Indigenous Consultation-Fee Disclosure and Subsequent Biomedical Referral Among Togolese Ewe Diviners: A Factorial Vignette Estimation of Payment Framing and Referral Deferral

The study treats referral deferral as a decision-theoretic outcome under conditions of fee dependency and reputational risk, and proposes a factorial vignette design capable of estimating the causal effect of payment framing on deferral. Because no primary observational data were collected, the analysis characterises the operating characteristics of a before-after-control-impact estimator under a declared variance structure: between-cluster standard deviation of 6.0, residual standard deviation of 4.5, and intraclass correlation of 0.64. Power was estimated across 2000 design cells spanning cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The design achieves 80% power to detect a 5-percentage-point effect at 54 clusters. Fee disclosure is not a neutral administrative act but a framing device that alters the perceived cost of referral, and that the proposed design can identify this framing effect while accommodating the clustered structure of diviner practice. The contribution is a methodologically explicit framework for studying referral behaviour in indigenous therapeutic systems without requiring the researcher to treat diviners as either gatekeepers or obstacles to biomedical care.