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Naturopathic medicine and aboriginal health: an exploratory study at Anishnawbe Health Toronto.

Health care for Aboriginal people in Canada is inadequate. Aboriginal people consistently score lower on measures of health and well-being, experience lower life expectancy and higher mortality rates than the rest of the Canadian population. (1,2) Research suggests that the way in which health care is delivered is fundamental to the success of any health care strategy in this population. (3,4) A systemic approach to Aboriginal health should reflect a holistic type of care that addresses the broad range of social and environmental health determinants, be culturally relevant, and be aligned with Aboriginal perspectives. (3-6) Despite consensus regarding the fundamental values and approaches needed for effective Aboriginal health care, there are few examples of innovative health care systems that move beyond the need to correct overt pathology. Instead a holistic system is necessary that includes care of the community, the environment and the spirit to address the wide and unique range of health-related needs of Aboriginal people in Canada. (7,8)

Anishnawbe Health Toronto (AHT; www.aht.ca), a community health centre in Toronto, Ontario, is an example of health care system innovation. AHT has incorporated a holistic health model by offering naturopathic medicine in addition to other traditional (e.g., through healers, elders,

medicine people) and conventional healing services (e.g., through physicians, nurses). AHT serves Aboriginal people regardless of history or background, including Metis and non-status Aboriginal people. The range of health care providers come together within a "Circle of Care" to improve the health and well-being of Aboriginal people in spirit, mind, emotion and body. (9) Resources and funding are provided predominantly by the Ontario Ministry of Health and Long-Term Care and AHT is accredited by the Community Organizational Health Inc. AHT services a population with a broad spectrum of health concerns with a focus on health issues relating to diabetes, mental health, abuse, homelessness, and nutrition-related disorders. (10-12) AHT is an urban centre and experiences unique challenges inherent to addressing the needs of this population. (7,13-15)

The inclusion of naturopathic medicine within the AHT model is of particular interest. Naturopathic medicine is a primary health care system which aims to prevent and treat disease and optimize health through the use of natural agents and therapies that encourage the body's innate ability to heal. The emphasis is on holistic treatment, with attention to achieving harmony in the physical, psychological, social and spiritual planes. Naturopathic Doctors (NDs) are unique in their use of conventional scientific biomedical approaches combined with knowledge derived from traditional modalities. Despite the inclusion of naturopathic medicine within the AHT model, we were unable to find evidence regarding the implementation of naturopathic medicine within Aboriginal communities. (4)

Our research question focused on exploring the commonalities and differences that exist between naturopathic medicine and Aboriginal people's perspectives on health. Specifically, the purpose of our research was to document the experiences and perceptions of providing and receiving naturopathic care within the Aboriginal community served by AHT, and some of the strengths and limitations therein.

METHODS

We used an exploratory qualitative descriptive approach to comprehensively document the understanding and experience of both providing and receiving naturopathic care, as it relates to Aboriginal health. Qualitative description involves a low inference interpretation to stay close to the words of participants and describe their experiences in terms recognizable to them.16 Following this approach, we conducted in-person interviews with individuals who had experience with the provision and receipt of naturopathic care in the context of Aboriginal health: seven naturopathic interns, three naturopathic supervisors, and seven Aboriginal patients at AHT. To ensure participants had sufficient relevant experience within the community setting, we included patients who had at least three months experience at AHT, and naturopathic interns and supervisors who had been at AHT for at least two months. We aimed for, and achieved, a maximum variation sample that included participants from a range of backgrounds, varied experience with AHT and both male and female participants (Table 1). After receiving informed consent, we conducted interviews and analyzed them iteratively following standard techniques of thematic content analysis (17) until theoretical saturation in regards to emergent analytic categories was achieved. (18)

The interviews were semi-structured, allowing for additional topics to be covered that were not originally within the interview guide (Table 2). All interviews lasted between 20 and 60 minutes, were digitally audio recorded, and were conducted in a semi-private hallway of the naturopathic clinic. The researcher (RW) who conducted the interviews is a Naturopathic Doctor (ND), but does not specialize in Aboriginal issues nor did she have a prior relationship with any of the study participants. Participants were observed for approximately one day per week for six weeks as a means to gain insight into the social context of the delivery of naturopathic medicine at AHT.

Data, including interview transcripts and participant observation records, were coded independently and then by consensus by two ND researchers (RW and KC) for perspectives relevant to our research question. The data were organized into a coding scheme that encompasses codes (representing specific perspectives on our topic), categories (groups of similar codes) and themes (concepts that run through the data and make an assertion about our topic).19,20 Data and coding were audited by a third researcher (LW) who is not an ND but has considerable experience with qualitative research. Regular meetings were held to discuss coding, key themes, and emerging issues from the data.

Finally, to enhance the credibility of our results and assess their applicability in other settings, we conducted three confirmatory interviews with NDs practicing in other Aboriginal communities across Canada. Because these interviews confirmed results emerging from our analysis of data from AHT alone, we present results from all interviews and observations collectively.

Ethics approval was received by the Research Ethics Board at the Canadian College of Naturopathic Medicine (CCNM) prior to commencement. AHT was consulted and permission was given from the executive director of AHT prior to our engaging with study participants.

RESULTS

The final analysis scheme is depicted graphically in Figure 1. Themes fell within three main categories, relating to: naturopathic medicine, AHT and CCNM, which implements the intern program at AHT. Within the naturopathic medicine category, each emergent theme encompasses data to describe the strengths of naturopathic medicine in this community. Within the AHT category, limitations perceived to inhibit the potential for optimal care from naturopathic medicine are described. Finally, within the CCNM category, recommendations regarding future implementation of naturopathic initiatives in other Aboriginal communities are provided based on the AHT experience. We describe each theme in more detail below, grouping similar themes together under the category they represent. In this paper, we have focused on elements of care that are least context dependent and most applicable to the broader community. Further, due to consistent overlap between participant perspectives (i.e., patients, interns, supervisors, community NDs), we most often describe our results with one common voice. We do, however, make distinctions between participant perspectives as they were apparent in our data.

Naturopathic medicine: Perceived strengths in Aboriginal communities

All participants, including patients, interns, supervisors and community NDs, agreed that naturopathic medicine addresses many fundamental needs of Aboriginal people in Canada. Experiences with naturopathic medicine were described in a way that intertwined these health care encounters with the personal, social and cultural context of the patient including the history of oppression and racism experienced by Aboriginal people. These issues support other research in health care for Aboriginal populations. (21,22) Participants consistently described naturopathic medicine as unique in its ability to treat each patient individually, work with their particular condition, and facilitate their ability to take control of their health. Importantly, the stereotypical power imbalance between patient and provider was diminished in many cases, with providers learning as much from their patients as patients would learn from them. Four themes--fit, needs, history and trust--emerged within this category and are described below.

Fit: Naturopathic Medicine's Suitability with Aboriginal Perspectives on Health

All participants agreed that naturopathic medicine fits well with Aboriginal perspectives, traditions and beliefs regarding the nature of health and healing. Many patients stressed the similarities between naturopathic philosophy and their personal need for health care that emphasizes all aspects of health and the connection of each part to the whole.

[FIGURE 1 OMITTED]
   [Naturopathicphilosophy is] totally in-line with my own. It's the
   connectivity. The reliance of all parts, all the parts are used to
   make the whole but the whole is reliant on every single part. So
   it's all of the parts: your emotional, your spiritual, your
   intellectual. If any part is ill then you need to recover that part
   so it can be of any use to yourself or your family or you can pass
   the healing on but you have to heal yourself. (P4)


Interns and supervisors also felt a connection between their philosophy and the needs of Aboriginal people in Canada, although they recognized some differences in language, for example:
   I think naturopathic medicine is very suited for First Nations
   because of their connection to the earth and really looking, I
   think that they look at chief concerns from a root cause point of
   view as well. They just put a different spin on it than us. (14)


Needs: Ability to Address a Range of Health Needs

Many of the patient participants stressed a need for health care providers who could address their range of physical, psychological, social and spiritual needs. They felt that the naturopathic providers at AHT took the time to listen to their health concerns, engage with them as individuals and work to develop the trust and rapport necessary for healing. Patients identified many positive outcomes associated with their experiences, including satisfaction with their individualized care.
   They didn't try and patch things up. They got to the core issue of
   stuff. They helped me look at my emotional and psychological issues
   as well as my physical issues. And they didn't just treat it, they
   went in there and looked at where it came from and how to address
   it and to view it from a more holistic approach. (P2)


History: Ability to Overcome Historical Problems and Provide Culturally Sensitive Care

A concern of several of the patients involves the history of oppression and racism experienced by Aboriginal Canadians. These participants felt that their health care providers must recognize how patients' past experiences shape current needs and experiences with the health care system. Their current health needs could not be separated from the broader social, cultural and historical context. Participants felt that naturopathic medicine is able to deliver health care in a manner that respects their past experiences, for example:
   It all goes back to the very word itself, respect, they [NDs] are
   willing to listen without intervening without contradicting you and
   contradictions in that respect would be disrespectful and
   degrading, pushing down. I deal with a lot of discrimination, with
   a lot of inaccessibility, with a lot of lying and tossing of the
   buck and it does not happen here. That's gold, and I got good
   advice with regards to a conscious diet and natural supplements ...
   [NDs] want to teach you. They do not make you feel stupid. (P3)


Trust: Reducing Power Imbalances

A final perceived strength of the naturopathic approach within the Aboriginal context is a reduction of the power imbalance that often exists between patient and health care provider. Many patient participants felt themselves as equal partners in healing; and, in many cases, providers felt they learned from their patients. For example, the perceived healing power of smudging (i.e., ceremonies to cleanse and give prayers) could then be shared with future patients. Patients also described a respect for their practitioners and a high level of comfort in discussing personal issues, an essential step towards mental and spiritual health.

AHT: Limitations to the provision of naturopathic medicine

Although all participants perceived naturopathic medicine to be clearly compatible with Aboriginal needs, a number of challenges and limitations were identified with regard to the way in which naturopathic care is provided at AHT. Importantly, many of the identified limitations were specific to the naturopathic clinic within AHT; interns and supervisors felt these could be overcome with some innovative planning and funding. The described limitations included resource constraints, space limitations, and lack of access. The constraints were seen as contrary to the philosophy of naturopathic medicine; however, interns viewed this as an opportunity to be creative in the provision of care. For example:
   I ... feel like it's teaching me how to work within stricter
   limits, with less resources and with people who have more severe
   issues. (I5)


Although interns developed somewhat effective ways to manage these challenges, all participants emphasized the limitations as serious barriers to the provision of optimal care.

CCNM: Recommendations for future naturopathic initiatives

Participants raised two main issues that could help improve the implementation of naturopathic medicine within AHT: training and communication.

Training

While participants felt their naturopathic care to be culturally sensitive, the history of oppression and racism experienced by Aboriginal people may have resulted in hostility by some patients towards their providers. Interns need to be better trained to handle these situations:
   Unfortunately there is racism ... and there are people that look at
   their interns and go 'I'm not dealing with that white woman'.
   Because I've heard it, so I'm not just thinking it, you know. (P2)


Several interns felt challenged by certain mental health problems and other complex and co-morbid conditions they had to treat. In the words of one intern:
   ... the learning curve is more also on an energetic front because
   you are dealing with a totally different type of community, you are
   dealing with homelessness. I really felt that I wasn't that
   prepared for it ... It can be really overwhelming to hear really
   sad stories, to have patients come through that have bugs crawling
   off them, to have patients who don't eat. How do you treat a
   population that doesn't have money, that doesn't have access to a
   lot of the basic things that a person with a nine to five job would
   have. It's really a different practice of medicine. (I6)


Accordingly, recommendations were made for improved training, particularly regarding the unique current and historical situation of Aboriginal people in Canada.

Communication

AHT follows a community-based approach to healing, and as such, effective communication is viewed as fundamental between patients, providers in the "Circle of Care", and the community. Participants therefore stressed the need for effective communication strategies to remain a priority for the development of a more effective health care system. Community NDs in particular addressed the importance of communication in addressing the needs of the population and to provide sustainable health care.
   The first thing is to forge relationships. The more you reach out
   and try to communicate the more trust you create and the more
   information you can share, both ways. (ND3)


Limitations of this study

This study was conducted at a single site and thus is subject to particular idiosyncrasies of that location. In addition, it is a naturopathic student teaching clinic, meaning that there are obstacles to care, such as the frequent turnover of student interns. Further, participants volunteered to participate in this study, and so might have more positive experiences with naturopathic medicine to share than others within the AHT community who did not volunteer. This issue might account in part for the consistent positive evaluation of the fit between naturopathic medicine and Aboriginal health by all participants. This result could be tested in other populations.

Despite the limitations inherent to this research, the naturopathic clinic at AHT can boast many positive patient outcomes. Each patient participant was encouraged by their experiences and improvements in health, although some concerns were voiced. The positive outcomes observed in the face of these limitations strongly suggest that the provision of naturopathic care at AHT is valuable to the population it serves. This type of facility is unique, however, and not available in many other communities. The benefit of culturally sensitive care and naturopathic medicine may be valuable in other settings, with additional attention to the needs of each individual population. Recommendations provided by participants in this study regarding training and communication might help guide the implementation of naturopathic medicine within other Aboriginal settings.

CONCLUSION

This exploratory study indicates that the naturopathic clinic at AHT is achieving positive patient outcomes and addresses specific health needs of the Aboriginal population: needs that are not apparently being met by other traditional or conventional health care providers. Naturopathic care is highly regarded by patients; however, limitations exist that interfere with the quality of care. Resource limitations, continuity of care, the need for historically and culturally sensitive care and maintaining privacy are important issues that need to be addressed.

Within this unique population, the potential for naturopathic medicine to offer an individualized and holistic approach to care, while remaining culturally relevant, became clear. Naturopathic medicine is a health care system that strives to promote health through an evidence-based model, (8) and may help address the unique health care needs of Aboriginal people in Canada.

Acknowledgements: The authors thank Joanne McCarthy for helpful input; transcribers Rochelle Fernandes and Adrian Nasager; Joe Hester, Executive Director, and the staff of Anishnawbe Health Toronto (AHT); and the study participants.

Received: July 27, 2009 Accepted: May 20, 2010

REFERENCES

(1.) Government of Canada. Report of the Royal Commission on Aboriginal Peoples. 1996.

(2.) Health Council of Canada. The Health Status of Canada's First Nation, Metis and Inuit People. 2005.

(3.) Shankar K, Liao L. Traditional systems of medicine. Phys Med Rehabil Clin N Am 2004;15(4):725-47.

(4.) Seely D, McCarthy J, Kennedy D, Rishma W, Cooley K, Grobys S, et al. Naturopathic medicine for improved health care within Canadian Aboriginal communities. Health Canada Report, Editor, First Nations and Inuit Health Branch, 2008.

(5.) Smylie J, Kaplan-Myrth N, Tait C, Martin CM, Chartrand L, Hogg W, et al.

Health sciences research and Aboriginal communities: Pathway or pitfall? J Obstet Gynaecol Can 2004;26(3):211-16.

(6.) Hunter L, Logan J, Barton S, Goulet JG. Linking aboriginal healing traditions to holisitic nursing practice. J Holist Nurs 2004;22(3):267-85.

(7.) Minore B, Katt M, Hill M. Planning without facts: Ontario's Aboriginal health information challenge. J Agromedicine 2009;14(2):90-96.

(8.) Jacklin K, Kinoshameg P. Developing a participatory Aboriginal health research project: "Only if it's Going to Mean Something". J Empir Res Hum Res Ethics 2008;3(2):53-67.

(9.) Anishnawbe Health Toronto. About Anishnawbe Health Toronto. Available at: http://www.aht.ca/about_anishnawbe_health_toronto (Accessed July 16, 2009).

(10.) Laliberte A, Tousignant M. Alcohol and other contextual factors of suicide in four aboriginal communities of Quebec, Canada. Crisis 2009;30(4):215-21.

(11.) Lemstra M, Neudorf C, Mackenbach J, Kershaw T, Nannabaneni U, Scott C. Suicidal ideation: The role of economic and aboriginal cultural status after multivariate adjustment. Can J Psychiatry2009;54(9):589-95.

(12.) O'Neil JD. The cultural and political context of patient dissatisfaction in cross-cultural clinical encounters: A Canadian Inuit study. Med Anthropol Q 1989;3(4):325-44.

(13.) King M. An overall approach to health care for indigenous peoples. Pediatr Clin North Am 2009;56(6):1239-42.

(14.) Young TK. Review of research on aboriginal populations in Canada: Relevance to their health needs. BMJ2003;327(7412):419-22.

(15.) Pyett P, Waples-Crowe P, van der Sterren A. Engaging with Aboriginal communities in an urban context: Some practical suggestions for public health researchers. Aust N Z J Public Health 2009;33(1):51-54.

(16.) Sandelowski M. Whatever happened to qualitative description? Res Nurs Health 2000;23:334-40.

(17.) Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: Sage Publications, 1998.

(18.) Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. London, UK: Sage, 1998.

(19.) Morse J, Richards L. Readme First for a User's Guide to Qualitative Methods. Thousand Oaks: Sage Publications, 2002.

(20.) Polit D, Hungler B. Nursing Research Principles and Methods. Philadelphia, PA: JB Lippincott Company, 1999.

(21.) Tang S, Brown A. 'Race' matters: Racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context. Ethn Health 2008;13(2):109-27.

(22.) Veenstra G. Racialized identity and health in Canada: Results from a nationally representative survey. Soc Sci Med 2009;69(4):538-42.

Rishma Walji, BSc, ND, PhD, [1] Laura Weeks, PhD, [2] Kieran Cooley, ND, [1] Dugald Seely, ND, MSc [1]

Author Affiliations

[1.] Department of Research & Clinical Epidemiology, The Canadian College of Naturopathic Medicine, Toronto, ON

[2.] Ottawa Hospital Research Institute, Ottawa, ON

Correspondence: Dugald Seely, The Canadian College of Naturopathic Medicine, 1255 Sheppard Ave East, Toronto, ON M2K 1E2, E-mail: dseely@ccnm.edu

Funding: First Nations and Inuit Health Branch of Health Canada

Conflict of Interest: During this research, three of the authors were employed in the research department by the Canadian College of Naturopathic Medicine (CCNM) and are NDs themselves (this research was in Naturopathic Medicine). The additional author (LW) was included on the study not only for her expertise in qualitative research but also as a third party for her objectivity in the subject.
Table 1. Research Participant Characteristics

Research                                    Age Range
Participant      Gender                     (years)

Supervisor 1     Included both male and     30-40
                   female supervisors but
                   cannot disclose gender
                   by participant as it
                   would greatly decrease
                   the likelihood of
                   confidentiality
Supervisor 2                                30-40
Supervisor 3                                30-40
Intern 1         Female                     20-40
Intern 2         Male                       20-40
Intern 3         Female                     20-40
Intern 4         Female                     20-40
Intern 5         Male                       20-40
Intern 6         Female                     20-40
Intern 7         Female                     20-40
Patient 1        Male                       30-40
Patient 2        Female                     40-50

Patient 3        Male                       40-50
Patient 4        Female                     40-50
Patient 5        Female                     30-40
Patient 6        Female                     60-70
Patient 7        Male                       40-50
Community ND 1   Female                     30-40
Community ND 2   Male                       30-40
Community ND 3   Male                       30-40

Research                                    Experience with
Participant      Health Concerns            Naturopathic Medicine

Supervisor 1     N/A                        Ranged between 6 months
                                              and 3 years at AHT
                                              (cannot disclose per
                                              participant in order
                                              to maintain
                                              confidentiality)
Supervisor 2     N/A
Supervisor 3     N/A
Intern 1         N/A                        4 months at AHT
Intern 2         N/A                        2 months at AHT
Intern 3         N/A                        2 months at AHT
Intern 4         N/A                        2 months at AHT
Intern 5         N/A                        2 months at AHT
Intern 6         N/A                        2 months at AHT
Intern 7         N/A                        2 months at AHT
Patient 1        Musculoskeletal            Seeing ND at AHT for 3
                                              months
Patient 2        Musculoskeletal,           Seeing ND at AHT for 9
                   emotional, history of      years
                   abuse, diabetes
Patient 3        Physical handicap, diet    Seeing ND at AHT for 2
                   and nutrition              years
Patient 4        Post traumatic stress,     Seeing ND at AHT for 3
                   musculoskeletal            years
Patient 5        Addiction history,         Seeing ND at AHT for 4
                   musculoskeletal,           years
                   emotional
Patient 6        Diabetes, emotional        Seeing ND at AHT for 10
                   stress                     years
Patient 7        Musculoskeletal, diet,     Seeing ND at AHT for 4
                   exercise                   months
Community ND 1   N/A                        Working part-time in
                                              Aboriginal communities
                                              for 1 year
Community ND 2   N/A                        Working part-time in
                                              Aboriginal communities
                                              for 2 years
Community ND 3   N/A                        Working part-time in
                                              Aboriginal communities
                                              for 4 years

Research
Participant      Additional Notes

Supervisor 1
Supervisor 2
Supervisor 3
Intern 1         Native background
Intern 2         2-4 patients per wk
Intern 3         2-4 patients per wk
Intern 4         2-4 patients per wk
Intern 5         2-4 patients per wk
Intern 6         2-4 patients per wk
Intern 7         2-4 patients per wk
Patient 1        Using other services at AHT for 1 year
Patient 2        Using other services at AHT for 9 years
Patient 3        Using other services at AHT for 2 years
Patient 4        Using other services at AHT for 4 years
Patient 5        Using other services at AHT for 4+ years
Patient 6        Using other services at AHT for 10 years
Patient 7        Using other services at AHT for 6 years
Community ND 1
Community ND 2
Community ND 3

Table 2. Interview Guides to Focus Interviews With Naturopathic
Interns, Supervisors and Patients at Anishnawbe Health Toronto

Research
Participant     Interview Question

ND Interns/     1.  What is it like to work at AHT?
Supervisors
                2.  Can you tell me about the population that you
                    treat at AHT?

                3.  What are the main concerns of your patients at
                    the AHT? (Probe: sociocultural issues, health
                    concerns)

                4.  How are you able to address those concerns?

                5.  What are some challenges that you face?

                6.  What resources are available to you and your
                    patients at AHT?

                7.  What would an ideal situation be for you at AHT,
                    in terms of resources, etc.? (Phrased in context
                    of previous answer)

                8.  Can you describe your treatment goals for your
                    patient population at AHT?

                9.  What is your relationship to other health care
                    providers and staff at the AHT?
                    (Probe: communication between providers,
                    integration of care)

                10. What strategies have been most effective for
                    you when working with patients?

                11. What strategies have been most effective for you
                    when communicating with other members of AHT?

                12. What has been ineffective for you when working
                    with patients?

                13. What has been ineffective for you when
                    communicating with other members of AHT?

                14. How can you compare your experiences working at
                    the AHT to other health clinics?

Aboriginal      1.  Can you tell me about your experience at AHT?
Patients            (Probe: What do you like about AHT? What do you
                    think can be improved at AHT?)

                2.  Why did you start coming to AHT?

                3.  How is your relationship with your health care
                    providers at the AHT?

                4.  How is your relationship with your ND?

                5.  What do you like about seeing your ND?

                6.  What would you like to improve (with your ND)?

                7.  How has seeing an ND influenced you?

                8.  What things has your ND been able to help you
                    with? (Probe: How? In what way?)

                9.  What has your ND not been able to help you with?
                    (Probe: What are the challenges that you still
                    face?)

                10. Ideally, what you would you like from your ND
                    services?

                11. How does your health now compare to before you
                    were seeing an ND?

                12. How do you feel about your ability to access
                    health services? Naturopathic services?

Naturopathic    1.  Can you tell me about your experience working
Doctors             with Aboriginal populations?
(confirmatory
interviews)     2.  What was the response by the community to
                    Naturopathic Medicine?

                3.  What were your biggest challenges in treating
                    Aboriginal populations with Naturopathic
                    Medicine?

                4.  How do you think Naturopathic Medicine does or
                    does not fit with Aboriginal populations?

                5.  What advice would you give for NDs working with
                    Aboriginal populations?
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Title Annotation:QUALITATIVE RESEARCH
Author:Walji, Rishma; Weeks, Laura; Cooley, Kieran; Seely, Dugald
Publication:Canadian Journal of Public Health
Article Type:Report
Geographic Code:1CANA
Date:Nov 1, 2010
Words:4423
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