**5. Poverty, illiteracy, and indigenous knowledge system effect on CVD**

Given the high cost and inaccessibility of biomedical care and medications for CVD, traditional healers are central to CVD treatment among patients in SSA [48, 49]. The spiritual underpinning of chronic diseases such as CVD, cultural beliefs, and taboos are reasons behind the preference of traditional healers over biomedicine as the first choice in some parts of SSA [50]. Consequently, it is not uncommon for individuals in the region to seek help from traditional healers to treat diabetes, hypertension, and stroke [51–53]. The belief that traditional healers are experts in treating and curing CVDs and their risk factors delays the transfer to biomedical care despite the clinical deterioration in some patients [50]. Those who transfer to biomedical care are less likely to maintain treatment compliance equivalent to traditional medicines. These culturally driven practices present the greatest threat to the treatment and control of CVDs and their risk factors [50]. Some cultural ideas partly explain the persistently low knowledge of CVDs, risk factors, and clinical symptoms in the SSA population [54]. Therefore, governments and other key stakeholder groups understanding these cultural-driven beliefs and practices are essential in devising strategies to improve health literacy in managing and controlling CVDs [55].
