Abstract
Keywords
Introduction
Despite the increasing attention to and investment in health inequity between Native Americans and white Americans (Chin et al., 2007; Gorin et al., 2012; Lavoie et al., 2016; Lewis & Myhra, 2017; O’Keefe et al., 2021; Sequist et al., 2011; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2022; Willging et al., 2018), health disparities persist. These disparities include higher rates of diabetes, heart disease, hypertension, obesity, and stroke (Goins & Pilkerton, 2010; Harwell et al., 2001; Holm et al., 2010; Kim et al., 2012; Okoro et al., 2007; Schieb et al., 2014; Veazie et al., 2014), as well as substance use and mental health problems (Brave Heart et al., 2016).
To explain these health inequities, some scholars have drawn attention to the high rates of poverty among Native Americans, the limited access to healthcare services (Liddell et al., 2018; McKinley, Scarnato et al., 2019), and the experiences of racism (Geronimus et al., 2006) and historical trauma (Joo-Castro & Emerson, 2021). Racism in the context of receiving healthcare services in particular (Street et al., 2007; Van Ryn & Burke, 2000) may contribute to these health disparities. The intersectionality of race, gender, and social class has been found to impact the quality of healthcare (Gomez et al., 2014). In particular, Native American women with lower socioeconomic status are likely to report receiving less thorough patient education on treatment options from their providers. They would also report that providers are less likely to engage in joint decision-making in their treatment planning and unlikely to support their rights to self-determination (Gomez et al., 2014).
Perhaps as a result of historical trauma in Western healthcare Broome & Broome, 2007; Canales, 2004a; Canales et al., 2011; Gurr, 2014; Liddell et al., 2018; Theobald, 2019) and contemporary experiences of discrimination in this system, some Native Americans experience apprehension in accessing care (Broome & Broome, 2007; Canales, 2004a, 2004b; Canales et al., 2011). Experiences of racism, sexism, and classism may be related to the overrepresentation of white healthcare providers from higher socioeconomic status backgrounds (Street et al., 2007; Van Ryn & Burke, 2000). There have been efforts to address systemic racism within the healthcare system (Gorin et al., 2012; Lavoie et al., 2016; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2022). One strategy is to incorporate more culturally relevant, natural, and holistic approaches in care (Napoli, 2002; O’Keefe et al., 2021) to respond to the preferences of Native American groups and individuals (Buchwald et al., 2000; Cordova-Marks et al., 2020; Walters & Simoni, 2002). Despite these endeavors, there is little research exploring how the patient and healthcare provider relationship may impact health disparities (Cordova-Marks et al., 2020; Gurr, 2014; Liddell, 2020; Liddell et al., 2018; Theobald, 2019). Moreover, there are no existing policies that mandate services to be based in cultural humility in the care of Native American patients (Cordova-Marks et al., 2020).
In addition to poverty, barriers to accessing care, and racism, King et al. (2009) argue that social inequality is related to “colonization, globalization, migration, and loss of language and culture, and disconnection from the land, lead to the health inequalities of Indigenous people” (p. 76). In particular, some Native American people have expressed concerns that healthcare providers will not support and respect the incorporation of traditional conceptualizations of health and healing practices in treatment planning (Liddell et al., 2018; Broome & Broome, 2007; Walters & Simoni, 2002). Some Native American women have even reported experiencing their providers as condescending and paternalistic (Cordova-Marks et al., 2020; Walters & Simoni, 2002). Other Native Americans have cited a history of exploitation in research as the source of some of the ambivalence to engaging in the Western healthcare system (Gurr, 2014; Smith, 2013).
Holistic Conceptualizations of Health and Traditional Medicine
The field of holistic nursing (Thornton, 2019) is uniquely positioned to address health disparities among Native Americans in the United States (Eschiti, 2004). The American Holistic Nurse Association (1998) defines holistic nursing as “all nursing practice that has healing the whole person as its goal.” This aligns well with the preferences of many Native Americans favor holistic or natural healthcare approaches (Buchwald et al., 2000; Cordova-Marks et al., 2020; Walters & Simoni, 2002). Many Native American traditions tend to conceptualize health more broadly or holistically than Western culture. Mussell et al. (1993) define holistic health as: The vision most First Nations peoples articulate as they reflect upon their future. At the personal level this means each member enjoys health and wellness in body, mind, health, and spirit. Within the family context, this means mutual support of each other. From a community perspective it means leadership committed to whole health, empowerment, sensitivity to interrelatedness of past, present, and future possibilities, and connected between cultures. (p. 23)
The World Health Organization (2000) defines traditional medicine as: The total of knowledge, skills, and practices based on the theories, beliefs, and experiences Indigenous to different cultures, whether explicated or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement of treatment of physical and mental illness. (p. 1)
Traditional medicine and traditional ecological knowledge play a crucial role in many Native Americans’ healing practices (Isaac et al., 2018). Unfortunately, climate change has decreased access to traditional medicines, herbs, and foods for many communities (Lynn et al., 2013). Ultimately, many Native Americans prefer a combination of traditional medicine and Western medicine (Buchwald et al., 2000; Gone & Trimble, 2012). Some findings even suggest that Native Americans who identify more strongly with their cultural and tribal identity prefer more integration of traditional medicine (Buchwald et al., 2000; Canales, 2004a, 2004b).
Research indicates that culturally relevant approaches to health and well-being can ultimately lead to increased engagement and improved outcomes (Sorrell, 2020), and is valued by patients (Handtke et al., 2019). For example, research with cancer patients has found that Native American women seek out traditional forms of healing practices not only because they believe they may be effective. But also because connecting with Native American culture itself is viewed as central to the healing process (Canales, 2004a, 2004b; Struthers & Eschiti, 2004).
Traditional Practices Related to Pregnancy and Childbirth
For many Native Americans, colonization has distanced people from traditional practices and ceremonies related to pregnancy and childbirth. Rooted in racist practices (Owens, 2017), Western medicine has medicalized the experience of pregnancy and childbirth, defining pregnancy as an “illness,” which some argue has allowed for increasing social control over childbearing individuals (Conrad, 1992). For example, in the early 20th century, in an attempt to reduce maternal and infant mortality (Theobald, 2019), the United States began to require Native American women to deliver their babies in distant healthcare facilities. Due to these policies, many women faced dangerous scenarios like giving birth in transit to a medical facility (Theobald, 2019). These policies often deterred women from engaging in traditional practices like using midwives, traditional healers, and engaging in childbirth ceremonies. Some women resisted these policies and continued to using midwives and engaging in traditional practices (Theobald, 2019).
Female family members (Dalla et al., 2010) and other community members are often very involved in providing knowledge and emotional support related to childbirth and childcare in Native American families (Claudia & Curry, 1998; Gurr, 2014; Hancock, 2016; Theobald, 2019). Many Native American tribes share common beliefs related to pregnancy and childbirth including: Pregnancy is a natural life event, knowledge related to pregnancy and childbirth should be passed down through generations, and parenting begins at conception (Claudia & Curry, 1998). Historically, female family members provided knowledge and physical and emotional support during childbirth. Native American tribes have unique traditions, for example, practices related to the disposal of placentas (Long & Curry, 1998). Due to forced assimilation policies and deaths of female elders, this cultural knowledge and traditional practices have been disrupted for some Native Americans.
Barriers and Opportunities
There are many barriers to continuing the development of intervention programs and practices rooted in traditional belief systems. Impediments include a research deficit, as funding is limited in studying these approaches. Insurance companies will not offer reimbursement or coverage for these interventions without extensive literature to illustrate best practices. Furthermore, there is a lack of policies to support the incorporation of traditional medicine.
Despite these barriers, there is emerging evidence to support incorporating family members and local healers as a part of these interventions. This social support connected to holistic/natural practices may benefit the interventions themselves. For example, many Native American people do not believe that Western healthcare opposes Native American healthcare practices, but that they can be used in a complementary fashion. What is essential is that the healthcare providers act respectfully and be open-minded (Canales, 2004a, 2004b; Struthers & Eschiti, 2004). Kirmayer et al. (2003) suggest that “strengthening ethnocultural identity, community integration, and political empowerment can contribute to improving mental health” among Indigenous people. In her review “Traditional Medicine and Restoration of Wellness Approaches,” Hill (2009b) recommends “restoring traditional healing practices and knowledge [as] a pathway to both empowerment and health for communities” (p. 36). These findings call for both practices and policies to inspire change and healing in individuals, families, organizations, and communities. This study builds upon prior work by Burnette et al. (2015, 2017, 2019, 2020) in the Gulf Coast region and is informed by the framework of historical oppression, resilience, and transcendence (Burnette & Figley, 2016).
Purpose
Although the need for more holistic approaches to healthcare has received increasing attention, the particular needs and experiences of tribes in the US Gulf Coast region are underexplored. The area is highly vulnerable to environmental changes, natural disaster, and the impacts of climate change. Native tribes in the region are often not state-recognized and consequently do not receive the resources of federally recognized tribes. The aim of this study was to examine the healthcare experiences of state-recognized tribal members in the Gulf Coast. In particular, we focus on the desires of tribal members for more holistic or natural approaches to healthcare.
Research Setting
This research was conducted with a state-recognized, but nonfederally recognized Native American tribe, located in the Gulf Coast region of the United States. The tribe has a tradition of strong female leaders and support of matrilineal heritage (Vinyeta et al., 2016) and a tradition of healers who use prayers and natural medicines (combination of plants and herbs; McKinley, Figley et al., 2019). Historically, some healers also acted as midwives for the community, though this practice is less common today (Johnson & Clarke, 2004; Maldonado, 2014). It is relevant to note that, unlike federally recognized tribes, this tribe does not access healthcare services through a centralized healthcare system like the Indian Health Services (IHS). Climate change has affected many Native American communities’ healing practices, as well as having impacts socially, emotionally, spiritually, and economically (Maldonado, 2014). Food sovereignty, which is the cultural autonomy or self-sufficiency over food production systems in a community, is also influenced by environmental changes (Vinyeta et al., 2016). Food sovereignty is intimately connected to health and is also negatively affected by changes to Native American subsistence food practices (Liddell et al., 2022a, 2022b; Vinyeta et al., 2016). Although geographically dispersed, community plays a vital role for many tribal members (McKinley, Figley et al., 2019). In addition to valuing family and community, important tribal values also include generosity, being close with family members, supporting community and family members, being self-sufficient, and acting as advocates for others (McKinley, Figley et al., 2019). Tribal members simultaneously value being self-sufficient, while also recognizing the interconnectedness of family and community members and the importance of supporting those in need (McKinley, Figley et al., 2019).
Methods
Research Design
A qualitative descriptive approach to data collection and analysis was employed to ensure an accurate representation of the participants’ words (Sandelowski, 2000). Qualitative description is particularly appropriate for conducting research in partnership with participants with marginalized identities (Burnette et al., 2014; Creswell, 2007; Smith, 2013). This methodology better captures cultural understandings and meanings than other qualitative approaches (Sullivan-Bolyai et al., 2005) and has been recommended for use with this tribe by the community advisory board (CAB) and other Indigenous scholars. Similarly, the descriptive language translates easily to intervention and policy recommendations (Burnette et al., 2014; Sullivan-Bolyai et al., 2005). Additional manuscripts emerging from this research include (Buxbaum et al., 2022; Carlson & Liddell, 2022; Liddell, 2020; Liddell, 2022; Liddell & Doria, 2022; Liddell & Herzberg, 2022; Liddell & Kington, 2021; Liddell & Lilly 2022a, 2022b; Liddell & McKinley, 2022; Liddell & Meyer, 2022; Liddell et al., 2022a, 2022b, 2022c; Liddell 2023; Sheffield & Liddell, 2023).
Participants ranged from 18 to 71 years old (M = 51.7). Ninety-four percent of women reported having health insurance coverage, with 70.97% reporting private health insurance coverage. Almost 84% of these participants have one or more children (M = 2.65 children). Eighty-seven percent of participants had earned a General Education Development Test (GED) or high school degree, and 51.61% had completed a postsecondary degree.
Data Collection
This study received approval from the tribal council Institutional Review Board (IRB) and University IRB of the primary investigator (PI). The PI worked with a CAB, which consisted of tribal members, to design this study, ensure ethical conduct, recruit participants, contextualize results, and disseminate findings (Burnette et al., 2015; McKinley, Figley et al., 2019; Smith, 2013). CAB members reviewed interview questions and cocreated the semistructured interview guide. The interview guide included the following prompts: (a) “Tell me about your experiences accessing health care in your community”; (b) “Tell me about a positive or negative health experience you’ve had”; (c) “What healthcare barriers and supports exist in the community?”; and (d) “Tell me about a positive or negative interaction or relationship you’ve had with a doctor or healthcare professional.” The guide was then piloted with two tribal members.
The research team worked with CAB members to recruit participants via word-of-mouth and fliers placed in tribal centers and in the community. The PI conducted all interviews in a location chosen by the participants (Minkler & Wallerstein, 2011) between Fall 2018 and Spring 2019. The interviews were recorded and transcribed verbatim and lasted between 30 and 90 min. All participating members in the interview received a $30 gift card as compensation for their time.
Data Analysis
Utilizing NVivo (QSR International Pty Ltd., 2015), the team applied a qualitative content analysis approach (Milne & Oberle, 2005). After listening to the interviews three times, broad open codes were assigned to the data. The PI then allocated more discrete codes (Saldana, 2009) for refining the themes. For example, the general theme “provider relationships” was refined into the codes “provider communication barriers” and “not feeling welcome at hospital.”
To enhance data collection and analysis rigor, the research team applied strategies outlined by Milne and Oberle (2005). In regards to data collection, the team engaged in purposeful sampling and took steps to ensure participants felt comfortable speaking openly about their perceptions and experiences. The team transcribed the interviews accurately to ensure precision the data analysis process. Thereafter, keeping participant context in mind, the data was coded using a participant or data-driven approach, which allowed themes to emerge, rather than imposing the researcher's ideas onto the data.
Ethical Considerations
The team applied strategies of the ethical and culturally sensitive conduct of research identified by Burnette et al. (2014). The PI traveled to accommodate the needs of participants and worked in collaboration with tribal members to design and conduct the study and disseminate the findings. The study was designed to build on the tribe's strengths, maintain confidentiality, and allow for flexibility as needed. The PI avoided imposing her perspectives and instead grounded the study in frameworks of the tribal members, evident by the rigorous qualitative description approach taken to data collection and analysis. Finally, through dissemination, the team hopes to advocate and communicate the needs of the tribal members, assist members in following up on the findings, contribute to building a research network and developing infrastructure, and invest resources in the community.
The team utilized member checking. The PI contacted all participants who consented to be contacted following the completion of the study two times and presented findings at tribal council events and meetings. No participants requested that any changes be made to the findings.
Results
All participants mentioned their preferences, views about, or experiences about using natural or traditional medicine approaches (referenced 65 times). Themes emerged including: (a) preference for and use of traditional medicine, (b) resistance to western healthcare and medical system, (c) preference for holistic approaches to health, and (d) negative provider interpersonal interactions. The passages below illustrate how themes are represented in the collected interviews. Identities of participants have been deidentified and assigned anonymous IDs to ensure confidentiality.
“He Didn't Take No Medicine. They Wouldn't Go to the Doctor. They Would Treat Their Own Self”: Preference for and Use of Traditional Medicine. Many women spoke about their family members or healers in the tribe using plants or traditional medicine to treat health problems. However, many women also reported that they felt that plants and traditional medicine were no longer as common and that the names of plants or where to get them were no longer known. Participant 4 recalled her family members treating themselves with plants and traditional medicines: My dad, when he died, he was 94 maybe. He didn't have nothing wrong until he caught Alzheimer's and then he had high blood but that was it. He didn't take no medicine. They wouldn't go to the doctor. They would treat their own self…. And then some time when we had a little sore they would go on the tree, they would take a bark, and then roll that and then the water, they would put it on. Or we'd drink… they'd make a tea, a certain kind of tea that they'd give us with certain things….I'm trying to think what's that… plantain. Well this guy from Honduras, one day he was in the yard picking up that [plantain] and I said “hey, what you doing with that” and he said, “I'm going to make a tea.” I said, “we used to-use that.” Like if you stick a nail in your foot or something, they would wrap it up, you know? I remember banana leaves. I don't know why, banana leaves, but they use, but they would put like a suave and all underneath it… or for fever, [or] if you had…from being outside in the sun, or heat stroke, they say, put a banana leaf around your head.
Participant 22 described the use of roots to treat stomachaches: “They would boil some of the… I remember her [healer] doing that if somebody had stomachache or something, they'd pick up the roots. How they would call it [the name of the plant], that I don't remember. They would boil that, and make us drink that.” Although many participants recollected the use of plants as medicines, the name of the specific plants themselves were not always recalled, or the information was not passed down. These quotes highlight the tribal values of self-sufficiency and resilience, and also a wariness of Western medicine, often due to previous negative experiences. Generational changes were prominent in that older women were more likely to describe specific plants that were used. However, both younger and older women expressed a preference for traditional and holistic medicine.
“We Wouldn't Go to The Doctor. We'd Just Patch Ourselves up”: Resistance to Western Healthcare and Medical System. Many women either described their own or family members’ resistance to the western medical healthcare system. This resistance is often related to structural barriers to receiving quality healthcare, such as feeling like medical providers treated patients poorly, did not end up solving health problems, and that the system was designed to make money, not to care for patients. As discussed previously, many participants described treating themselves at home instead of going into the doctor, filling in the gaps left by the Western medical system. Participant 6 discussed not going to the doctor for minor aliments: “As far as for colds and stuff like that, we wouldn't go to the doctor. Cuts, we wouldn't go to the doctor. We'd just patch ourselves up.” Participant 22 described a family member not going to the doctor and taking care of issues herself: “She does not… She just don't feel… Does not go to the doctor, medicine herself [heal herself].” Participant 6 described taking care of herself after cutting off the tip of her finger: See I cut this finger right here [gestures to hand]. The whole finger. The whole tip end was gone, they wanted to take me to the hospital, I said “I don't think so, I ain't going to the hospital for that, so I patched it up myself.”
“We're All Kind of Like Plant-Based People”: Preference for Holistic Approaches to Health. Many of these female tribal members reported avoiding taking Western medicine, preferring a holistic or traditional approach to addressing health problems, such as changing their diet or using plants or natural remedies. These preferences reflect community values for holistic and traditional medicine. Women reported appreciating doctors and medical staff who respected this desire. Participant 18 stated that she favored traditional medicine because she felt it had fewer negative side effects: Definitely the medicines these days are like all combined with something, with another thing, which is like they come out with more [causes] symptoms than it relieves…most medicines these days are like that. And I'm like, what is this? What is this cure for, its practically nothing…. I found that…natural medicine has like less side effects and like more cures for it. But like not everybody sees things how I see them. Definitely, yes…. I was always like a nature person. Like I love the plants and I like to learn about them…. I feel like older people definitely like know more…. they should tell like their younger siblings and like their children about it, but it's not being talked about.
Participant 20 described her desire to treat her children at home when they had a cough, and to treat the symptoms more holistically: If my children have a cough, I'll do like the little honey lemon and…let's see, what's the other thing I put in there…we'll do that with the children….as far as that's concerned…I don't do a lot of medicines with the children…we try to be as holistic as possible…. I think people are now trying to go back more holistically versus…running to the doctor for everything, trying to get away from antibiotics…. we didn't…understand the importance of that until we had our first child.
Interestingly, this participant stated that she appreciated the holistic approach more once she became a parent. Participant 13 described her family's belief in the connection between faith in a Creator and doing what you can at home first using ingredients from the land when she was growing up: “So we just believed in healing. We believed in not only the Creator, God.” This participant went on to acknowledge that when she had to be treated for pneumonia as a child, she was grateful for Western medicine, although people would first still try to treat it at home: “You do thank God for the physicians and the surgeons, but you also…you do everything you can do at home first. So, soup, and everything is just off the land.” When the participant was asked if she believed that the process of natural healing was still practiced, she responded: Time has changed big time…. I find the morals are getting lost, but not the knowledge. The knowledge is, that is the same, the knowledge is to me, getting, I mean, it's keeping up with time. That's the best way to say. Just keeping up with time…Yeah. Meaning that…everything is going back to organic, back to the natural, back to the, just no perfume and man added in, a lot of them are going back to that. We have a herb lady right here. She's right here in [place name] and I go see her once in a while because I don't like… a lot of pills I don't take because of all the side effects so I rather just take a vitamin and take that, so I go and find her. So this old lady, she's 90, she goes to the doctor, they take her blood tests but they do not give her no medicine because she won't take it, she refuses to take it so she heals herself with herb[s]… Like they put me on Nexium, but I don't take that…. The old lady told me, she said, “don't be taking no Nexium, it's going to send you to the old folks home.” I done said, “Miss [name] I think you're right, I said I ain't taking that,” I said, “so what do you have for me to take” because she gives me stuff for heartburn and stuff so, I don't want none of that stuff [Western medicines]. Some of them old people, they don't understand, they think they'd better have that, you have to take that medicine or they're not going to live. It's like, it don't work like that. They need to learn how to educate them…. So I think the medicine just hurts people…. A lot of people won't go to the doctor for [because of] that. They'll try to cure themselves at home before doing that. I know my husband doesn't want to go to the doctor. He'd rather try to cure himself at home.
This participant felt that elders in the community did not fare well mentally and physically because of all the medications they were taking and stated that some people avoided the doctors because of these perceived adverse effects of receiving Western healthcare. They also noted that they felt a general need for health education, especially related to diet. Interestingly, although generational changes were noted, both older and younger women still opted for traditional and holistic medicine and a preference for self-treatment prior to visiting a doctor. Participants also expressed concerns about the adverse side effects of prescribed medications, and some felt that natural medicines had fewer harmful long-term impacts. For some participants, their desire for traditional and holistic approaches was explicitly linked to their Native American identity and was an expression of their health-related values.
“We Were Kind of Just Like Was a Tough It Out Kind of Family”: Negative Provider Interpersonal Interactions. Many women described either their own or a family members’ reluctance to see the doctor unless it was necessary. This reluctance was often related to previous negative experiences with providers or the healthcare system, compounded with the belief that many healthcare issues can be treated at home. Participant 10 stated that in her family, they only went to the doctor when it was absolutely necessary: “We would go to the doctor if we really had to, but if it was just something small, we'd stay home.” Participant 11 similarly described only going when it was perceived as needed: But as far as like a family doctor that my mom and them, or that my aunts and them would take me to, I don't ever remember that. We were kind of just like was a tough it out kind of family, you know? Or they would give me something that they've always used, and it always usually worked…My family was never one to run to the doctor every time something happened. Never like that…my in-laws are totally different. They're like, oh my God, the baby fell down. We have to go to the hospital. And then it [not being believed you are in pain] leaves you thinking, well, if you're not going to believe me, then why should I even say anything?…if I'm telling you that I was just in an accident and that the emergency room was telling you, but you know, you need to do this and you're not believing it, then who's going to believe me when, you know, the next time I have a medical emergency and it just kind of leaves you…I didn't go to the doctor for a long time after that…because, it was like, what's the point? What's the point? Because this participant's pain was not validated by her medical provider after her car accident, highlighted the deep mistrust that contributes to her uncertainty about returning for care.
Discussion
The change in the transmission of knowledge between elder and younger tribal members was of particular concern for women. Though women spoke about learning about the use of plants and natural medicines from community elders, particularly from their grandmothers, aunts and mothers, many were worried that this healer's knowledge was no longer being transmitted to future generations. Women felt that the wisdom about the natural environment was not taught to the younger generations. Women would share stories about going to a family member, usually a mother, aunt, or grandmother, who would treat minor ailments and injuries. These experiences were remembered warmly, and women disclosed using some of what they had learned in their childhood with their own children and families.
An emergent theme was a preference for avoiding Western medicine, preferring a holistic or natural approach to addressing health needs, such as changing diet, using plants or natural remedies. Women reported appreciating medical providers who respected this desire for integrated care. Women described the importance of advocating for oneself and one's family in the healthcare system. Women either described their own or family member's resistance to the healthcare system and not seeking western medical attention unless it was vital. This resistance often related to feeling like healthcare providers treated patients poorly, did not end up solving health problems, and that the healthcare system was designed to make money, not to care for patients. It also related to previous adverse experiences with providers or the healthcare system, in addition to belief that many health-related problems could be taken care of at home.
Barriers and supports in accessing healthcare were also particularly salient in women's discussion of their own or family member's resistance to the Western healthcare system. Therefore, this resistance must be viewed in context to avoid pathologizing non-care-seeking behavior. Walters and Simoni (2002) have proposed an “indigenist” stress-coping model for conceptualizing Native American women's healthcare. This model centers on women's health experiences within settler colonialism and socio-environmental contexts. Participants’ resistance often related to feeling like healthcare providers treated patients poorly, did not end up solving health problems, and that the system was designed to make money, not to care for patients. Women described either their own or a family member's reluctance to going to see the doctor unless it was necessary. Women's ambivalence in seeking care makes sense considering the long history of medical oppression Native American women have experienced (Broome & Broome, 2007).
In addition, this resistance, in some cases, related to beliefs that many healthcare problems could be taken care of at home, and reflects cultural values of self-sufficiency and caring for family members instead of institutional care. This belief is consistent with participant's preference for family caregiving and home treatment, with a strong preference for using plant and natural remedies while avoiding western medications. As a result, medical providers have also often pathologized and undermined the health of Native American people through ignoring and dismissing the holistic view of well-being and health that is often integral for many Native American people (Walters & Simoni, 2002). In addition, researchers have noted that Native American women report often being treated in a patronizing and paternalistic way by their healthcare providers (Walters & Simoni, 2002).
The desire for traditional and holistic approaches to healthcare reflects tribal and community conceptualizations of health and well-being, in addition to community support and concerns about the continuing dissemination of this knowledge to generations in the future. It also demonstrates family and tribal values, such as the importance of taking care of family members. Women reported appreciating doctors and medical staff who respected these values. Native American women with cancer are more likely to seek out traditional forms of healing practices because they believe in its efficacy and because connecting with Native American culture itself is viewed as central to the healing process (Canales, 2004a, 2004b; Struthers & Eschiti, 2004). Consistent with our findings, research has found that many Native Americans do not feel that Western healthcare is necessarily in stark opposition to Native American healthcare practices, but that they can be used in a compatible manner. The patient–provider relationship is important, and it is essential that the healthcare providers are respectful and open-minded (Canales, 2004a, 2004b; Struthers & Eschiti, 2004).
These traditions may be decreasing in part due to environmental changes to the land (Johnson & Clarke, 2004; Maldonado, 2014). Environmental changes, including climate change, have weakened the social, emotional, spiritual, and economic ties to the land many Native American people have and undercut Native American healing practices and traditions (Vinyeta et al., 2016). Rapid loss of land also undermines the intergenerational transmission of cultural knowledge among the members of this tribe (Fitzgerald, 2015). Environmental changes have, in some cases, made it so that traditional medicines and food can no longer grow in the increasingly saline soil (Fitzgerald, 2015). Though not a focus in these results, elders mentioned changes to the land in relation to their ability to grow food. Food sovereignty, which is the cultural autonomy or self-sufficiency over food production systems in a community, is also impacted by environmental changes (Vinyeta et al., 2016). Food sovereignty is intimately connected to health and is also negatively affected by changes to Native American subsistence food practices (Burnette et al., 2018; Vinyeta et al., 2016).
Going to Native American healers was a common experience for women, especially elderly tribal members. This tribe has a tradition of strong female leaders and use of traditional Native American healers (Vinyeta et al., 2016). Going to family members and traditional healers was a significant form of resilience, especially for older tribal members who often had limited access for Western medical facilities.
Eschiti (2004) identifies three approaches to addressing health disparities among American Indian/Alaskan Native (AI/AN) people, which are supported by our findings, including: (a) “providing culturally appropriate health education, (b) promoting educational opportunities in nursing for AI/AN people, and (c) mentoring nursing students and new nurses” (p.201). Given that patient perception of the quality care and health outcomes is associated with being treated by providers of the same racial/ethnic identity (Street et al., 2007; Van Ryn & Burke, 2000), investment in attracting and retaining Native American healthcare providers is essential to addressing health inequities. In addition to more Native American healthcare providers, providers of all backgrounds could benefit from additional education and training in holistic approaches to health and well-being and natural, holistic practices to care. Furthermore, policies requiring this type of education and training could contribute to the quicker adoption of these approaches (Cordova-Marks et al., 2020).
Culturally relevant healthcare programs, interventions, and practices must be created in partnership with Native American communities through community-engaged and or community-based participatory research approaches (Burnette et al., 2017; Whitbeck, 2006). This approach also allows for healthcare systems and providers to adapt their practices, policies, and their physical environment to the Indigenous people living in their communities. Though there are some shared belief systems and practices that exist among tribes (Martin, 2001), tribes have unique beliefs, traditions, and practices and have had unique experiences of colonization that impact health and well-being in unique ways (Blankenau et al., 2010). Partnering closely with tribes can help healthcare providers and systems to better tailor their approaches and physical space to the needs of those tribes. These healthcare programs and practices should be implemented across systems—with individuals, groups, organizations, and communities. They should emphasize prevention, intervention, and the integration of holistic conceptualizations of health and traditional medicine and practices (Hill, 2009; Kirmayer et al., 2003).
Limitations and Implications for Research in Holistic Nursing and Health Care
There are multiple limitations to this study. First, these cross-sectional interviews were conducted with only women and in English. This study also does not include the perceptions and experiences of healthcare providers. Despite these limitations, this study begins to fill a gap in the literature by exploring the healthcare perspectives of women who are members of a state-recognized tribe in the Gulf South. Future research is needed to explore the perceptions and experiences of other Native American tribes and healthcare providers. A longitudinal approach to interviews may shed light on changes in healthcare experiences and perceptions over time and the impact of past experiences on subsequent engagement with the healthcare system. Participants are members of a nonfederally recognized tribe and did not access medical care from a centralized provider (e.g. IHS). Not having access to IHS may have been a barrier to receiving services but may have been protective in other ways (Gurr, 2014; Theobald, 2019).
Future research should further explore the experiences of other nonfederally recognized tribes to identify similarities and differences between nonfederally recognized tribes. Finally, this research focused on understanding women's healthcare experiences, we did not specifically focus on desired changes or interventions in the healthcare system. Going forward, healthcare researchers should collaborate with state-recognized tribes to explore the development of healthcare interventions and meet the specific healthcare needs of tribal members.
Conclusion
This study addresses a dearth of research related to Native Americans’ preference for natural and holistic approaches to health and well-being and relationships with healthcare providers (Gomez et al., 2014; Street et al., 2007; Van Ryn & Burke, 2000). All of the participants in the study reported a preference for natural, holistic approaches to health. Participants shared concerns about side effects of medication, a value of self-reliance, negative experiences with healthcare providers, and reluctance to go to the doctor. These findings support the integration of a holistic conceptualization of health and traditional medicine and practices into healthcare settings to meet the needs of Native American patients. The field of holistic nursing is poised to be a leader in this area (Eschiti, 2004). Healthcare organizations may also benefit from investing resources in recruiting and retaining Native American healthcare providers, as well as providing training and ongoing coaching to all providers around cultural humility and culturally relevant healthcare practices. Many tribes are committed to and engaged in nation building—“the political, legal, spiritual, educational, and economic process through which Indigenous peoples engage in order to build local capacity to address their educational, health, legal, economic, nutritional, relational, and spatial needs” (Brayboy et al., 2012, p. 578). By reducing barriers to higher education and promoting workforce development in healthcare settings, Indigenous people can bring their beliefs, experiences, and practices into healthcare settings and impact change from within those settings. In addition, policies and funding structures that promote the integration of natural or holistic care are likely essential to the success of these initiatives. Finally, considering a holistic view of health, community-based prevention and intervention programs built in collaboration with tribal members and grounded in traditional beliefs and practices may be a useful approach in addressing health inequity among Native American people.
Footnotes
Authors’ Contributions
The third author (Jessica Liddell) conducted all aspects of the study conception and design. Material preparation, data collection and analysis were performed by Jessica Liddell. The manuscript was written in full by Sarah Reese, Jessica Liddell and Angie Dang.
Consent to Participate
All participants completed informed consent before participating.
Consent for Publication
The third author conducted all aspects of the study and consents for publication. Publication of data findings in a deidentified format has been approved by the tribal council.
Ethics Approval
Tulane University IRB approval and Tribal Council approval were granted before beginning research.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Tulane School of Liberal Arts and the New Orleans Center for the Gulf South at Tulane University.
