Abstract

Objective: This systematic review aimed to describe traditional, complementary and integrative medicine (TCIM) use among Indigenous peoples with diabetes from Australia, Canada, New Zealand and the United States (US).

Methods: A systematic search following the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) statement guidelines was conducted. Data were analysed using meta-aggregation.

Results: Thirteen journal articles from 12 studies across Australia, Canada and the US were included in the review (no articles from New Zealand were identified). Indigenous peoples used various types of TCIM alongside conventional treatment for diabetes, particularly when conventional treatment did not meet Indigenous peoples’ holistic understandings of wellness. TCIM provided opportunities to practice important cultural and spiritual activities. While TCIM was often viewed as an effective treatment through bringing balance to the body, definitions of treatments that comprise safe and effective TCIM use were lacking in the articles.

Conclusions: The concurrent use of TCIM and conventional treatments is common among Indigenous peoples with diabetes, but clear definitions of safe and effective TCIM use are lacking.

Implications for public health: Healthcare providers should support Indigenous peoples to safely and effectively treat diabetes with TCIM alongside conventional treatment.

It is well documented that Indigenous peoples in Australia, Canada, New Zealand and the United States (US) experience higher rates of diabetes1 and higher mortality rates from diabetes than their non-Indigenous counterparts.2-6 These higher rates are attributable to a range of known risk factors including, central obesity, cigarette smoking, dyslipidaemia, albuminuria, inflammation and socioeconomic disadvantage.7-11 Furthermore, the complications resulting from diabetes negatively affect one's health-related quality of life, with even mild diabetic complications being found to have a significant impact.12

People with diabetes are increasingly using complementary medicines alongside conventional diabetes care to improve their overall wellbeing.13, 14 The World Health Organization (WHO) defines complementary medicines as referring “to a broad set of health care practices that are not part of that country's own tradition or conventional medicine and are not fully integrated into the dominant health-care system”.15 Complementary medicine refers to healthcare, either self-administered or practitioner-led, and examples include massage, chiropractic and western herbal medicine.16

Indigenous culture, customs and lore often include traditional forms of healing to enhance health and wellbeing through reconnection to land, spiritual and ancestral roots.17, 18 Examples of traditional healing practices and medicines include singing/chanting, ceremonies, bush medicine, traditional healers and external remedies.17, 19, 20 The WHO defines traditional medicine as “knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health”.15 These traditional medicines and practices are usually unregulated and operate outside the public healthcare system, while complementary medicine refers to healthcare, both self-administered or practitioner-led.16 The integration of these traditional knowledges in Primary Health Care has been posited as an important part in moving forward toward health equity globally. Indeed, this is supported by both the Astana Declaration and UNESCO's Convention on the Protection and Promotion of the Diversity of Cultural Expression.21, 22

Traditional,19, 23 complementary and integrative medicines16 (hereafter, TCIM) is a catch-all phrase that includes a broad range of technologies, products, practices, practitioners, knowledge systems and approaches to healing and/or preventing illness and/or promoting wellbeing.15, 19 TCIM in the vast majority of cases are defined by their continuing provision and use beyond the routine focus of conventional medical practice.16

A recent worldwide systematic review reported the use of complementary medicines among people with diabetes ranged from 17% to 73%, with nutritional advice and supplements, herbal medicines, spiritual healing and relaxation techniques used most frequently.13 It was further reported that many people with diabetes did not communicate their complementary medicines use to their healthcare providers.13 A review of traditional medicines among North American Indigenous peoples for general health and wellbeing also found limited disclosure of use to healthcare providers.20 This is concerning due to the potential for harmful interactions and compounding effects between complementary medicines and conventional diabetes care,13, 24 missed opportunities for culturally safe care20 and the benefits of optimal integration of complementary medicines and conventional medical perspectives.

To our knowledge, there is limited evidence regarding Indigenous peoples diagnosed with diabetes use of TCIM alongside, or instead of, conventional medical practices from Australia, Canada, New Zealand and the US. This systematic review aims to describe TCIM use among Indigenous peoples with diabetes from Australia, Canada, New Zealand and the US.

Methods

A systematic review of the published literature was conducted to identify and describe TCIM use among Indigenous populations in Australia, Canada, New Zealand and the US.

Eligibility criteria

The review was limited to published articles that reported on Indigenous populations from Australia (Aboriginal and Torres Strait Islander), Canada (Aboriginal, First Nations, Inuit or Métis), New Zealand (Māori) or the US (American Indian, Native American, Alaskan Native, American Samoan, Eskimo and Native Hawaiian). As in our previous review on cancer patients,25 these countries were included due to their shared history of colonisation and disproportionally poorer health in Indigenous populations.26, 27 The Indigenous populations of these four countries comprise of many diverse groups with distinct languages, beliefs and cultural practices, however, we respectfully refer to them collectively as ‘Indigenous’ for the purpose of this review. Books or book chapters, commentaries, literature reviews, editorials, poster abstracts, dissertations, articles published in languages other than English and efficacy studies were all excluded from this review.

Search strategy

The search aimed to identify peer-reviewed literature reporting original empirical data from qualitative, quantitative or mixed-methods studies examining TCIM use by Indigenous adults (18 years and older) with a diagnosis of diabetes from Australia, Canada, New Zealand and the US.

We searched AMED, AltHealthWatch, CINAHL, EMBASE, PsychINFO and MEDLINE via PubMed for records of original research published between January 2000 and April 2020 (the year 2000 was chosen due to changes in complementary medicine and service systems that might limit the applicability of studies prior to this date).28 Keywords included using free-text terms representing: 1) Indigenous populations from and residing in Australia, Canada, New Zealand, and the US; 2) diabetes; and 3) TCIM (Table 1). Keyword selection was guided by our previous systematic review on TCIM use in Indigenous populations with cancer.20 Diabetes search terms were selected using database-specific controlled vocabulary and broad free-text terms such as ‘diabetes’. We further searched the reference lists of articles that had previously conducted systematic literature reviews on similar topics to ours (e.g. complementary medicine use), and those of articles identified for inclusion.

Table 1. Free-text terms for all databases and controlled vocabulary for CINAHL.

Search Terms

Indigenous Population Terms

[Title/Abstract search: Indigenous OR Aborigin∗ OR Torres Strait Islander∗ OR Māori∗ OR American Samoa∗ OR First Nation∗ OR Canadian Indian∗ OR Native American∗ OR American Indian∗ OR Inuit∗ OR Métis OR Eskimo∗ OR Alaska∗ Native∗ OR Aleut OR Native Hawaiian∗ CINAHL headings: Indigenous peoples OR American Samoa OR Native Americans]

Condition Term

[Title/Abstract search: diabetes CINAHL heading: Diabetes Mellitus]

Traditional, Complementary and Integrative Medicine Terms

[Title/Abstract search: complementary medicine∗ OR complementary therap∗ OR alternative medicine∗ OR alternative therap∗ OR natural medicine∗ OR natural therap∗ OR holistic medicine∗ OR holistic therap∗ OR Integrative medicine OR traditional medicine∗ OR bush medicine∗ OR traditional medicine practice∗ OR ethnomedicine∗ OR traditional healer∗ OR traditional practitioner∗ OR traditional health practice∗ OR native American medicine∗ OR Native American healing practice∗ OR spiritual treatment∗ OR medicine man OR medicine men OR native medicine∗ OR aboriginal healer∗ CINAHL headings: Alternative Health Personnel; Alternative Therapies; Research, Alternative Therapies; Detoxification, Alternative Therapy]

Review process

The systematic review process was guided by the Cochrane Collaboration29 and the Centre for Reviews and Dissemination30 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines31 as outlined in Figure 1.

Study selection and PRISMA flow diagram.

After removing duplicates, authors AG and TB independently examined titles and abstracts using Rayyan systematic review software.32 Articles not meeting eligibility criteria were excluded. All retrieved full-text articles were independently assessed by AG and TB and the reasons for excluding articles were documented and discrepancies were resolved by consensus. Extraction tables were developed by AG. AG and TB independently piloted the tables with three purposively selected articles. When consensus on data extraction was achieved, AG proceeded with the remaining data extraction independently. AG and TB met and resolved all discrepancies by consensus and consulted SL for any that could not be resolved. Extracted descriptive data were synthesised via the Joanna Briggs Institute's method of qualitative research synthesis (meta-aggregation) as it avoids re-interpreting data and attempts to accurately and reliably present the findings of included articles consistent with the intent of the original authors.33 AG piloted this approach33 and then proceeded with the synthesis of extracted findings into categories. TB reviewed the synthesis, then AG and TB met to resolve any discrepancies.

Ethics

Ethical approval was not required for this systematic literature review.

Results

Of the 176 records retrieved, 22 duplicates were removed, and 154 records were screened by title and abstract. An additional two records were identified through checking the reference lists. Of the 156 abstracts considered for inclusion, 22 full-text articles were assessed for eligibility and 13 records were subsequently considered eligible for inclusion (see Figure 1).

Characteristics of the included articles

The 13 articles represented 12 individual studies: three were conducted in Australia,34-36 four in Canada,37-40 none in New Zealand and six in the US.41-46 Our sample included two mixed-methods articles,40, 45 five qualitative articles34, 36-39 and six quantitative articles35, 41-44, 46 (including four cross-sectional, and one randomised controlled trial). Of the ten articles that reported geographical remoteness, urban35, 36, 39, 40, 43 and rural areas34, 37, 38, 41, 42 were equally represented. The included articles were conducted in a range of clinical and community settings and most contained solely Indigenous (n=8; 73%34, 36-40, 43, 44) and female participants (range=48% to 85.5%). Sample sizes varied extensively, from a small four-participant qualitative study,38 to a quantitative study with 1,543 participants of which 243 were Indigenous.35 Findings are reported only for those data that could be attributed to Indigenous participants specifically.

Few articles reported on the included participants’ type of diabetes, with only three articles reporting they sampled participants diagnosed with non-insulin dependent diabetes mellitus.35, 36, 39 Eight of the articles focused exclusively on TCIM use,35, 40-46 while the remaining articles reported TCIM use as a component of the broader research question.34, 36-39 The modalities and ‘home remedies’ considered to be TCIM varied greatly; for this reason, we are not able to report the percentage of TCIM use overall. Usage data for individual articles, where available, are reported in Table 2.

Table 2. combined summary extraction data for all included articles.

First-named Author (Year)

Indigenous population, specific nation and localitya

Sample size - whole sample/Indigenous sample (percent Indigenous)

Age

Sex (% female)

Prevalence TCIM use (overall Indigenous population usage)

Predictors of TCIM use (quantitative articles only)

United States

Arcury41 (2006)

Native Americans (two Central North Carolina counties)

697/180 (25.8%)

NIB

NIB

Native Americans and African Americans had greater odds of using food home remedies (ORs − 2.37 and 2.21, respectively) and other home remedies (ORs − 2.88 and 4.20, respectively) for diabetes care than Whites.b

Ethnicityb

Buchwald43 (2000)

American Indian/ Alaska Natives, Seattle, Washington

829/829, 60 with diabetes (100%)

NDB

NDB

42 users, and 18 non-users of traditional health practices

NDB

Grzywacz42 (2006)

Native Americans (two Central North Carolina counties)

698/181 (20.6%)

65–74 years old: 58.6% (106); 75–84 years old: 36.5% (66); 85+: 5.0% (9)

92 F; 89 M (50.8%)

60.2% of Native Americans used food home remedies; 67.9% used other home remedies (see Table 1, p. 44)

NIB

McCabe44 (2005)

Native Americans, Navajo Indians

203/203 (100%)

NR

NR

Traditional Medicine use data for 195 participants. 58 of 195 (30%) reported using traditional herbs

Participants who travelled ≥ 60 min to reach clinic significantly more likely to use traditional herbs than those who travelled ≤ 30 min (p<0.02)b

Schoenberg45 (2004)

Native Americans, Great Lakes Indians

80/20 (20%)

Mean: 66.15 SD: 5.88

60% F; 40% M

15% used CM

“No differences in these multiple use patterns were distinguishable.” P.1064

VillaCaballero46 (2010)

Native Americans

806/63 (7.9%)

NIB

NIB

“Native Americans were significantly more likely to use American ginseng and aloe vera compared to Caucasians… [traditional] Healers were used almost exclusively by Native Americans…”p.246b

NIB

Canada

Barton37 (2005)

Canadian Aboriginals, Nuxalk Nation, Bella Coola Valley, British Columbia

8/8 (100%)

NR

5 F; 3 M (62.5%F)

“For all of the participants, the use of both western and traditional medicines was commonplace.” P.243

NA

Barton38 (2008)

Canadian Aboriginals, Nuxalk Nation, Bella Coola Valley, British Columbia

4/4 (100%)

NR

3 F; 1 M (75%F)

NA

NA

Sherifali39 (2012)

First Nations, Hamilton, Ontario

(79.2% with diabetes, 20.8% caregivers) (100%)

Ages ranged from 34 years to 83 years.

(85.5% F)

NA

NA

Waldram40 (2000)

Canadian Aboriginals, Saskatoon (Plains Cree, Saulteaux, Northern Cree, Metis and Other Nations)

60/60 (100%)

Female mean − 47; Male mean − 55; median and SD NR

31% M; 69% F

34% had taken some form of Indian medicine in the past to treat their diabetes; 10% actively taking Indian medicine at time of interview; 19/60 have taken Indian medicine for diabetesb

NR

Australia

Dussart34 (2009)

Aboriginal Australians, Warlpiri, Central Australia

84/84 (plus 14 family members) (100%)

range: 16 to 81; 16–29 − 19%; 30–49 − 25%; 50–69 − 35%; 70–81 − 21%b

60 F; 24 M (71.4%F)

NA

NA

Thompson36 (2000)

Aboriginal Australians, Melbourne, Victoria

52/52b (100%)

Ages ranged from 20 years to 50 yearsb

12 F; 13 M with diabetes (48%F)

NA

NA

Yarash35 (2020)

Aboriginal Australians (Fremantle, Western Australia)

1543/approx. 243 (15.7%)

NIB

NIB

Of 672 complementary medicine users, 17.1% identified as Aboriginal, approximately 115 people.

“CM use amongst… Aboriginal Australians …was less likely than those from other ethnic backgrounds.” p.8. Odds ratio 0.21 (0.10–0.44), p<0.001. p.21.

Notes: Abbreviations: CM, Complementary Medicine; NA, not applicable; NDB, no disease breakdown; NIB, no Indigenous breakdown; NR, not reported; TCIM, Traditional, Complementary and Integrative medicine; F, Female; M, Male. a: if supplied in article b: abbreviated for table, see source article for more detail.

Factors affecting TCIM use was reported by five articles.35, 41, 42, 44, 45 Two articles reported no distinguishable differences in patterns of use by education, gender/sex, age, duration of diabetes, ability to speak and understand English or insulin use.44, 45 One article with urban Native Americans found those who travelled for more than 60 minutes to access healthcare were more likely to use herbal medicines than those who only needed to travel for 30 minutes or less.44 Similarly, another found that older adults with diabetes living in open country, a category in which Native Americans were over-represented, were more likely to use home remedies than those living closer to towns.42 One article found Native Americans were more likely to use TCIM than ‘whites’41 while another reported Aboriginal Australians were less likely to use TCIM than people from other ethnic backgrounds (odds ratio 0.21 (0.10–0.44), p<0.001).35 Lastly, one article found that approximately 20–35% of the difference in food and other home remedies use between Native Americans and whites was explained by the availability of care, economic hardship and health disparities (which the authors collectively called structured inequalities). Furthermore, the authors found ethnic differences in home remedies use persisted even after controlling for structural inequalities, so they suggest that cultural explanations (not explored in their research) are likely to explain these differences in use.42

Descriptive data synthesis of findings

Following meta-aggregation, thematic analysis revealed three broad themes: 1) Types of TCIM used; 2) Reasons for TCIM use; and 3) TCIM co-treatment. The Indigenous population, specific Indigenous nation and locality (if supplied in the article) and country is provided alongside each extract.

Types of TCIM used

Participants reported using multiple types of TCIM to treat their diabetes condition. There were large variances across the articles in what was classified as being a traditional or complementary medicine. The most widely used complementary medicines reported in two articles (one study) among older rural adults with diabetes included other home remedies (67.9% of participants) such as tobacco, WD-40, Epsom salts, Vic's VapoRub, liniments, salves, kerosene or turpentine, and motor oil.41, 42 Food Home Remedies (60.2%), such as honey, lemon and garlic baking soda, yeast, teas or whiskey were also widely used among these rural participants.41, 42 Although Arcury and colleagues (2006) provided specific usage statistics of other home remedies and food home remedies, this was not broken down by Indigenous status. However, yeast, teas, whisky, tobacco, kerosene/turpentine, WD-40 and motor oil were all used by fewer than 10% of all the participants (African American n=220, Native American n=180, White n=297). Furthermore, these articles provided little detail on what purpose many of the remedies served for the participants. For example, kerosene and turpentine were reported to be “used topically on wounds and orally for colds”, and WD-40 was “used to relieve joint pain”.41(pS65) Other remedies were merely listed as being for either health purposes or diabetes care.

These home remedies differ from other articles that reported on traditional medicine use, which included various ceremonies, topical and ingested remedies traditionally used by the respective Indigenous populations:

From a traditional perspective, this included the use of food and medicinal plants, and ceremonial practices such as healing circles.37 Canadian Aboriginals, Nuxalk Nation, Bella Coola Valley, British Columbia, Canada

Examples provided included taking herbal medicine, smudging, and participating in specialised healing or sweat lodge ceremonies.43 American Indian/Alaska Natives, Seattle, Washington, US

“Religious or spiritual… [traditional medicines] … were also grounded in cultural background. Several Native American respondents recommended involvement in sweat lodges, native healing ceremonies, and dance rituals.45 Native Americans, Great Lakes Indians, US

… Aboriginal spiritual ceremonies, especially sweat lodges40 Canadian Aboriginals, Saskatoon (Plains Cree, Saulteaux, Northern Cree, Metis and Other Nations), Canada

The use of herbal and tea-based remedies was commonly reported throughout the included articles (eight of the 13 articles reported this use):

27 different plants identified – sage most frequently mentioned (15%) with cedar/juniper at 10%.44 Native Americans, Navajo Indians, US

… water and old man weed …; water, apple cider vinegar, extracts from the tree or old man weed.36 Aboriginal Australians, Melbourne, Victoria, Australia