Indigenous health is a worldwide concern.1,2 Irrespective of a country's level of economic development, Indigenous peoples experience worse health than the non-Indigenous population.2 The reasons behind the reported, often large, discrepancies in health status lie in the social and cultural determinants of health, including poverty, education, employment, access to health services, social exclusion, and, in some countries, lack of recognition.2,3
There is no internationally agreed definition of the term “Indigenous peoples”.2 Instead, the United Nations Permanent Forum on Indigenous Issues has developed an understanding of Indigeneity based on the following characteristics: self-identification as an Indigenous person and accepted by the community as their member; historical continuity with pre-colonial/settler societies; strong link to territories and surrounding natural resources; distinct social, economic or political systems; distinct language, culture and beliefs; form non-dominant groups within society; and determination to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities.4
The terms “indigenous healing” and “traditional healing” or “traditional medicine” are often used interchangeably to encompass all long-standing traditions, including Chinese medicine, Ayurvedic medicine and Aboriginal/First Nations medicine.5 In this scoping review, the former term will be used with a capital “I” to refer, specifically, to the traditional healing practices of Indigenous peoples, as characterized by the United Nations Permanent Forum on Indigenous Issues.4
“Integrative health care” and “integrative medicine” involve the combination of Indigenous, traditional or complementary medicine with western biomedical health care, either alongside (i.e. as an adjuvant) or integrated in some way. The extent of integration is reflected in corporate and clinical governance structures, management and service delivery, objectives and outcomes, and the health care provider's philosophy of care.6,7 Boon et al. describe a continuum of seven team-oriented models that range from parallel, consultative and collaborative practice at one end to a fully integrative approach at the other.6 In its ideal form, integrative health care is interdisciplinary, non-hierarchical and collaborative. The process of integration is facilitated through consensus building, mutual respect, and a shared vision of health that involves practitioners, patients and communities.6,8 Both empirical evidence and experience-based evidence are acknowledged and valued.9 By synergistically combining therapies and services, holistic outcomes are realized that are more than the collective effect of individual practices.7
The term “integrative heath care” is used throughout this review as being more consistent with Indigenous worldviews, which emphasise spirituality, relationships and connection to the land.10 Furthermore, the use of the word medicine in “integrative medicine” may reflect some degree of biomedical dominance and subsuming of Indigenous healing practices.7 The integration of Indigenous healing practices with western biomedicine has become commonplace in many countries in Africa, America, Asia and the Pacific.11,12 They are increasingly seen as an invaluable resource in addressing the global health crisis in low- and middle-income countries.13 Recognition and support for Indigenous healing practices in Australia and other industrialized countries have been variable.11
Indigenous Australians (Aboriginal and Torres Strait Islanders peoples) are believed to have lived on the mainland for over 60,000 years and on the Torres Strait islands for over 10,000 years.14 Prior to European settlement in 1788, there were approximately 600 different Indigenous groups with distinct languages, cultures and beliefs.14 Despite concerns that Indigenous healing practices would eventually disappear due to the impact of colonization, there is evidence of their continuing use in many parts of the country.11,15,16 The past decade has seen renewed calls for their recognition as part of an integrated, two-way or both-ways approach to Indigenous health care delivery in contemporary society.17-19 Although the notion of “two-way medicine” has been contested,20 such an approach would be consistent with the United Nations Declaration on the Rights of Indigenous Peoples.21 Current Australian Government policy acknowledges the centrality of culture in the health and wellbeing of Aboriginal and Torres Strait Islander peoples. Strategies include building a contemporary evidence base on all aspects of health care including use of traditional healing.22
Across the Tasman Sea, the Māori occupied Aotearoa New Zealand for at least 1000 years prior to colonization.10 Canada's Indigenous peoples include First Nations, Inuit and Métis (descendants of European men and First Nations women in western Canada).10 The Indigenous population of the USA comprises American Indians, Alaska Natives and Native Hawaiians.10 Although there are many similarities, including a holistic approach, Indigenous healing practices vary considerably both between and within the four countries.23-26 They encompass a wide range of methods, including use of physical techniques and medicinal plants, insects and animals, as well as ceremonies and rituals, healing songs and spiritual healing.16,27 They are used for a range of conditions including women's heath, child health, palliative care, cancer, mental health, substance use disorders and spiritual disorders.27,28
There is considerable literature on the integration of complementary medicine and traditional healing (broadly defined) with western biomedicine in these countries,29-31 yet the integration of Indigenous healing practices with biomedicine has been relatively unexplored. The social and cultural determinants of Indigenous health bring additional complexity and this area requires targeted policies and programs.2,32 Furthermore, the history of colonization means that overcoming Indigenous disadvantage is inherently political; it cannot be separated from the ongoing struggle for self-determination, human rights and the full benefits of citizenship.2,33
The objective of this scoping review is to identify, describe and map examples of integration of Indigenous healing practices with, or used alongside, western biomedical practice in Australia, Canada, New Zealand and the USA. These four high-income countries with common colonial origins are often compared and contrasted in the Indigenous health literature, as they have much to learn from one another.34,35 Findings will highlight approaches that could be translated or adapted elsewhere, as well as further avenues for research.
This scoping review will include examples of integrative health care where Indigenous healing practices are used alongside biomedicine with the explicit intention of doing any of the following:
- Managing illness (including minor ailments, serious illness and chronic disease).
- Promoting early intervention and preventing lifestyle illness and disease (including bush tucker nutrition).
- Improving holistic aspects of health and wellbeing (emotional, social or spiritual, including strengthening connection to culture).
A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, PubMed and CINAHL found no systematic reviews, existing or underway, that address this topic.
Individual participants are not a feature of the scoping review and therefore will not be considered in the selection of material.
As used in this scoping review, the term “Indigenous healing” with a capital “I” refers the traditional healing practices of Indigenous peoples, as characterized by the United Nations Permanent Forum on Indigenous Issues.4 The review focuses on the traditional healing practices of Australia's Aboriginal and Torres Strait Islander peoples, New Zealand's Māori, Canada's First Nations, Inuit and Métis, and American Indians, Alaska Natives and Native Hawaiians in the USA. ‘Biomedicine’ refers to modern medicine, also called “western medicine” or “allopathic medicine”. “Traditional and complementary medicine” is an umbrella term often applied to any healthcare practice outside the biomedical mainstream, particularly in industrialized countries, including acupuncture, chiropractic and herbal medicines.12 “Integrative healthcare” refers to the combining of indigenous, traditional or complementary medicine with biomedical healthcare, either alongside (i.e. as an adjuvant) or integrated in some way (e.g. an interdisciplinary team approach).6,7 Services offering integrative healthcare use a range of service models and provider arrangements.6,30 This review will consider the following features: governance and management, principles and values, service and program delivery, and health care personnel.
The context is health services and health care delivery settings in Australia, Canada, New Zealand and the USA, including community-based primary health and specialist services, hospital-based services, rehabilitation and palliative care.
Types of sources
This scoping review will include both research and non-research evidence. It will consider any and all of the following that meet the inclusion criteria: primary research studies, reviews and meta-analyses, reports of patient and practitioner experiences, publications by government agencies and Indigenous organizations, opinion papers and commentary.
This scoping review will adhere to the JBI scoping review methodology as described in the Joanna Briggs Institute Reviewers’ Manual.36,37
The search strategy will aim to be systematic and comprehensive, including both published and unpublished (gray) literature. A three-step search strategy will be utilized. The first step will be an initial limited search of MEDLINE and CINAHL using MeSH and other terms, followed by analysis of the text words contained in the title and abstract of the articles retrieved and the index terms used to describe the articles. A second search using identified keywords and index terms will then be undertaken across all included databases. Gray literature will be located by searching government, academic and community websites. Thirdly, the reference list of identified articles and reports will be searched for additional material. Google Scholar will be used to locate other studies by identified authors. If necessary, authors will be contacted directly for further information. It is expected that the search process will be iterative, with additional search terms and sources being incorporated as the search progresses.
The databases to be searched include CINAHL, MEDLINE, PsycINFO and SocINDEX (all using the EBSCOHost platform), Embase, Science Direct and Informit. The search for gray literature will include government websites in Australia, New Zealand, Canada and the USA, as well as Australian Indigenous HealthInfoNet and websites of the Lowitja Institute Aboriginal and Torres Strait Islander Health CRC, the National Aboriginal Health Organization in Canada, and the Indian Health Service in the USA.
See Appendix I for a search strategy example.
All identified citations will be collated and uploaded into bibliographic software EndNote X7 (Clarivate Analytics, PA, USA), and duplicates removed. Documents will be assessed against the inclusion criteria for the review, with at least two reviewers examining each record by title and abstract. The full text will be retrieved if documents meet the inclusion criteria or if further examination is necessary before exclusion. Two reviewers will independently confirm if the full text meets the inclusion criteria. Any disagreements will be decided by a third reviewer. Full text records that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix to the final scoping review report. Search results will be reported in full and presented in a PRISMA flow diagram for the scoping review process showing numbers of records identified, screened, assessed for eligibility, and included. Multiple articles and reports from the same program will be treated as one for the purposes of data extraction and presenting the findings.
This scoping review will consider studies and other documents written in the English language from 1970 onwards. That year corresponds to the beginning of the primary health care movement internationally, and establishment of the first Aboriginal community-controlled health service in Australia.20,38
Data will be extracted from documents included in the scoping review by one reviewer and verified by another reviewer. The reviewers involved in the data extraction will meet beforehand to pilot the process, considering at least two examples of each of the literature types. The data extracted will include details about geographic focus, Indigenous peoples, literature and study type, aims and questions, concepts and definitions, and main findings or conclusions, as well as findings and conclusions relevant to the review questions. As this is a scoping review, included studies will not undergo a process of critical appraisal, however limitations will be noted. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Two draft charting tables have been prepared to facilitate the extraction process: one to record the document characteristics and main findings or conclusions, and one to record data relevant to the review questions (Appendix II). The completed charting tables will form an appendix to the final scoping review report.
Findings will be presented in tabular form with narrative summaries. Examples of integration of Indigenous healing practices with western biomedicine in health services and health care delivery settings in the four countries of interest will be analyzed thematically. It is expected that the main features of the integrative health care models identified will be captured, e.g. governance and management, principles and values, services and programs, and personnel.6,30 It may also be possible to categorize the more detailed examples according to the continuum of team-oriented models of practice,6 or an alternative framework.39 Knowledge gaps will be identified.
The authors acknowledge the guidance and support given to the Bush Medicine Research Program by Frances (Auntie Fran) Bodkin, Dharawal Elder and Adjunct Fellow at the Western Sydney University Translational Health Research Institute and School of Medicine. Geoffrey Lattimore, Medical Librarian, provided valuable advice.
Appendix I: Search strategy
Example of search strategy for CINAHL using MeSH and free text words.
Appendix II: Draft charting tables
Document characteristics and main findings or conclusions
Data relevant to scoping review questions
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