Traditional healing and medicine in dementia care for Indigenous populations in North America, Australia, and New Zealand: Exploring culturally‐safe dementia care policy from a global perspective

Abstract

INTRODUCTION

In 2018, the World Health Organization recognized traditional healers as community stakeholders in dementia care. This scoping review aimed to summarize the existing dementia care literature regarding strategies for the integration of traditional healing in dementia care and the roles of traditional healers.

METHODS

A group of Indigenous Elders from Northern Ontario, Canada, guided, reviewed, and validated the research process and findings. The Joanna Briggs Institute approach was applied to a structured search strategy across the CINAHL, Embase, MEDLINE, and PsycINFO databases. A title and abstract screening were completed, followed by a full‐text assessment of the identified manuscripts.

RESULTS

A total of 143 full manuscripts were reviewed, of which two studies fully met the community‐determined inclusion/exclusion criteria.

DISCUSSION

The integration of traditional healing practices into dementia care offers a pathway to culturally‐safe care for people with dementia. The findings identified policy advocacy as key to engage, educate, and empower traditional healers.

Highlights

• The WHO recognized traditional healers as community stakeholders in dementia care and prevention worldwide in 2018; however, traditional healers are underrepresented and marginalized in healthcare systems due to the lack of culturally‐safe dementia care (CSDC) policies at community and national levels globally.

• Community‐based CSDC models were critically reviewed and validated by local Indigenous community stakeholder consultations.

• The result is a call to action to assist the WHO and Alzheimer's Disease International in developing guidelines for CSDC policy improvements with the global Indigenous community for the engagement and empowerment of traditional healers to navigate dementia care and to implement the WHO Global Action Plan on the Public Health Response to Dementia (2017–2025).

• Integration of Western biomedical and Indigenous traditional healing and medicine in dementia care in the healthcare system can reduce health disparities and empower traditional healers on a global scale. Indigenous‐led models that include traditional healers in dementia care are critical for improving equity gaps in dementia care for Indigenous Peoples.

1. INTRODUCTION

The Global Alzheimer's and Dementia Action Alliance (2018) declared dementia to be one of the biggest global health crises of the twenty‐first century, with a new case arising every 3 seconds. ¹ Dementia has become a serious health and social concern for Indigenous Peoples that continues to increase in magnitude among Indigenous populations around the world. ²

In Canada, the prevalence rates of dementia for First Nations people over the age of 60 are projected to increase 4‐fold compared to a 2.3‐fold increase in the non‐First Nations population by 2031. ³ Diverse views on dementia exist around the world. Some Indigenous communities view dementia as part of the normal aging process, ⁴ as a spiritual phenomenon, ⁵ or as a “second childhood” on the circle of life's continuum. ⁶ In some cases globally, dementia has evoked fear and mistrust, ⁷ causing people with dementia to be accused of witchcraft, ⁸ or to suffer abuse and extreme violence. ⁹

Access to culturally‐safe dementia care (CSDC) for Indigenous populations is an emerging priority worldwide. This is evidenced by the World Health Organization (WHO) Dementia Plan Guide (2018) which recognizes traditional healers, community, and religious leaders as community stakeholders in the care and prevention of dementia globally. ⁷ However, little existing research has been explicitly dedicated to traditional medicine and healing options that focus on dementia care and prevention for Indigenous populations. ¹⁰ Traditional healers can contribute to dementia assessment, diagnosis, and care in unique ways, acting as catalysts in the process of dementia care access, planning, and navigation in collaboration with mainstream healthcare providers.

Traditional healers in dementia care include (but may not be limited to) Elders, knowledge holders, spiritual and faith healers or practitioners, prayers, medicine people, and herbal or plant‐based medicine practitioners. This scoping review study summarizes the published literature, outlines the roles and experiences of traditional healers, and evaluates strategies for integrating Indigenous traditional healing and Western dementia care approaches as well as existing policy barriers and research gaps in Canada, the United States, Australia, and New Zealand, due to some commonalities in the experiences with colonization from the perspectives of Indigenous Peoples from these four nation‐states.

2. METHODS

Following the Joanna Briggs Institute (JBI) Model for Evidenced‐Based Healthcare, ¹¹ this scoping review draws on emerging evidence while highlighting the need for improved dementia care for Indigenous Peoples. In this way, priority areas are identified and gaps between Western medicine and traditional healing practices are clarified. While recommendations are made for how to improve policy moving forward, the results are not prescriptive; rather, they offer considerations for improving dementia care for Indigenous populations.

2.1. Protocol development and refining research questions

The protocol was developed in collaboration and cooperation with knowledge sharers consisting of First Nations’ Elders, community members, and community researchers uniquely involved in community dementia care across Manitoulin Island in Northwestern Ontario. The Principal Investigator (HS) worked with three knowledge sharers to define and refine the research questions so that they reflected the perspectives and priorities of their communities. The questions were then aligned to the Population/Participant, Concept, and Context (PCC) framework outlined in the JBI Guide (2020) and the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) Extension for Scoping Reviews (PRISMA‐ScR). ¹¹ , ¹² , ¹³

2.2. Research questions

The three research questions that underpinned this study were the following: (1) What is known about traditional healers’ roles and experiences surrounding dementia care within Indigenous populations in North America, Australia, and New Zealand; (2) what strategies have been recommended and evaluated to integrate traditional healing and medicine into CSDC; and (3) what are the policy barriers and research gaps?

2.3. Search strategy

To strengthen the work, an academic librarian supported the development of database‐specific search terms and filters for CINAHL, Embase, MEDLINE, PsycINFO, and JBI Evidence Synthesis. To refine the search strategy, a preliminary search for relevant literature was conducted. This iterative approach explored the titles and abstracts of white and gray literature to narrow the scope of the keywords. An example of the comprehensive search method for the MEDLINE database is shown in the supplementary appendix (A1). Following the search, all identified citations were collated and uploaded into Zotero reference management software where duplicates were removed. References were then transmitted to Covidence software for screening relevance using the title and abstract. The remaining studies were then subjected to a full‐text review based on the inclusion and exclusion criteria (Table 1).

TABLE 1.

Inclusion and exclusion criteria of the PCC framework.

PCC framework	Inclusion	Exclusion
Population/participants	Traditional and faith healers, religious leaders, spiritual practitioners of all ages, genders, Indigeneity, and Grandmother groups, who are integrating traditional Indigenous dementia care practices into the medical system through traditional medicine, plant‐based medicine, spiritual and religious healing practices (prayers, meditation, various ceremonies including dance and music) Grandmother groups are considered traditional healers themselves and providers of traditional wellness support and care for loved ones or persons with dementia in families and communities.
Concept	Concept 1 Perspectives, knowledge, or data of traditional healers Dementia includes Alzheimer's disease, senile dementia, memory loss, and related head or brain injury. Concept 2 →The involvement of traditional healers in dementia care →The role of traditional healers including Grandmothers Group in dementia, and perceptions of Indigenous healers on dementia care →Aspects of culturally‐safe dementia care, and the unique aspects of assessing, diagnosing, treating, and supporting dementia in Indigenous populations.	Studies focused on mental and psychiatric disorders, Parkinson's disease, schizophrenia, and epilepsy were excluded.
Context	Indigenous communities of North America, that is, Canada and the United States (First Nations, Metis, Inuit, Cree, American Indian/Native Indian, Alaska Native and Hawaii Native), Australia (Aboriginal and Torres Strait Islander), and New Zealand (Maori)	Excluded studies from geographical regions of Asia, Africa, Europe, and South America

Abbreviation: PCC, Population/Participant, Concept, and Context.

RESEARCH IN CONTEXT

1. Systematic review: A comprehensive analysis was conducted of the literature on the potential integration of Western biomedical and Indigenous traditional medicine in dementia care, including the experiences of traditional healers, policy barriers, and research gaps. The review was designed to include literature from North America, Australia, and New Zealand using the CINAHL, Embase, MEDLINE, and PsycINFO databases. The two identified studies were based in Canada.

2. Interpretation: The research findings can contribute to an exemplary model to integrate Western biomedical and Indigenous traditional medicine in dementia care with social support systems as a pathway to culturally‐safe dementia care (CSDC).

3. Future directions: Improvements to existing CSDC policy should include a thoughtful integration of Indigenous knowledge woven through the two selected studies. The models used in the two included studies incorporated CSDC approaches that were vetted and supported by local Indigenous community stakeholders from Northern Ontario as part of this study. Due to the colonial legacy, intergenerational trauma, and inequity of structural, social, and cultural determinants of health, there is a knowledge gap between healthcare providers and traditional healers. Respectful inclusion and empowering traditional healers are essential to improved dementia care and prevention for Indigenous Peoples globally.

2.4. Inclusion and exclusion criteria

The review included published studies of any design, including systematic reviews, studies that focused on traditional healers and grandmother groups, and studies that explored dementia care, including senile dementia and Alzheimer's disease. Also included were studies that explicitly explored the roles and experiences of traditional healers in dementia care, including traditional medicines and spiritual practices. Published manuscripts were from studies of Indigenous communities and populations in North America, Australia, and New Zealand. The review excluded editorial articles, commentaries, and gray literature. The search was limited to publications written in English from 2000 to 2020. Studies outside of North America, Australia, and New Zealand were also excluded.

2.5. Data extraction

For the studies that met the inclusion and exclusion criteria, key information was derived from the full text. Data collected from the articles included title, authors, year of publication, country of origin, study purpose and design, traditional healer roles and experiences, the integration of traditional healing into the healthcare system, policy barriers, research gaps, and key findings.

2.6. Summarizing and reporting

The search results were reported in full upon reaching the final review and presented in the PRISMA flow diagram. ¹³ , ¹⁴

2.7. Local community stakeholder consultation

Following the analysis of the summary and review, a local community stakeholder consultation was undertaken via a virtual (Zoom) circle gathering on May 18, 2021, with three Elders and knowledge holders and a community researcher in dementia care on Manitoulin Island, Canada. This was a practical step toward sharing knowledge among Indigenous community advisors and Indigenous scholars for contextual interpretation and validation.

The purpose of this gathering was to guide the interpretation and meaning of the results. The presentation focused on the following questions: what important questions this review set out to answer, what answers the study found and what questions remained, why are the results important and how can they be used at the community level? Each of the Elders and knowledge holders shared their perspectives on the importance of results and discussed the best practices for dementia care and assessment in First Nations Anishinaabe communities in Northern Ontario. They reviewed the proposed two community‐based CSDC models as a framework for the integration of traditional healers in dementia care, and the five key steps toward establishing CSDC by healthcare providers, traditional healers, and community leaders.

2.8. Ethical considerations

To ensure the ethical considerations of Indigenous research, substantial consultations were organized in December 2019 and 2020 for the research proposal to refine methodologies. This included two Elder knowledge holders and members of an established Community Advisory Council from across Manitoulin Island Anishinaabe communities, a Wikwemikong Health Centre’s Dementia Community‐based Researcher, and a Laurentian University Elder and knowledge holder.

3. RESULTS

An initial search of the CINAHL, Embase, MEDLINE, and PsycINFO databases resulted in 516 records published between 2000 and 2020. After removing 164 duplicates and 352 titles, the abstracts were screened, 209 of which were rejected because they did not meet the inclusion criteria. The second‐stage review of the remaining 143 full‐text studies resulted in the further exclusion of 141 studies. Of these, 111 studies did not include the roles, experiences, and engagement of traditional healers for the integration of traditional healing and medicine into dementia care, and 30 studies did not involve Indigenous populations or meet study design criteria. After a full‐text review, only two studies met the inclusion criteria for data extraction. A PRISMA flow diagram and bar graph (Figures 1 and 2) depict the exclusion of 141 full‐text studies out of 143.

FIGURE 1.

PRISMA 2020 flow diagram for traditional healing and medicine in dementia care for Indigenous populations in North America (Canada and the United States), Australia, and New Zealand. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐analyses.

FIGURE 2.

Ineligible studies in North America, Australia, and New Zealand (2000 to 2020).

3.1. Study design, population, and themes

Only two studies met the inclusion criteria, both of which were peer‐reviewed studies. One was conducted in Ontario and published in the Canadian Journal of Aging in 2012, and the other was conducted in Saskatchewan and published in the Journal of Cross‐Cultural Gerontology in 2011. Both studies used a community‐based participatory action research framework. The first study took place in an urban First Nations community in Southwestern Ontario. The researchers applied constructive grounded theory, semi‐structured interviews, and thematic analysis. ¹⁵ The study included seven participants, one of whom was a male traditional healer; others included a social worker, a personal support worker (PSW), a registered practical nurse (RPN), a community health worker (CHW), a health educator, and a registered nurse (RN). The second study was conducted in Saskatchewan with diverse Cree, Salteaux, and Metis populations in remote communities, with the participation of three Indigenous grandmothers. It was an applied qualitative study design that included semi‐structured interviews and thematic analysis. ⁶

The following themes were addressed in both studies.

3.1.1. Role and perception of traditional healers in dementia care

Finkelstein et al. ¹⁵ identified the interdisciplinary role of the traditional healer as an investigator, collaborator, navigator, and evaluator involved in searching and determining the cause of dementia and treating symptoms in a First Nation community in Southwestern Ontario. Data were collected through in‐depth interviews and analyzed using a constructivist grounded theory methodology. The traditional healer's role included investigating and determining the cause of dementia and treating symptoms, at times requiring assessment of the severity of dementia symptoms in dementia patients who failed to share information by hiding or denying signs and symptoms required to provide everyday care; the traditional healer used investigation in accordance with their traditional healing approach to determine the cause of a dementia condition and to navigate a care plan. The role of the traditional healer was seen as critical in articulating a balanced synergetic collaboration with the RN, RPN, PSW, CHW, health educator, and social worker for dementia care among First Nations community members. This study concluded that a lack of knowledge among healthcare professionals is a major barrier that negatively impacts dementia care and recommends knowledge‐sharing strategies.

The second research project ⁶ focused on “Strategies to Improve the Care of Persons with Dementia in Rural and Remote Areas” in a remote community clinic in the Canadian province of Saskatchewan. Three grandmothers were recruited for 6 monthly key informant group interviews. These meetings were held at the Saskatoon Community Clinic because the participants were Indigenous seniors who met on a regular basis for educational sessions and social gatherings. The grandmother's group of Cree, Salteaux, and Métis demonstrate the diversity of Indigenous populations in Saskatoon, as they spoke different languages and came from different nations and worldviews. One grandmother was fluent in Plains Cree, Mitchif Cree, French, and Salteaux. The three grandmothers in the group spoke English fluently. The roles and perceptions of grandmothers on dementia, aging, and caregiving provided a holistic insight.

The grandmothers reflected that there is no Cree word for dementia but described it as “losing your memories” and “back to the baby stage” as metaphors that capture dementia in the Cree language. One grandmother described someone she later recognized as having dementia as “not with her mind.” Grandmothers described aging as “going back to the baby stage,” illustrating the “circle of life.” One grandmother described caring for her mother, who had dementia, and her fear of developing dementia. This study examines grandmothers' perspectives on how they dealt with Indigenous seniors suffering from dementia and memory loss in remote communities. Furthermore, kinship, access to resources and healing support, and engagement in cultural and spiritual ceremonies are important factors in identifying and assessing dementia and memory loss. According to Anderson, grandmothers have traditionally played a key role in keeping their communities alive and taking responsibility and leadership for their community's health, well‐being, and longevity. ¹⁶ Thus, this study recognizes grandmothers' roles as traditional healers in dementia and memory care in their community. Their dynamic leadership role and community‐led experiences in memory and dementia care can lay a solid foundation for knowledge transfer and the transmission of teachings from generation to generation. 

3.1.2. Strategies for integration of traditional healing into CSDC

According to Finkelstein et al., culturally appropriate dementia care entails strategically integrating collaborative approaches. ¹⁵ A social worker, for example, developed a bereavement program for families that used both Western and traditional healing methods. A health educator was in the process of adapting dementia education resources and developing a program specifically for First Nations' needs, and she had met with community Elders for suggestions on how to provide culturally appropriate care by combining Western and traditional medicines to meet the needs of patients. A social worker collaborated with traditional healers to care for two dementia patients using traditional medicines and healing practices. She also worked with a traditional healer in following his instructions to assist them with house cleaning with sage seed.

As part of a Western model of care, traditional healers interact with dementia clients and work with them to improve their health while maintaining open‐door policies and being available for crisis support. One shared his experiences with many dementia patients who cannot communicate, express words, or speak, but he worked with them and spent more time as part of caregiving. These traditional healing and medicine approaches and strategies contribute to filling gaps in the integration of geriatric care and therapeutic interventions for patients with dementia in First Nations communities to begin CSDC.

This study concluded that encouraging patients with dementia to undergo cognitive evaluations and treatment for symptoms led to greater success. The traditional healer witnessed the patient's early fears and unpleasant feelings following a dementia diagnosis as undesirable reactions that further exacerbated the illness.

Lanting et al. described the context of culturally appropriate healthcare and the importance of sensitivity in communication. ⁴ Through the assessment of the Grandmother Group, visual images convey information while ensuring familiarity and relevance to improve the care of people with dementia in rural and remote areas. The significance of language translation services and the prominence of humor in language enhanced cultural appropriateness of developing rapport and conducting an accurate assessment. One grandmother described an example of the strategy of integration into culturally appropriate dementia assessment and care as an example of the importance of sensitivity in communication. The Grandmothers agreed that color graphics are critical for capturing an older adult's interest and involving them in the assessment process. One grandmother emphasized the significance of creativity and visual imagery, because a color illustration of the anatomy is eye‐catching and draws attention, and they needed to come up with some words for many terms, such as diabetes, for which they do not already have a Cree equivalent.

The grandmothers emphasized the importance of language in fostering comfort in the medical setting. One grandmother stated that when it came to assessments, she had the terminology on hand—to be precise so that the subject she was assessing would be comfortable and understandable—and that she used it to be specific. This study demonstrated the positive impact of people with dementia on the potential integration of traditional and culturally grounded healthcare for aging illnesses and dementia.

3.1.3. Policy barriers and research gaps

Finkelstein et al. ¹⁵ highlighted the experiences of a traditional healer who faced critical problems in terms of policy barriers and research gaps. Due to research gaps and policy barriers, he witnessed that physicians may not accept the validity of traditional healing and alternative medicine, making collaborative client care difficult. Despite this, the traditional healer was attempting to transform clients' initial fears and negative emotions toward dementia diagnosis and navigation. For patients with dementia, access to combined geriatric care and therapeutic supports, as well as traditional healing, medicine, and ceremonies, improves holistic wellness and quality of life.

Lanting et al. emphasize the importance of visual language and translation services in healthcare settings by telling stories about communication breakdowns caused by language barriers between a patient and the CHW. ⁴ A grandmother shared a humorous perspective on translation or language services in healthcare, recalling an elderly man who went to the doctor and returned home telling his son that he had a horse on his liver. His son was shocked and immediately called the nurse, who informed him that he had liver cirrhosis. How important is a translator in communication?

The same grandmother told another funny story about a nurse and a patient's miscommunication caused by language barriers and carelessness due to workload. For example, a 12‐year‐old boy told his grandfather, who had prostate cancer, that the nurse was going to give him two “shots” right away, but the boy did not understand the meaning of the words, so he told his grandfather that the nurse was going to “shoot” him twice right now. The grandfather was terrified and said there was no hope for him.

This study examines the effect of communication gaps on relationships between healthcare providers and the grandmother's group. They emphasized the importance of language in creating comfort in the healthcare environment when discussing culturally competent healthcare. However, cultural perceptions of aging and dementia have a significant impact on aging care because they are visually engaging. This study contributes to changing the appropriate assessment process and accuracy of diagnosis within rural and remote memory clinics to facilitate interventions that incorporate a culturally based understanding of dementia among Canadian Indigenous people. Furthermore, the rigorous 6‐month interaction between researchers and grandmothers facilitated modifications of existing screening instruments and neuropsychological testing protocols to improve their cultural appropriateness for Indigenous seniors. ⁶ As a result, the new screening tool was created for use by frontline care workers. ¹⁷ Grandmothers assisted the researchers on some home visits to pilot‐test the assessment protocols with Aboriginal seniors. These visits were carried out in collaboration with a family physician and Indigenous homecare staff and managers. ¹⁷ This is an example of pragmatic collaboration between frontline healthcare workers and grandmothers to fill policy and research gaps at the local community level for dementia and memory care in a rural memory care setting.

3.2. Learnings from local community stakeholder consultation

Three Elders, knowledge holders, and community researchers on dementia research shared their knowledge at the gathering, which is important for guiding and locally conceptualizing the interpretation and validation of the findings. These include the importance of acknowledging how people have moved away from traditional teachings and ways of life, which has resulted in an increase in dementia cases in younger people; changes in food, diet, and technological distractions; the use and strengthening of the Anishinaabemowin language to maintain a connection to traditional practices and to communicate with those who have dementia; and developing a community‐based CSDC model that is endorsed and validated as Models 1 and 2 integration roadmaps for the community advisory groups of traditional healers and healthcare providers (Figure 3).

FIGURE 3.

Local community Models 1 and 2 with five key steps to form culturally‐safe dementia care by traditional healers and integrate traditional healers and healthcare providers.

4. DISCUSSION

The WHO Traditional Medicine Strategy (2014–2023) emphasized that, despite a long history of practice in healthcare, disease prevention, and treatment, traditional medicine is an important but often marginalized healthcare service globally. ¹⁸ Traditional Indigenous knowledge and practices are often based on observation and experience passed down orally or in writing from generation to generation. Most Indigenous traditional medicine has been integrated at the primary healthcare level, ³ which can include services to support people with memory loss, mild cognitive impairment, dementia, and early familial onset Alzheimer's disease. As such, it is essential to recognize, empower, and honor traditional healers' roles, experiences, and knowledge in dementia care and assessment. ⁹

Numerous studies suggest the inclusion of traditional healers and ceremonies in Alzheimer's disease and related dementia care is meaningful. ⁵ , ¹⁹ , ²⁰ , ²¹ , ²² First Nations Elders in Canada support individuals to seek spiritual, emotional, physical, and mental balance in preventing dementia and empowering First Nations people to live healthy lives. ²³ In their article, “Experience of being an Anishinaabe man healer: ancient healing in a modern world,” Struthers et al. emphasized the importance of educating Western healthcare practitioners, nurses, and physicians about Indigenous healing to foster respect and trust between Indigenous patients and Western practitioners. ²⁴

Numerous studies in Canada have focused on the people who play caregiving roles to support people living with dementia among diverse Indigenous communities and culturally appropriate dementia care strategies in British Columbia ³ and Ontario. ⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ The role of traditional healers in supporting the resilience and care of family and community caregivers is not well covered in the academic literature but is a critical component of integrating the gifts of traditional healers in dementia care.

One of the key advances in culturally‐grounded dementia diagnosis and care is the development and validation of the Kimberley Indigenous Cognitive Assessment and the adaptation of that tool in many contexts globally, including the Canadian Indigenous Cognitive Assessment (CICA). The CICA tool was adapted, piloted, and tested for reliability and validity with Anishinaabe communities on Manitoulin Island. ²⁸ Notably, while language speakers and traditional knowledge carriers were involved in the adaptation, refinement, and testing of the CICA, traditional healers have not been integrated into the implementation of the CICA tool in practice. ²⁸ Better integration of traditional healers in the process of screening and diagnosis of dementia can facilitate the implementation of the WHO Global Action Plan on the Public Health Response to Dementia as community stakeholders for dementia care and prevention globally.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest. Author disclosures are available in the Supporting Information.

CONSENT STATEMENT

The authors confirm that all human subjects' consent was not necessary.

Supporting information

Supporting Information

Supporting Information

Shrestha HL, Shrestha L, McArthur M, Rowe RK, Maar M, Walker JD. Traditional healing and medicine in dementia care for Indigenous populations in North America, Australia, and New Zealand: Exploring culturally‐safe dementia care policy from a global perspective. Alzheimer's Dement. 2024;e12620. 10.1002/dad2.12620