea, and headaches, especially in the dry season (FGD 1 participant 5). We had chicken pox, and the owner of the school gave us calamine lotion that we applied to our bodies, and those pimples disappeared (FGD 2 participant 4). We used to have minor coughs and diarrhea. So, diarrhea was because of us eating pork, but with time it would stop after we used herbal medicine (FGD 3 participant 3). We usually see septic wounds, some cases of diarrhea and vomiting. Some initiates come with pulmonary tuberculosis symptoms and test positive for tuberculosis (KII 2 participant 2). Additionally, deaths were also reported by the initiates, traditional healers, and the teachers. Some deaths were said to have resulted from failure to disclose pre-existing diseases. Some deaths resulted from diarrhea and Pneumonia. Four respondents had this to say on the situation: There was an outbreak of diarrhea and vomiting which resulted in 2 deaths of students. It was a very bad situation as parents were very angry at school owners (FGD 4 participant 2). One student was a married man, and he died due to sejeso (cultural food poisoning associated with witchcraft) according to my assessment. As part of their culture, the student should have first held a traditional ceremony with the family before being admitted to the traditional school. The student had initially violated this cultural rule thus was withdrawn from the school to perform this ceremony where he consumed poisoned food. This cultural food poisoning was later discovered by me at the traditional school where he died (IDI 3 participant 3). One student died from pulmonary tuberculosis (PTB). We then later discovered that he had defaulted his pulmonary tuberculosis (PTB) treatment. The traditional healer used different traditional herbs to treat the initiate but failed to heal the student. He was later admitted but could not make it and passed on (FGD 6 participant 1). There was an outbreak of abdominal pain associated with diarrhea and vomiting which resulted in deaths of 2 students and the rest were rushed to the hospital for treatment. Some had to be admitted for the day (FGD 1 participant 6).

Barriers to seeking medical care: multiple barriers to accessing timely medical care by initiates were reported by most participants. The following barriers were identified by different participants.

Remote schools and infrastructure barrier: the teachers and the student reported that distance was not a barrier to reaching the health facility because they used donkeys as means of transport when they had sick initiates. Contrarily, doctors, traditional healers and the chief revealed that far distance was a barrier to receiving timely medical care. Some of them had this to say: Transport and distance are not a problem because we have donkeys that we use as a form of transport in case we need to transport the student to the hospital (FGD 1 participant 4). Money to pay for students at the hospital for them to be treated is not a problem as the owner of the school pays for the bill. Sometimes when parents are informed about the sickness of their children, they also help in settling the hospital bills with the owner of the school. Transport and the far distance from the school is not a problem because we have horses and donkeys that can be used to transport sick students (FGD 6 participant 3). No, since we want all the students to be alive, spending money on making them cured is not a problem, we do use the horses to take the students near the road where access to cars will be easy. (FGD 5 participant 6). Despite the distance, roads leading to these schools are also bad and cars can’t even reach some places with ease, so this results in delays in receiving care in case of emergency (KII 2 participant 2). Yes, distance to the health facility: some schools are in remote areas and as a result, even if nurses have to go see the ill initiates, they spend a lot of time before reaching the initiation school. This delay may result in delayed care (IDI 1 participant 1). Some of the schools are located far in the mountains and in cases of emergencies it is so difficult to transport sick initiates hence delays may lead to complications. Parents also hide chronic diseases of their children as they have a belief that they will be cured by traditional healers. So, when these diseases occur in the mountains, the traditional healer and the teachers will take time dealing with such the disease. Unfortunately, the disease will be progressing and by the time the decision to go to the clinic is reached the disease has already advanced leading to long hospital stays and increased bills (IDI 4 participant 4).

Financial barrier: the teachers reported that finances were not a barrier to seeking medical care. But the village chief contradicted and argued that financial barrier was a problem in some cases especially when money was not readily available. The respondents had this to say: We want the students to graduate and go home alive, so we do everything in our power to ensure they get the medicines required to cure the diseases. So, there is no problem in spending money to pay hospital bills for the students for them to be cured when sick (FGD 4 participant 5). Finances also contribute to delays as it is the responsibility of the owner of the traditional school to take initiates to the hospital. So sometimes he might not have the money readily available, and this can result in delayed medical care. However, the delay might be hours to 1 day (IDI 1 participant 1)

Negative attitude of health personnel: doctors and traditional healers stated that negative attitudes of health personnel towards the initiates discouraged them from seeking medical care. Both the teacher and the doctors emphasized that health personnel must change their negative attitude towards the initiates. The health personnel must also change their negative attitude towards male initiates as this also makes initiates to be afraid of disclosing their sickness with fear of being taken to the hospital. (IDI 1 participant 1). Health personnel have a very negative attitude towards initiation school and are very judgmental so communication between the health personnel and initiates can never be cordial (KII 3 participant 3). Health professionals really treat traditional healers, teachers working in the initiation school and initiates themselves badly: for example, they will be asking them in a rude way how and why they have wounds? What are the benefits of going to the traditional school? And that school is just a waste of time. After all the statements, the initiates cannot communicate freely with nurses and doctors. They really need to change how they view the Basotho culture (KII 1 participant 1).

Cultural influence: cultural beliefs were reported by the village chief to be contributing factors to seeking timely medical care. According to the law of the traditional school, initiates were only allowed to be attended to by male health professionals who were once initiated. They also reported that due to the presence of some initiated health personnel, they consulted them for advice concerning the sick initiates. Some respondents explained that: The other barrier is culture; according to our culture, initiates are not supposed to be around people who never attended the traditional school, so we really have difficulty when it comes to taking initiates to the hospital. However, of late it is now better because we have nurses who went to the Initiation School who help us with advice, and they come to see our sick initiates. In some clinics and hospitals, these nurses who attended the traditional initiation school are helping our initiates by providing them with care (IDI 1 participant 1). Yes, some diseases require immediate medical attention. For me and my people, it is easier because we have male nurses that we once initiated, so we work with them for advice. When we have sick initiates, we just call those nurses that help us identify cases that need urgent medical care. This is so helpful because we take our initiates to the clinics or hospital on time, resulting in good health outcomes (IDI 1 participant 1).

Disease interpretation: according to the traditional healers, diseases can either be because of witchcraft or a natural process. They further explained that they were able to identify diseases associated with witchcraft. Below are disease interpretations explained in detail: There is too much witchcraft in the initiation school, but we know when it’s witchcraft or not. Some diseases are a normal phenomenon, and some are related to witchcraft (IDI 5 participant 5). We interpret some diseases as normal phenomena, while others we consider as witchcraft. (IDI 4 participant 4).

Lack of knowledge about danger signs: the head chief, village chief, and students showed a concern that they couldn’t identify danger signs that needed immediate medical attention. They also made a plea that the initiated health personnel had to visit the initiation schools and provide health education concerning the danger signs to look out for among sick initiates. This was evidenced from the following quotes: We have no idea about dangerous signs to look out for. People from the health department have never visited us and discussed health issues with us. However, police men do come and visit and tell us to avoid criminal activities and teach us that we must respect each other. It would be nice to have nurses and doctors who attended the traditional school to educate us, especially because they do understand the traditional school’s culture (FGD 3 participant 8). I strongly recommend that the teachers and traditional healers be educated on the danger signs to look out for among initiates, as this may prevent unnecessary deaths (IDI 1 participant 1).  Training of teachers and traditional healers should be done to ensure they know danger signs and what to do in such cases (IDI 2 participant 2).

Perceived causes of disease in the initiation school: a number of participants highlighted a number of possible causes of diseases in initiation schools. Some of them included cultural practices, overcrowding, drinking contaminated water, hospital admission refusals by teachers, failure to disclose diseases, poor communication, and lack of inspections of initiation schools, among others

Cultural practices: the teachers reported that some cultural practices done in the traditional schools predisposed them to some health conditions. However, due to cultural rules, they requested not to explain in-depth. Some of them had this to say: Yes, some practices result in injuries/ diseases, but we cannot go deeper into those because of culture. It is not everything that we are allowed to share due to cultural beliefs and rules (FGD 4 participant 4). You know, sometimes these students become naughty, and you tell them many times to stop doing certain things, and they don’t listen. As a teacher, you end up disciplining them in the process; problems can occur (FGD 6 participant 5).

Overcrowding: some participants echoed that the schools were allowed to admit as many students as they could for as long as the owner of the school was able to feed the initiates. However, the head chief pointed out that in his catchment area he restricted the number of students to be admitted to 100 and said he was willing to reduce the number as per health personnel recommendations. Participants had different views regarding the relationship between overcrowding and the spread of diseases. Most participantS reported that overcrowding had nothing to do with the spread of diseases. While a few participants supported the fact that overcrowding led to the fast spread of diseases. The quotes below prove this point: The number of students is determined by the owner of the school; if he thinks the students are enough, he then stops admitting students, and he will say "lenaka le koetsoe," implying the horn is closed (FGD 5 participant 6). In terms of maximum number of initiates, I am open to discussion; if health personnel think 100 is a big number and they feel we should reduce it, I am ready to support them because they know best in terms of how large numbers affect communicable diseases. (IDI 1 participant 1). I don’t think large numbers can contribute to the spread of diseases because sometimes it happens that a smaller number of students is affected by many diseases than a large number. For example: I was a teacher for 100 students who were not that sick, but I also had 40 students. The 40 students became too sick; they gave me headaches and later healed (FGD 5 participant 4). Overcrowding helps in spreading diseases like tuberculosis. Poor hygienic practices when dressing the wound lead to septic wounds, and delay in seeking timely medical care results in students being seen with complications (KII 3 participant 3).

Drinking dirty/contaminated water: teachers, traditional healers and students knew that they drank contaminated water which predisposed them to diarrheal diseases. They reported that despite knowing that they needed to boil water, they didn’t. Some put it this way: Diseases like diarrhea and vomiting are common, especially in dry seasons because people tend to drink contaminated water or water that has been stagnant for a long time, which we believe is not clean (FGD 2 participant 2). Sometimes we drink water contaminated by diapers that we see but just drink and later develop abdominal pain and diarrhea (FGD 3 participant 1). Due to drinking contaminated water, our students mostly suffer from diarrhea and vomiting associated with abdominal pain. Last year, some students were infected with tuberculosis by a student who had defaulted on TB medication and didn’t disclose that he had TB. Fortunately, the sick student was sent to the hospital, where he was initiated on TB and HIV medication. Later, the clinic where he was first taking his medication made a follow-up until they discovered that he went to the traditional initiation school (IDI 5 participant 5). We are aware that we must boil it, but sometimes we become thirsty there and then, and then we feel the need to drink water as boiling it first will take time (FGD 6 participant 4).

Hospital admission refusal by teachers: in cases where the sick initiate had to be admitted to the hospital, teachers sometimes refused because the decision to agree to the admission of a sick initiate had to involve the traditional healer and the owner of the school. They also reported that sometimes they had no cell phones; therefore, they failed to communicate with the traditional healers, and as a result, they refused to give admission consent. Additionally, traditional healers voiced that they were not comfortable with their student being managed by non-initiated male health professionals, hence the refusal of admissions. Some of them had this to say: Sometimes the person taking the students to the hospital is not even anticipating that the student will be admitted and has no phone to report to the owner of the traditional school that the student has to be admitted so it is usually difficult as the decision to accept admission is not easy when he doesn’t know what the owner of the medicine (traditional healer) will say about admission of the student (IDI 5 participant 5). According to the culture, these students need to be treated by health personnel who also attended the traditional school, not just any other person; that is why it is not easy for us to accept. So sometimes we think the doctor should give medicines so that we go back with our students (IDI 4 participant 4).

Failure to disclose diseases: teachers and traditional healers affirmed that parents hid the health status of their children, and as a result, they were faced with challenges of treating such chronic diseases. The teachers urged the parents to disclose the health status of their children as they wouldn’t spend time treating them using herbal medicine. They further emphasized that failure to disclose led to avoidable deaths.

Some respondents had this to say on the situation: Sometimes some parents know the diseases their children are having but decide to hide them; then while in the initiation school such a student will start being sick, some even die, and parents start blaming us. But when we ask around, the community members where the students are coming from disclose that this child had that sickness before joining the school (FGD 6 participant 2). Some parents do not come; they just give permission over the phone, so health issues affecting their children before joining the school are unknown. So, with time, we just see the student with diseases like fitting, and when we dig deeper, we teachers discover that the child already had that disease. (FGD 5 participant 4). This issue of testing people for HIV after they have joined the school plays a crucial role, as people who had hidden their statuses will be exposed and be put on medication. Also, newly diagnosed people will be put on medication. Some people still think that by joining the school, they will have their chronic illnesses cured, as they will be attended to by traditional healers, and it is a myth they have (IDI 3 participant 3). It is my wish to have parents disclose the sickness of their children before they become students, as this can make our lives easy. We really struggle and take time using traditional medicines which sometimes fail, and this results in deaths that could be avoided (FGD 4 participant 2).

Poor communication: poor communication between the traditional healer and the teachers was seen as a contributing factor to delayed medical care. This meant that the initiates staying with the sick initiates were at risk of being infected if the disease was contagious. Some respondents explained that: Yes, we do get involved when initiates are unwell; however, sometimes we get to be involved at a later stage. So, the teachers will provide medicine; if it fails, the teachers will inform the traditional healers, and we will visit the school and see the students. We will give our medication. If it fails, we then involve the modern Doctors by taking the student to the hospital (IDI 3 participant 3). Sometimes we get to know about the disease at a very late stage, and we then take students to the hospital in their worst state. The initiates spend most of their time with teachers and know about their health more than traditional healers, so if they fail to report on time, this tends to affect the students as they will not be treated for their condition on time (IDI 4 participant 4).

Lack of inspections of the traditional initiation schools: the traditional schools were never inspected by the environmental health personnel to ascertain their safety. The environmental factors in initiation schools that caused and enhanced the spread of disease remained unknown. This is what some participants said: Traditional schools are never inspected by people from the Ministry of Health. Just community elders that are part of the committee pass by and ask about the well-being of the students (FGD 4 participant 5). Inspection by the Department of Health is not done, and maybe it could be helpful as some diseases will be identified early by nurses or doctors and be treated (FGD 5 participant 1). No inspection is done by health personnel. However, some people from the committee just pass by here and there just to find out about the wellbeing of the students. So, this person from the committee is someone who lacks knowledge about diseases, it is just someone from the community, so even if we say the students are not too well, he will not do a lot (FGD 6 participant 3).

Discussion     

This study explored health-seeking behavior among males attending traditional initiation schools in Leribe District, Lesotho, and found that access to healthcare is shaped by a complex interplay of cultural beliefs, structural barriers, and health system factors. The main delay identified in this study reflects how people understand illness and make care-seeking decisions within their everyday social and cultural worlds. When illness occurs in initiation schools, it is often seen as having spiritual or moral causes, which leads families to first seek help from trusted traditional healers and to delay turning to biomedical care. Young people may also hesitate to report symptoms early because of fear of stigma, blame, or breaking cultural expectations. Limited understanding of medical danger signs and experiences of feeling disrespected or unheard in health facilities further reduce confidence in formal services. Together, these lived experiences explain why care is often sought only when illness becomes severe, a pattern also reported in studies from Nigeria and Tanzania, where cultural beliefs and medical pluralism shape treatment choices and delay engagement with the formal health system [11-13]. Initiation schools are intentionally located in remote and mountainous areas to maintain secrecy, but this isolation makes emergency access difficult and time-consuming. Although animals such as donkeys and horses are sometimes used for transport, poor roads, long distances, and rough terrain often result in significant delays, particularly in urgent situations. Hence, when a health issue arrives, traditional healers who are  located in these extremely remote areas fill the health needs primarily, a pattern also seen in other rural and hard-to-reach populations [14,15].

Financial barriers further complicate access, as funds for transport or treatment are not always immediately available, leading to postponed referrals [16]. Even short delays were reported to worsen outcomes, especially for conditions like diarrhea, pneumonia, and tuberculosis. Economic pressures and the growing commercialization of initiation schools may further limit investment in health and safety, deepening these access challenges [17]. Experiences of negative attitudes, disrespect, and cultural insensitivity from healthcare providers often discouraged initiates and traditional practitioners from seeking care or speaking openly about symptoms. Cultural rules that required treatment by male clinicians who had themselves undergone initiation further restricted access, leading to delays, incomplete disclosure, and sometimes misdiagnosis. Similar patterns have been reported in Zambia (2021), where mistrust between traditional and allopathic providers meant collaboration occurred only sporadically, and in Ghana (2017), where skepticism between providers arose from differences in healing approaches [18,19]. In addition, weak and informal referral systems often require multiple approvals without reliable communication, further delayed hospital admissions and occasionally resulted in premature discharge. The lack of formal referral pathways represents a major policy gap, undermining timely care and continuity, especially in emergency situations [20].This study has both strengths and limitations. By using focus group discussions, in-depth interviews, and key informant interviews, the study was able to gather rich and diverse perspectives, allowing for triangulation and a deeper understanding of health-seeking behavior. However, there were also limitations. The research was conducted in a single region with a relatively small sample, which may limit the generalizability of the findings. Cultural restrictions meant that participants could only share information they felt comfortable discussing, which may have influenced the depth and scope of the data. For these reasons, the findings may not fully represent experiences in other settings, highlighting the need for similar studies in different settings to allow for comparison and validation of results.

Conclusion     

This study shows that delayed health-seeking among males in traditional initiation schools in Leribe District is driven by tightly interconnected cultural beliefs, structural barriers, and health-system weaknesses. Cultural norms around secrecy, masculinity, reliance on traditional healing, and non-disclosure of pre-existing illnesses delay decisions to seek care, while geographic isolation, poor transport, and inconsistent financial preparedness hinder timely access to health facilities. These challenges are further compounded by negative attitudes of health personnel, limited availability of culturally concordant providers, and weak referral and admission systems, resulting in preventable morbidity and mortality from conditions such as diarrhoeal disease, pneumonia, septic wounds, and tuberculosis. To address these gaps, the study recommends mandatory pre-initiation medical screening with enforced disclosure of chronic conditions, routine health education for teachers, healers, and initiates on danger signs, establishment of formal referral and emergency transport plans for initiation schools, and training of health workers in culturally respectful care, with active involvement of initiated male health professionals as liaison officers.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Mats'eliso Meriam Mohapi and Lukundo Siame conceptualized and designed the study. Mats'eliso Meriam Mohapi led data collection and field coordination. Benson Malambo Hamooya, Shike Kapanga, Nema Siame, and Kalusambu Mandumbwa contributed to study methodology, participant recruitment, and data collection support. Lukundo Siame and Shike Kapanga conducted data analysis. Tshibuabua Serge Ngoy and Chilala Cheelo contributed to data interpretation and provided critical intellectual input. Mats’eliso Meriam Mohapi and Lukundo Siame drafted the initial manuscript. All authors reviewed, edited, and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Acknowledgments     

The authors thank Mulungushi University School of Medicine and Health Sciences and the District Health Management Team in Maseru, Lesotho, for institutional support. We further acknowledge the National Health Research Ethics Committee of Lesotho for ethical oversight.

References