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Use of Native American Healers Among Native American Patients in an Urban Native American Health Center
Anne M. Marbella, MS;
Mickey C. Harris, PhD;
Sabina Diehr, MD;
Gerald Ignace, MD;
Georgianna Ignace
Arch Fam Med. 1998;7:182-185.
ABSTRACT
To gain an understanding of the prevalence, utilization patterns, and practice implications of the use of Native American healers together with the use of physicians, we conducted semistructured interviews at an urban Indian Health Service clinic in Milwaukee, Wisc, of a convenience sample of 150 patients at least 18 years old. The mean age of patients was 40 years, and the sex distribution was 68.7% women and 31.3% men. Thirty tribal affiliations were represented, the largest groups being Ojibwa (20.7%), Oneida (20.0%), Chippewa (11.3%), and Menominee (8.0%). We measured the number of patients seeing healers and gathered information on the types of healers, the ceremonies used for healing, the reasons for seeing healers, and whether patients discuss with their physicians their use of healers. We found that 38.0% of the patients see a healer, and of those who do not, 86.0% would consider seeing one in the future. Most patients report seeing a healer for spiritual reasons. The most frequently visited healers were herbalists, spiritual healers, and medicine men. Sweat lodge ceremonies, spiritual healing, and herbal remedies were the most common treatments. More than a third of the patients seeing healers received different advice from their physicians and healers. The patients rate their healer's advice higher than their physician's advice 61.4% of the time. Only 14.8% of the patients seeing healers tell their physician about their use. We conclude that physicians should be aware that their Native American patients may be using alternative forms of treatment, and they should open a respectful and culturally sensitive dialogue about this use with their patients.
INTRODUCTION
Native American communities are challenged by many significant health problems. The 1992 age-adjusted mortality rates for Native Americans were greater than the age-adjusted mortality rates for non–Native Americans by 340% for tuberculosis, 447% for alcoholism, and 154% for diabetes mellitus.1 Native Americans also have higher mortality rates from accidents (168%), homicide (34%), and suicide (42%) than non–Native Americans.1
The traditional health and healing practices of Native Americans remain an important factor in many of their lives.2-3 Little is understood, however, about how these practices can affect the health care of Native American patients. Coulehan4 presented 3 case reports from his experiences while serving the residents of a Navajo reservation in Arizona. He found that integrating traditional healing practices into his medical practice resulted in more efficacious treatment of his Native American patients.
Several models have been developed and approaches have been suggested to improve communication and understanding between physicians and patients from different cultures.5-8 A model described by Kramer9 serves as the basis of this project. Kramer describes forming a "miniethnography" of the patient population being served to avert possible cross-cultural misunderstandings in the health care of patients. This study's purpose is to focus efforts on this high-risk population and to begin the formation of an ethnography of the Native American patients being served by the participating clinic by looking at their use of alternative healers.
METHODS
A cross-cultural research advisory group was formed to develop a patient questionnaire on the use of healers. The group included 3 members of the Department of Family and Community Medicine: a family medicine physician (S.D.), a community health worker (M.H.), and an epidemiologist (A.M.) and several members from the Native American community: a Native American physician (G.I.), a Native American patient educator from the participating clinic, and a Native American person who had sought care from both healers and physicians. Involving Native Americans in the research group ensured the development of a patient survey form that would be relevant, clear, and meaningful to those being surveyed. In addition to survey development, the advisory group provided recommendations on how to implement the study in the clinic setting so that the patients would feel that they had enough privacy to speak openly about the issues and that the patient flow of the clinic would not be disturbed.
The survey instrument developed by the advisory group included both structured and open-ended questions. The open-ended questions were added to provide the patients with opportunities throughout the interview to share their personal experiences about encounters with their healers. The demographic information collected included age, sex, and tribal affiliation. The information relating to the use of traditional Native American healers and conventional medical physicians included the following: the use or desired use (or both) of traditional healers, the types of healers used, rites and ceremonies the patient participated in, the reasons for seeing healers, ratings of the advice of healers and physicians, and whether their physician was told about the concurrent use of healers.
The sample size was calculated using a point estimate table.10 An earlier study, a cross-sectional survey of the United States,11 reported a 34% use of alternative medical therapies with a confidence interval of 31% to 37%. Estimating a similar use among our study participants, with a 95% confidence interval and a margin of error of ±.08, the sample size table indicated that surveying 150 persons would give a good estimate of the prevalence of use of Native American healers in our population.
The study site was the Milwaukee Indian Health Center, located on the near south side of Milwaukee, Wis. The center provides a full range of health care for Native American patients of all ages and both sexes, including physical examinations, immunizations, prenatal care, obstetrics and gynecology, minor trauma, and infections. All patients older than 18 years receiving medical care at the clinic were eligible to participate, and patients seen in the clinic more than once during the data collection period were interviewed only once. Both the investigators' institution and the participating clinic approved the informed-consent application for the project, which included a guarantee that persons participating in the study would remain anonymous. Two Native American part-time research assistants were hired to conduct the patient interviews at the clinic. The assistants obtained signed informed consent from the patients before the interview, and they were trained in asking both the structured and open-ended questions on the interview form. Patients were recruited by the assistants from the waiting room before their visits with their physicians and taken to a private room for the interview. The method of recruiting patients in this study was that of convenience sampling; patients who happened to be scheduled for a physician's appointment on the days that the research assistants were in the clinic were the ones recruited for the study. The assistants interviewed the 150 patients between July 1, 1994, and March 31, 1995; each assistant completed about half of the interviews. Each patient in the study was assigned an identification number, and no names were included on the interview forms to ensure confidentiality.
Data from the patient survey were entered into a database (FoxPro 2.6, Microsoft, Seattle, Wash), and analyses were conducted using a statistical analysis software package (SAS 6.10).12 Analyses involved tabulations of healer use and cross-tabulations of demographic information with healer use.  2 Analyses were run on categorical data, and 2-tailed t tests were run on continuous data to determine if there were statistically significant differences in healer use among the different demographic groups.
RESULTS
The mean age of the study population was 40 years, with a range of 18 to 83 years. The sex distribution was 68.7% women and 31.3% men, which is representative of the overall clinic population. There were more than 30 tribal affiliations represented in the study population; the largest groups were Ojibwa (20.7%), Oneida (20.0%), Chippewa (11.3%), and Menominee (8.0%).
Of the 150 patients, 57 (38.0%) reported seeing a traditional healer in addition to seeking care from a physician, and of those who were not currently seeing a healer, 90 (86.0%) reported that they would consider seeing a healer in the future. More female patients (43 [41.7]) sought additional care from healers than male patients (14 [29.8]). Older patients were more likely to seek care from healers (46.6%) than younger patients (29.9%); this difference is statistically significant at P<.05 (Table 1).
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Table 1. Frequency of Use of Healers by 150 Patients in an Urban Family Practice Clinic*
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Among those seeing healers, the most frequently mentioned were spiritual healers (50.9%); herbalists were mentioned by 42.1%, and medicine men were mentioned by 28.1% (Table 2). These percentages add up to more than 100.0 because some patients reported seeing more than 1 type of healer. There are no standard definitions for the variety of healers within the Native American communities,13 and the different types of healers mentioned by the interviewees represent more their tribe's name for a healer than a specific set of services. Sweat lodge ceremonies, herbal remedies, and spiritual healings were the most common therapeutic activities that the patients participated in when seeing their healer (Table 3). Other frequently mentioned healing rites included pipe, drum, and naming ceremonies.
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Table 2. Types of Healers Seen by 93 Native American Patients
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Table 3. Rites and Ceremonies in Which 93 Native American Patients Have Participated
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Among those who see a healer, we asked an open-ended question about what they were seeking in their encounters with their healers. Most responses dealt with spiritual aspects such as spiritual well-being, guidance, truth, balance, reassurance, and cleansing of oneself. Only 5 of those seeing a healer said that they were seeking physical well-being only.
More than a third of the patients seeing healers report receiving different health advice from their physician and healer for the same condition. The dilemma most often described by the study participants involved the decisions they made to take either the herbal remedies suggested by the healer or the medicines recommended by the physician. The patients rate their healer's advice higher than their physician's advice 61.4% of the time (Figure 1). Only 14.8% of the patients seeing healers tell their physician about this use. Although a few patients think their physician would understand, most patients who use healers think the physician would be skeptical or uncomfortable with the patient's use of healers. Several of the comments by the patients included, "the physician wouldn't understand," "the physician would think that it was primitive," "the physician would want to know too many details," and "the physician would not believe what the healer could accomplish."
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Patients' comparisons of advice from physicians and healers.
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COMMENT
There are some limitations to this study. The use of traditional healers was self-reported, which could result in overreporting or underreporting. The use of Native American research assistants to conduct the interviews and the guarantee of confidentiality to patients were attempts to increase the likelihood that they would feel more comfortable about sharing their experiences. Also, this was a convenience sample from a single office site, which could limit the generalizability of the findings.
This is the first study to gather detailed information from Native American patients about their concurrent use of traditional healers and physicians. The study found that among an urban Native American population, 38.0% of those interviewed currently use healers in concordance with physicians. This proportion in our population is similar to that found by others11 of 34% (95% confidence interval, 31%-37%) using "unconventional therapy" among a survey of 1539 subjects across the country.
The large number of patients describing concurrent use of healers or possible concurrent use in the future indicate that many patients are or will be getting advice from outside the clinic, which could affect the health care that they receive at the clinic. The fact that several patients report receiving conflicting advice from their healers and physicians is a concern. Yet, it does not need to be a problem if there is open communication between the patient and physician. The physician will have a more comprehensive understanding of the patient's mental and physical status if time is taken to elicit information on social and cultural aspects of the patient's life relating to health.
Most patients report seeing a healer for spiritual reasons. These findings support the anecdotal reports by Coulehan,4 who explains that the traditional ceremonies met needs of the Native American population that were not dealt with by western medicine and concludes that nonphysician healers and physicians can play a part in the patients' health. Just as physicians often ask non–Native American patients about their visits with religious counselors such as ministers, pastors, or priests, physicians should ask their Native American patients about their visits with healers. Some researchers suggest that information on nonphysician healer use can become a routine part of obtaining a patient's medical history. The physician could ask how many prior visits have been made to medical facilities for the same complaint and how often did this involve an alternative care provider.14 Others have recommended that physicians not only should initiate discussions with their patients about the use of alternative medicine but they should monitor this use when health problems occur. Physicians should accept the patients' use of alternative therapies when the outcomes look favorable and contact the alternative practitioner should the condition become more serious.15
Movement toward integrating health practices between traditional healers and physicians could prove to be beneficial to patients. There is a continuum of spiritual and physical needs of a patient, and healers and physicians working together could effectively cover that continuum. This research has shown that many Native American patients have an interest in obtaining care from both physicians and alternative healers, and if conflicting advice arises from this concurrent use, the physician needs to be aware and informed of the implications to best evaluate and act in the situation. We recommend that medical education institutions expose medical students and residents to multicultural issues during their training to better prepare them for practicing medicine in culturally diverse settings.
| Editor's Note: The interaction between physical and spiritual healing is unclear. Physical healing is emphasized by physicians, and spiritual healing is emphasized by different types of individuals, depending on religious affiliations, from priests to Indian spiritual healers. Some cultures and religions blend physical and spiritual healing, which can lead to confusion when people seek care from both traditional physicians and indigenous healers.
I do not see this as alternative health care but as the natural striving of the individual for complete well-being, ie, health. Physicians are not good at spiritual healing, and generally, we should leave spiritual healing to the experts. Furthermore, there are times when, instead of merely asking whether our patients have sought help from religious figures, we should get a consultation and send our patients who appear to be having difficulties in their spiritual lives to the expert (ie, religious figure) most consistent with the patients' personal religious philosophies (see Matthews et al in this issue).—Marjorie A. Bowman, MD, MPA
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AUTHOR INFORMATION
Accepted for publication May 8, 1997.
This project was supported in part by a grant from the American Academy of Family Physicians' Grant Awards Program, Kansas City, Mo.
We thank the staff and patients of the Milwaukee Indian Health Board for their cooperation and support throughout the project.
Reprints: Anne Marbella, MS, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226.
From the Department of Family and Community Medicine, Medical College of Wisconsin (Ms Marbella and Drs Harris, and Diehr), and the Harwood Medical Clinic (Dr Ignace and Ms Ignace), Milwaukee, Wis.
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