Abstract
Background. The cancer toll on Indigenous Australians is alarming with overall cancer incidence and mortality rates higher and the 5-year survival rate lower for Indigenous Australians compared with non-Indigenous Australians. Meanwhile, a range of approaches to health and illness—including both complementary and alternative medicine (CAM) and traditional Indigenous medicine (TM)—are used by cancer patients. Little work has focused on Indigenous cancer patients with regard to CAM/TM use. This article reports findings from the first examination of the prevalence and profile of TM/CAM use and users among Indigenous Australians with cancer. Methods. A structured questionnaire was administered via face-to-face interviews to 248 Indigenous Australian cancer patients diagnosed with a range of cancer types. All received treatment and were recruited from 1 of 4 large hospitals located in Queensland, Australia. Results. A substantial percentage (18.7%) of Indigenous cancer patients use at least one TM/CAM for support with their care, including traditional Indigenous therapy use (2.8%), visiting a traditional Indigenous practitioner (2.8%), CAM use (10.7%), visiting a CAM practitioner (2.4%), and attending relaxation/meditation classes (4.0%). Having a higher level of educational attainment was positively associated with CAM practitioner consultations (P = .015). Women with breast cancer were more likely to attend relaxation/meditation classes (P = .019). Men with genital organ cancer were more likely to use traditional Indigenous therapies (P = .017) and/or CAM (P = .002). Conclusion. A substantial percentage of Indigenous Australians reported using TM/CAM for their cancer care, and there is a need to expand examination of this area of health care using large-scale studies focusing on in-depth specific cancer(s).
Keywords
Introduction
Cancer is the second leading cause of mortality among Indigenous Australians, and recent data (2004-2008) show that Indigenous Australians have higher cancer incidence and mortality rates than non-Indigenous Australians. 1 Such incidence and mortality rates among Indigenous Australians have been identified as rising. 2 Wide disparities exist in cancer survival between Indigenous and non-Indigenous Australians, and a recent report identified Indigenous people as 50% more likely to die in the first year after a cancer diagnosis than non-Indigenous people.3,4
In Australia, as elsewhere, a wide range of practices, technologies, and approaches to health and illness not historically associated with the dominant medical profession, medical curriculum, or publicly funded health system are available and attract much patient attention and use.5,6 A national population-based survey conducted in 2005 identified 68.9% of the Australian population as complementary and alternative medicine (CAM) users. 7 Included among such therapies and medicines beyond the mainstream of conventional services and practices are a range of CAM (such as acupuncture, chiropractic, massage, and herbal medicine among others) and traditional Indigenous medicine (TM) practices (such as bush medicine, traditional healers, singing/chanting, and external remedies).8,9 Indigenous Australians have a strong connectedness to land and their belief systems, and medicines follow lore and tradition. 10 Traditional medicines, for example, are generally botanically based, herbal remedies administered by a person accepted as qualified in the eyes of the tribe or community. 11 Indigenous bush medicine is perceived as enhancing holistic health, often signifying a reconnection to land, ancestral and spiritual roots that enhance the person’s overall wellbeing. 12 Traditional healers have a variety of roles, including providing strong spiritual and social support. 13 Whereas both broad groups of practices, medicines, and treatments house much diversity (and unlike TM the different CAM do not have an Australian Indigenous heritage), they both exist predominantly outside the publicly funded health system and practices/curriculum of the conventional medical community. 14
CAM has witnessed exponential growth over recent years, 15 and cancer care is one area where CAM (and TM outside Australia) has gained popularity among patients.16-18 Indeed, an emerging body of literature has explored the role of CAM with regard to a range of cancer patient issues and experiences, including profiles and prevalence, 17 perceived benefits for patients, 19 patient decision making, 20 and patient-practitioner communication, 21 among others. Also, in recent years, formal conventional medical bodies such as the Clinical Oncological Society of Australia have responded to the increasing popularity of CAM among cancer patients, publishing official statements on the implications of CAM use, including potential interactions with conventional medicine. 22
Unfortunately, research (focused on cancer care and beyond) has paid little attention to examining the circumstances and experiences of CAM use and practice with regard to Indigenous Australians. Moreover, amid the international literature examining the beliefs and practices of cancer patients, 23 only a very small number have focused on TM and the experiences of Indigenous Australians with cancer. Although this work has provided insights into beliefs and decision making,9,24 these studies have been invariably small-scale, secondary reviews of literature or local qualitative investigations, and this general area of Indigenous cancer care remains in need of much further empirical analysis. Among the numerous areas that require attention to ensure safe, effective, culturally sensitive delivery of services to Indigenous cancer patients is the need for critical public health/health services research providing prevalence and profile data and offering a platform for future investigations.25,26 In response to this identified gap, this article reports the findings from the first examination of the prevalence and profile of TM and CAM use and users among Indigenous Australians with cancer.
Methods
Study Setting and Participants
This study is a component of a much larger project being conducted in (the state of) Queensland, Australia, to investigate the supportive care needs of Indigenous adults with cancer. The study is described elsewhere, 27 but briefly, Indigenous adults diagnosed with cancer (any type), hospitalized, or attending a hospital outpatient clinic for cancer treatment or follow-up care were recruited from 1 of 4 large Queensland hospitals. Patients were eligible to be included in the study if they received cancer treatment before or after being enrolled in the study and were both mentally and physically capable of being interviewed. Cancer patients identified as Aboriginal and/or Torres Strait Islander in the hospital information system were approached, and their Indigenous status was confirmed (self-reported) by the potential participants prior to inclusion in the study.
Data were collected using a structured questionnaire and delivered via face-to-face interviews conducted in English at a place convenient to both participants and the interviewer. The structured questionnaire included a section on the participant’s sociodemographic characteristics (eg, age, sex, place of residence). Participants were also asked about their previous and current use of treatment(s) to treat their cancer, including surgery, chemotherapy, radiation therapy, hormone therapy, traditional Indigenous therapy, complementary medicine, and other. Participants were also asked if they accessed any community or allied health services for support with their cancer. The list of 26 services included traditional Indigenous practitioner, complementary medicine practitioner, and relaxation/meditation class.
Area of residence was determined using the postcode of place of residence and the Accessibility/Remoteness Index of Australia (ARIA).28,29 Socioeconomic status was defined using the Socioeconomic Indexes for Areas (SEIFA) 30 to classify a patient’s usual area of residence as “advantaged” or “disadvantaged.”
Data analysis was conducted using STATA version 11.1 (StataCorp, 2009). 31 χ2 Tests were used to test the association between categorical variables. However, Fisher’s exact tests were used where appropriate. Furthermore, the magnitude of the associations was determined through odds ratios and associated 95% confidence intervals, produced by logistic regression models. Statistical significance was set at α = .05.
Ethics approval for this study was obtained from the Human Ethics Committees of the Queensland Institute of Medical Research and from the 4 participating hospitals.
Results
A total of 500 Indigenous cancer patients were admitted to or attended cancer outpatient clinics at 1 of the 4 hospitals from September 2010 to December 2012. Among these patients, 396 (79.2%) were eligible for the study, and 104 (21.0%) were excluded. Of the 396 eligible participants, 295 (74.5%) were invited to take part in the study (248 were interviewed [84.1% response rate], 43 refused [10.9% refusal rate], and 100 were missed [25.2%]). The main reasons for not approaching all eligible patients were that the patient was discharged before contact was possible or the patient missed their planned outpatient appointment. After medical chart review, 4 patients were excluded from the study on account of not adhering to the treatment criteria (within the past month).
Of the 248 participants included in the study, more than half were women (56.9%); the average age of participants was 52.7 years (SD = 12.8; range = 20 to 78 years). Most participants were living with their spouses/partners or in a de facto relationship (46.3%); 33.5% were single; 12.5% were separated or divorced; and 7.7% were widowed. The majority of participants reported having an education level of junior high school (<year 12, 67.5%), being unemployed at the time of the interview (75.4%), and speaking mainly English at home (86.3%). More than half (56.1%) were classified as having advantaged socioeconomic status, and 37.1% of participants lived in an outer regional area. The most frequent cancer groups reported by participants were as follows: breast (24.2%), lung (13.7%), blood related (12.9%), digestive organs (12.5%), head and neck (8.9%), female genital organs (7.3%), and male genital organs (7.3%). At the time of the interview, 69.4% of patients were using hospital outpatient clinics.
The patients missed (n = 100, 25.2%) were similar in characteristics to the study group, in that they were mostly female (55.0%), with a mean age of 51.6 years (SD = 13.9; range = 23-92 years). However, this group was more likely to be diagnosed with female genital organ (17.0%), breast (14.0%), gastroenterological (12.0%), lung (12.0%), and blood-related (11.0%) cancers.
Of the 248 participants, 47 (19.0%) reported that they utilized at least 1 CAM for support with their cancer. Of the 47 participants, 7 (2.8%) reported that they used traditional Indigenous therapy; 27 (10.9%) used complementary medicine; 7 (2.8%) visited a traditional Indigenous practitioner; 6 (2.4%) visited a complementary medicine practitioner; and 10 (4.0%) used relaxation/meditation classes.
The association between CAM use and the demographics, socioeconomic status, and area of remoteness characteristics is presented in Table 1. A greater proportion of patients with an education level of high school or more consulted a CAM practitioner, compared with patients with an education level less than high school (P = .015). There were no other statistically significant associations. Table 2 shows the association between cancer type and TM and CAM use. There were no statistically significant associations identified.
The Association Between Demographics, Socioeconomic Status, and Area of Remoteness Characteristics and CAM Use, by Indigenous Cancer Patients in Queensland, Australia.
Abbreviations: CAM, Complementary and Alternative Medicine; OR, odds ratio; CI, confidence interval; SEIFA, Socioeconomic Indexes for Areas; ARIA, Accessibility/Remoteness Index of Australia.
OR and Associated 95% CI: association between use of traditional, and complementary and alternative medicine categories and sociodemographic and remoteness characteristics.
The Association Between Traditional, and Complementary and Alternative Medicine Use and Cancer Type, by Indigenous Cancer Patients in Queensland, Australia.
Abbreviations: OR, odds ratio; CI, confidence interval.
OR and associated 95% CI: association between use of traditional, and complementary and alternative medicine categories and cancer type.
Discussion
This article reports findings from the first quantitative analysis of the use of TM and CAM by Indigenous cancer patients in Australia. Our analysis shows that approximately 1 in 5 Indigenous cancer patients in this study used some form of TM and/or CAM. Although this prevalence is less than TM/CAM use rates among non-Indigenous populations, 7 this nevertheless remains a significant finding given that we expect to see an increase in the absolute number of cancer cases among Indigenous Australians over coming years, in line with an improvement in the life expectancy of Indigenous Australians. 32 These findings may support other work highlighting how culture, belief system, and interpretations of the meaning of illness have an important impact on peoples’ approaches to treatment. 23 Indigenous Australians’ holistic view of health may also influence their use of TM and/or CAM as bush medicine is often viewed as addressing holistic health. 12
Moreover, studies of CAM use and users more broadly—both in the context of cancer care and beyond—have consistently identified a lack of communication around CAM use between patient and conventional provider,33,34 a situation often attributed to the nondisclosure of patients and the lack of enquiry on behalf of practitioners. 35 Unfortunately, we currently know very little about the communication, disclosure/nondisclosure, or decision making of Indigenous Australians regarding TM and/or CAM use for their cancer, and this is an area for urgent research attention, given the potential for direct and indirect risks associated with some TM and CAM use. 36
Although not statistically significant, our analysis shows that traditional Indigenous therapy use appeared to be greater for women, those older than 50 years, and those from advantaged socioeconomic status. These findings do not reflect the general trends identified among non-Indigenous Australians with regard to CAM use. 37 Non-Indigenous Australians who use CAM tend to be younger, and CAM use decreases with age. Further research is required to explore the motivations for traditional Indigenous therapy use to help explain the profile of users among Indigenous Australians with cancer. Meanwhile, remoteness and education did not appear to influence the use of traditional Indigenous therapies. This is an interesting finding that requires further investigation, especially given the disparity of access to cancer services across rural and remote Australia, 38 and is in contrast to recent findings for non-Indigenous patients regarding CAM use.39-41
In line with previous research findings regarding non-Indigenous Australians’ use of CAM, 42 CAM use in our study was significantly greater for those with a higher level of education. Remoteness and socioeconomic status did not appear to influence the use of CAM among the Indigenous Australians with cancer in the study, and this is in contrast to recent findings for non-Indigenous patients regarding CAM use both generally39-41 and for their cancer. 43 Again, this finding highlights the need for further research to help establish the social determinants of CAM use among Indigenous Australians to inform practice and policy on this issue.
Our findings highlight the need to expand examination of this important area of health care use to include national-scale health studies focusing on specific cancer(s) in-depth. These findings should be considered in the context of the methodological features of the study. The reasonably large study sample and the recruitment of patients from 4 major cancer-treating hospitals ensure good representation of Indigenous cancer patients across the state of Queensland. However, it is important to bear in mind that this study included a small number of participants in some strata (eg, remote), resulting in little statistical power to assess differences. Given that more than 95% of Indigenous cancer patients are treated exclusively in the public sector, 44 we restricted our study to public hospitals. Although a potential weakness of the study is that the participation rate was 60.7% of those ascertained, our response rate was 85.4% of patients invited to take part, and this limits the potential for selection bias. Because information about TM and/or CAM use was self-reported and collected retrospectively via interviews, there is the potential for recall bias. Nevertheless, there is no reason to believe that misclassification, if any, was systematically different for TM and/or CAM use (eg, over- or underestimation of use). Finally, the study included patients who were either receiving cancer treatment or had recently completed their treatment at a public hospital; including private patients, those who refused treatment, and those who received cancer treatment over 30 days prior to the study interview may produce somewhat different results.
Conclusions
A substantial percentage of Indigenous Australians appear to use TM and/or CAM with regard to their cancer care, and this is a significant health services issue. It is important that those providing and managing conventional cancer care and services for Indigenous Australians be cognizant of the need to enquire with their patients regarding the use of TM and CAM in their ongoing efforts to provide safe, effective, and culturally sensitive care and support.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in the article was funded by a National Health and Medical Research Council Project Grant (Grant #552414).