**Background:** Indigenous populations in rural areas face significant health inequities, with high rates of infectious diseases and child mortality. In Ecuador, child mortality increased by 5.1% in the indigenous ethnic group between 2000 and 2010. Traditional healers are a key component of healthcare in these communities, but barriers exist between traditional and biomedical systems. Fever is a common symptom in children, and improving its management could reduce complications and mortality. This study aimed to improve the skills of traditional healers in managing children with fevers in rural indigenous areas of southern Ecuador.
**Methods:** The study used participatory action research (PAR) with an empowerment approach, conducted from September 2016 to December 2021 (four years). The PAR comprised four phases: (1) Observation — eight focus groups were conducted with 65 healers aged 28–70 years from Kichwa, Shuar, and Cholos Cuencanos ethnic groups, including shamans, herb-healers, midwives, and bonesetters. Clinical cases were presented to understand healers' management of children with fever. Content analysis with a phenomenological approach was used, with data coded using N-Vivo version 11. Code saturation was achieved in the third focus group. (2) Planning — based on observation results, three reflexive group sessions were held to develop a culturally adapted flowchart titled "Management of children with fever." The flowchart incorporated healers' suggestions including adding terms like "purple or bluish skin" for cyanosis. (3) Action — ten workshops were held with 56 healers (six per group, 2 hours each), covering thermometer use and interpretation, recognition of alarm signs, and patient referral. Each healer received a folder with the flowchart and a digital thermometer. (4) Evaluation — one year after training, 60 healers were surveyed to assess flowchart use, alarm sign recognition, and referral practices.
**Key Results:** In the observation phase, four main themes emerged: (1) Caring for children with fever — healers used hands to check temperature (few used thermometers), physical means (warm cloths, herbal water) for treatment, and asked about culturally specific conditions like "mal aire" and "el espanto." (2) Alarm signs — healers looked for loss of appetite, physical inactivity, altered consciousness, dehydration signs (dry mucous membranes, dry skin), and skin color changes (pallor, cyanosis). (3) Patient follow-up — healers conducted home visits, used rituals like "egg cleansing" and "diagnosis through urine," and emphasized holistic healing. (4) Referral barriers — obstacles included lack of coordination with the biomedical system, distance to hospitals, and impaired communication due to perceived power dynamics. In the evaluation phase, all 60 healers had seen at least 10 patients with fever in 12 months. Fifty percent reported using the flowchart at least once. The most observed alarm signs were inactivity and dehydration. Only 15% of healers had transferred patients to the biomedical health system, with 70% of transfers accompanied by the healer. Sixty percent of healers found the flowchart moderately understandable and useful, while 5% found it poorly understood and not very useful. A total of 120 healers were ultimately trained, including additional communities at the request of the Public Health Ministry of Ecuador.
**Clinical Implications:** This study demonstrates that participatory action research can effectively bridge traditional and biomedical health systems in indigenous communities. The co-creation of culturally adapted tools like flowcharts can improve recognition of alarm signs in children with fever and facilitate appropriate referrals. The findings support the development of training programs based on healers' needs and the integration of culturally adapted tools into local health guides. The ongoing relationship between researchers and healers, along with follow-up assessments, were strengths of the study. Limitations include reliance on focus groups rather than deeper interviews and lack of differentiation between Shuar and Kichwa cosmovisions. The results underscore the need for explicit recognition of traditional healers' roles and the creation of communication bridges to improve child health outcomes in underserved indigenous populations.